Substance Abuse Services (Residential)

Initial Screening: Staff must screen each client for SA-R services using the Texas Department of Insurance criteria per the TAC standards for substance abuse services. The screening process should collect all information necessary to determine the type of services required to meet the client’s needs.

To be eligible for admission to a treatment program, an individual must meet the current Diagnostic and Statistical Manual (DSM) criteria for substance use or dependence (or substance withdrawal or intoxication in the case of a detoxification program).

1. Percentage of client charts with documentation of a completed initial screening.

Comprehensive Psychosocial Assessment: A licensed substance use disorder counselor must conduct a comprehensive psychosocial assessment for all clients. Staff should complete and sign a comprehensive assessment within 3 days of admission, and should offer and provide a copy of the completed assessment to the client. If emergent needs prevent the assessment from being completed within 3 days, staff must document this in the client’s record.

The comprehensive assessment should include:

• Presenting problem(s)
• Alcohol and other substance use
• Previous psychiatric and chemical dependency treatment
• Medical history, including current HIV treatment and level of adherence
• Relationships with family, including domestic or intimate partner violence
• History of trauma
• Housing status
• Social and leisure activities
• Education and vocational training
• Employment history
• Legal issues
• Cognitive status
• Strengths and challenges

During the initial assessment, providers should assess clients for care coordination needs and make referrals to case management or other support programs as appropriate. 

Staff should use a valid and reliable assessment tool such as the Substance Abuse and Mental Illness Symptoms Screener (SAMISS) or Addiction Severity Index (ASI) to evaluate substance use.  For cognitive assessment, providers may use the Mini-Mental State Examination (MMSE) or other validated tool. 

A licensed health professional must conduct a health assessment for all residential clients within 96 hours of admission per 25 TAC Section 488.803.

2. Percentage of clients with an initial comprehensive psychosocial assessment completed within 3 days of admission.

3. Percentage of clients evaluated using a valid and reliable assessment tool for substance use.

4. Percentage of clients evaluated using a valid and reliable assessment tool for cognitive assessment.

5. Percentage of clients with a health assessment completed within 96 hours of admission.

Treatment Plan: Providers should complete a treatment and filed it in the client record within 5 days of admission. Treatment planning is a collaborative process through which the provider and client develop desired treatment outcomes and identify the strategies for achieving them. Providers should discuss all available treatment options with the client and incorporate the client’s wishes regarding the treatment course and modality.
 
The treatment plan should include: 

• Goals and objectives of treatment
• Treatment modalities and interventions to achieve treatment goals
• Discharge criteria and initial plans for discharge
• Projected length of stay
• Client’s primary counselor
• Signature and date of the counselor developing the treatment plan

Staff should evaluate the treatment plan on a regular basis and revise as needed to reflect the ongoing reassessment of the client’s issues, needs, and response to treatment. At a minimum, agencies must review and update treatment plans midway through the projected duration of treatment and no less frequently than monthly.

6. Percentage of clients with treatment plans completed within 5 days of admission.

7. Percentage of clients with treatment plans updated midway through the projected duration of the treatment at a minimum, and no less frequently than monthly.

Progress Notes: Agencies will provide services according to the individual's treatment plan and document in the client's record. Counselors will document progress notes for every professional counseling session and these should include: 

• Client name
• Session date 
• Clinical observations 
• Focus of the session 
• Interventions 
• Assessment 
• Duration of session 
• Newly identified issues or goals 
• Client’s responses to interventions and referrals 
• HIV medication adherence 
• Substance use treatment adherence 
• Signature of the counselor conducting the session

 For detox program clients, notes should include:

• Vitals assessed
• Medications provided to client during detox program 
• Medical evaluation(s)
• Discussion regarding transition plan after the detox program completed

8. Percentage of clients with progress notes for each counseling session.

9. Percentage of clients accessing detox programs with progress notes.

Referrals: Agencies must make appropriate referrals for clients with medical or support needs. For clients accessing detox programs, staff should make referrals to outpatient or residential substance use programs for continuity of care.

10. Percentage of clients with referrals based on need demonstrated in the assessment and progress notes, as applicable.

Discharge Planning: Providers should conduct discharge planning collaboratively with all clients and complete planning before the client’s scheduled discharge. A written discharge plan must address ongoing client needs and continuity of services, and should include:

• Individual goals or activities to sustain recovery
• Referrals to case management and primary care providers, as appropriate 
• Outpatient substance abuse services and other recovery maintenance services, as applicable
• Date and signatures of the counselor and client 

Providers and case managers should ensure that, to the greatest extent possible, clients who leave care are linked with appropriate services to meet their needs.

11. Percentage of clients with a completed discharge plan prior to discharge from the residential program.

Discharge Summary: Staff must complete a discharge summary for each client within 30 days of discharge and should include:

• Dates of admission and discharge
• Needs and issues identified at the time of admission, during treatment, and at discharge
• Services provided
•  Assessment of the client’s progress toward goals
• Reason for discharge
• Referrals and recommendations, including arrangements for recovery maintenance
• Signature of the counselor

The facility must contact each client no sooner than 60 days and no later than 90 days after discharge from the residential program and document the client’s current status or the reason contact was unsuccessful

12. Percentage of clients with a discharge summary completed within 30 days of discharge.

13. Percentage of clients with documentation of attempts to contact the client 60-90 days after discharge with the client’s current status or the reason contact was unsuccessful.