Current through Reg. 49, No. 38; September 20, 2024
(a) A facility providing detoxification
services shall ensure every individual admitted to a detoxification program
meets the DSM criteria for substance intoxication or withdrawal.
(b) All detoxification programs shall ensure
continuous access to emergency medical care.
(c) The program shall have a medical director
who is a licensed physician. The medical director shall be responsible for
admission, diagnosis, medication management, and client care.
(d) The medical director or his/her designee
(physician assistant, or nurse practitioner) shall approve all medical
policies, procedures, guidelines, tools, and the medical content of all forms,
which shall include:
(1) screening instruments
and procedures;
(2) protocol or
standing orders for each major drug category of abusable drugs (opiates,
alcohol and other sedative-hypnotic/anxiolytics, inhalants, stimulants,
hallucinogens) that are consistent with guidelines published by nationally
recognized organizations (e.g., Substance Abuse and Mental Health Services
Administration, American Society of Addiction Medicine, American Academy of
Addiction Psychology);
(3)
procedures to deal with medical emergencies;
(4) medication and monitoring procedures for
pregnant women that address effects of detoxification and medications used on
the fetus; and
(5) special consent
forms for pregnant women identifying risks inherent to mother and
fetus.
(e) The medical
director or his/her designee (physician assistant, nurse practitioner) shall
authorize all admissions, conduct a face-to-face examination, to include both a
history and physical examination of each applicant for services to establish
the Axis I diagnosis, assess level of intoxication or withdrawal potential, and
determine the need for treatment and the type of treatment to be provided to
reach a placement decision.
(1) The
examination shall identify potential physical and mental health problems and/or
diagnoses that warrant further assessment.
(2) The authorization and examination shall
be documented in the client record and shall contain sufficient documentation
to support the diagnoses and the placement decision. If the physician
determines an admission was not appropriate, the client shall be transferred to
an appropriate service provider.
(3) The face-to-face examination (history and
physical examination) and signed orders of admission shall occur within 24
hours of admission.
(4) The program
may accept an examination completed during the 24 hours preceding admission if
it is approved by the program's medical director or designee and includes the
elements of paragraphs (1) and (2) of this subsection. The program may not
require a client to obtain a history and physical as a condition of
admission.
(5) Detoxification
programs shall have a licensed vocational nurse or registered nurse on duty for
at least eight hours every day and a physician or designee on call 24 hours a
day.
(6) Detoxification programs
shall ensure that detoxification services are accessible at least 16 hours per
day, seven days per week.
(f) Providers shall develop and implement a
mechanism to ensure that all direct care staff in detoxification programs have
the knowledge, skills, abilities to provide detoxification services, as they
relate to the individual's job duties. Providers must be able to demonstrate
through documented training, credentials and/or experience that all direct care
staff are proficient in areas pertaining to detoxification, including but not
limited to areas regarding:
(1) signs of
withdrawal;
(2) observation and
monitoring procedures;
(3)
pregnancy-related complications (if the program admits women);
(4) complications requiring
transfer;
(5) appropriate
interventions; and
(6) frequently
used medications including purpose, precautions, and side effects.
(g) Residential and ambulatory
(outpatient) detoxification programs shall provide monitoring to manage the
client's physical withdrawal symptoms. Monitoring shall be conducted at a
frequency consistent with the degree of severity of the client's withdrawal
symptoms, the drug(s) from which the client is withdrawing, and/or the level of
intoxication of the client. This information will be documented in the client's
record and reflected in the client's orders.
(1) Monitoring shall include:
(A) changes in mental status;
(B) vital signs; and
(C) response of the client's symptoms to the
prescribed detoxification medications
(2) Use of instruments such as the Clinical
Institute Withdrawal Assessment-Alcohol, revised (CIWA-Ar) for alcohol and
sedative hypnotic withdrawal and the "clinician's assessment" in the Behavioral
Health Integrated Provider System (BHIPS) is recommended.
(3) More intensive monitoring is required for
clients with a history of severe withdrawal symptoms (e.g. a history of
hallucinosis, delirium tremors, seizures, uncontrolled vomiting/dehydration,
psychosis, inability to tolerate withdrawal symptoms, self harming attempts),
or the presence of current severe withdrawal symptoms and/or co-occurring
medical and psychiatric disorders.
(4) At a minimum, monitoring should be done
every four hours in residential detoxification programs for the first 72 hours
and as ordered by the medical director or designee thereafter, dependent on the
client's signs and symptoms.
(5)
Medication should be available to manage withdrawal/intoxication from all
classes of abusable drugs.
(6)
Medication "regimens", "protocols" or standing orders can be used, but
detoxification should be tailored to each client's need based on vital signs
and symptom severity (objective and subjective) and noted in the client's
record.
(7) Ambulatory
detoxification should have clear documentation by the physician or designee
that the client's symptoms are or are expected to be of a severity that
necessitates a minimum of once a day monitoring.
(h) In addition to the management of
withdrawal and intoxicated states, detoxification programs shall provide
services, including counseling, which are designed to:
(1) assess the client's readiness for
change;
(2) offer general and
individualized information on substance abuse and dependency;
(3) enhance client motivation;
(4) engage the client in treatment;
and
(5) include a detoxification
plan that contains the goals of successful and safe detoxification as well as
transfer to another intensity of treatment. At least one daily individual
session by a registered nurse, QCC or counselor intern with the client will be
conducted.
(i) Ambulatory
detoxification shall not be a stand alone service and services shall be
provided in conjunction with outpatient treatment services. When treatment
services are not available in conjunction with ambulatory detoxification
services, the ambulatory detoxification program shall arrange for
them.
(j) Bunk beds shall not be
used in residential detoxification programs.
(k) In residential programs, direct care
staff shall be on duty where the clients are located 24 hours a day.
(1) During day and evening hours, at least
two staff shall be on duty for the first 12 clients, with one more staff on
duty for each additional one to 16 clients.
(2) At night, at least one staff member with
detoxification training shall be on duty for the first 12 clients with one more
staff on duty for each additional one to 16 clients.
(l) Clients who are not in withdrawal but
meet the DSM criteria for substance dependence may be admitted to
detoxification services for 72 hours for crisis stabilization.
(m) Crisis stabilization is appropriate for
clients who have diagnosed conditions that result in current emotional or
cognitive impairment in clients such that they would not be able to participate
in a structured and rigorous schedule of formal chemical dependency treatment.
(1) The specific client signs and symptoms
that meet the DSM or other medical criteria for the disorder must be documented
in the client record.
(2)
Documentation must also include what symptoms are precluding the client from
participating in treatment and the manner in which they are to be
resolved.
