Rules, Rules, Rules'

1
Rules, Rules, Rules.

• September 2004
• Texas Commission on Alcohol and Drug Abuse
• 144, 147, 148
• Rhonda G. Patrick, LMSW, MPA
• Blue Basin, Inc.

2
Schedule

• 830 am - 845 am Introductions
• 845 am - 900 am Overview of New TCADA
  Rules Structure
• 900 am 1015 am Chapter 144
• 1015 am 1030 am Break
• 1030 am 1200 pm Chapter 147
• 1200 pm 100 pm Lunch
• 100 pm 230 pm Chapter 148
• 230 pm 245 pm Break
• 245 pm 400 pm Chapter 148
• 400 pm 430 pm Questions and Answers

3
Course Objectives

• Participants will be able to understand the
  purpose of TCADA regulations.
• Participant will be able to identify the changes
  made in the rule revisions and their impact on
  organization processes.
• Participants will understand TCADA Chapter 144
  Contract Management rules and their application
  on contracting with TCADA.
• Participants will understand TCADA Chapter 147
  Contract Program Requirements rules and their
  application to prevention, intervention and other
  specialized programs.
• Participants will understand TCADA Chapter 148
  Standards of Care rules and their application
  to all treatment providers.
• Participants will understand how changes at the
  State level will impact rule interpretation and
  program oversight.

4
Overview Of New Rules Structure

• Delineation of rules by function and activity
• TCADA General Activities
• Investigations
• General Contracting
• Prevention and Intervention Contracting
• Standards of Care
• Counselor s
• Peer Assistance Programs
• Offender education Programs

5
Eating

• If you bite your tongue while eating, it is
  because you have recently told a lie.

6
Overview Of New Rules Structure

• What is changed in the structure?
• 141 General Provisions- Revised 2/1/04
• 142 Investigations Hearings- Revised 2/1/04
• 144 Contract Requirements- Repealed ABCD on
  2/1/04 and EF 9/1/04 and Replaced with 144
  Contract Administration Requirements
• 145 Faith-Based Repealed 9/1/04 and Part of 148
  after 9/1/04
• 147 Contract Program Requirements- New addition
  effective 9/1/04
• 148 Licensure Requirements- Repealed 9/1/04 and
  Replaced with Standards of Care effective 9/1/04.
• 150 Counselor Licensure- Revised 2/1/04
• 151 Peer Assistance Programs- No Changes
• 153 Offender Education Programs- Revised 2/1/04

7
Overview Of New Rules Structure

• What are we actually left with and who does it
  apply too?
• 141 General Provisions- Applies to TCADA
• 142 Investigations Hearings- Applies to
  Facilities
• 144 Contract Administrative Requirements- Applies
  to funded
• 147 Contract Program Requirements- Applies to
  funded
• 148 Standards of Care- Applies to all treatment,
  intervention and prevention programs
• 150 Counselor Licensure- Applies to all
  counselors and counselor interns
• 151 Peer Assistance Programs- Applies to all peer
  assistance programs
• 153 Offender Education Programs- Applies to all
  offender education programs

8
Chapter 144Overview Application

• Applies to all substance abuse programs funded by
  the commission.
• Careful not to say TCADA, but Commission
• Covers
• Funding
• Contracting Organization
• Contract Administration
• Contract Oversight

9
Old Wives Tales

• If you cut an apple in half and count how many
  seeds are inside, you will also know how many
  children you will have.

10
Chapter 144

• 144.301 General Requirements
• 144.302 Organizational Structure
• 144.303 Policies Procedures
• 144.305 Personnel Requirements Documentation
• 144.401 Contract Provisions
• 144.404 Program Income

11
Chapter 144

• 144.405 Indirect Costs
• 144.406 Prior Approval
• 144.407 Equipment and Supplies
• 144.408 Minor Remodeling
• 144.409 Subcontracting
• 144.411 Procurement
• 144.412 Travel
• 144.413 Financial Eligibility

12
Chapter 144

• 144.415 Cost Reimbursement
• 144.416 Billing for Treatment Services
• 144.417 BHIPS
• 144.418 Reporting
• 144.419 Obligating
• 144.420 Contract Closeout

13
Try this one.

• To prevent an unwelcome guest from returning,
  sweep out the room they stayed in immediately
  after they leave.

14
Chapter 147Overview Application

• Completely New Chapter
• Only applies to funded
• Involves Prevention, Intervention and Special
  Programs
• Moved from old 144
• Most significant changes occur in OSAR
• Builds in definitions to rules rather than
  separate them out

15
Chapter 147Prevention and Intervention

• 147.103 Program Design
• 147.110 Problem Identification and Referral
• 147.112 Environmental and Social Policy
• 147.113 Intervention Services
• 147.114 Community Coalitions
• 147.116 Pregnant Parenting Adult
  Adolescent Female Prevention Services

16
Chapter 147 HIV Programming

• 147.202 HIV Required Services
• 147.203 Minimum Operational Requirements-HIV
• 147.204 Minimum Operational Requirements- HEI

17
Chapter 147 Narcotic Treatment Programs

• 147.303 Required Services
• 147.304 Minimum Operational Requirements

18
Off to the Chapel

• If a single woman sleeps with a piece of wedding
  cake under her pillow, she will dream of her
  future husband.

19
Chapter 147 OSAR Services

• 147.402 Standards
• Screening
• Motivational Interviewing
• Stages of Change
• Resource Directory
• Coordinate Client Care
• Outreach

20
Chapter 147Performance Standards

• Performance Definitions
• Completion
• Abstinence
• Follow-Up
• Referral

21
Chapter 147Pregnant Post Partum Women

• 147.604 Individualized Plan of Services
• Service plan
• Service Requirements
• Counseling
• Services for children
• Employment
• CPS Involvement
• Service Coordination
• Outreach

22
Feeling a little sick

• To cure a cough take a hair from the coughing
  person's head, put it between two slices of
  buttered bread, feed it to a dog, and say, "Eat
  well you hound, may you be sick and I be sound."

23
Chapter 148 Overview Application

• No longer Licensure rules
• Now standards of care that apply to all who
  provide substance abuse services.
• All substance abuse service providers must comply
  with section B
• All treatment providers must comply with B, D-N
• All prevention or interventions providers must
  comply with B and C

24
Chapter 148 Required of All Programs

• 148.201. General Standard.
• The provider shall provide adequate and
  appropriate services consistent with best
  practices and industry standards. The provider
  shall maintain objectivity. The provider shall
  respect each individual's dignity, and shall not
  engage in any action that may cause injury and
  shall always act with integrity in providing
  services.
• 148.202. Scope of Practice.
• The provider shall recognize the limitations of
  their ability and shall not offer services
  outside the provider's scope of practice or use
  techniques that exceed their professional
  competence.
• 148.203. Competence and Due Care.
• Providers shall plan, supervise adequately, and
  evaluate any activity for which they are
  responsible. Providers shall render services
  carefully and promptly. Providers shall follow
  the technical and ethical standards related to
  the provision of services, strive continually to
  improve personal competence and quality of
  service delivery, and discharge their
  professional responsibility to the best of their
  abilities. Providers are responsible for
  assessing the adequacy of their own competence
  for the responsibility to be assumed. Services
  shall be designed and administered as to do no
  harm to recipients. The provider shall always
  act in the best interest of the individual being
  served. The provider shall terminate any
  professional relationship that is not beneficial,
  or is in any way detrimental, to the individual
  being served.

25
Chapter 148 Required of All Programs

• 148.204. Appropriate Services.
• Services should be appropriate for the
  individual's needs and circumstances, including
  age and developmental level, and should be
  culturally sensitive.
• 148.205. Accuracy.
• The provider shall report information fairly,
  professionally, and accurately when providing
  services and when communicating with other
  professionals, the Commission, and the general
  public. Each provider shall document and assign
  credit to all contributing sources used in
  published material or public statements.
• 148.206. Documentation.
• The provider shall maintain required
  documentation of services provided and related
  transactions including financial records.
• 148.207. Discrimination.
• The provider shall not discriminate against any
  individual on the basis of gender, race,
  religion, age, national origin, disability
  (physical or mental), sexual orientation, medical
  condition, including HIV diagnosis or because an
  individual is perceived as being HIV infected.
  The provider may consider economic condition and
  financial resources in admission criteria, but
  economic condition shall not affect the services
  once an individual is admitted.

26
Chapter 148 Required of All Programs

• 148.208. Access to Services.
• The provider shall provide access to services,
  including providing information about other
  services and alternative providers, taking into
  account an individual's financial constraints and
  special needs.
• 148.209. Location.
• The provider shall not offer or provide services
  in settings or locations that are inappropriate
  or harmful to individuals served or others.
• 148.210. Confidentiality.
• The provider shall protect the privacy of
  individuals served and shall not disclose
  confidential information without express written
  consent, except as permitted by law. The
  provider shall remain knowledgeable of, and obey,
  all State and Federal laws and regulations
  relating to confidentiality of records relating
  to the provision of services. The provider shall
  not discuss or divulge information obtained in
  clinical or consulting relationships except in
  appropriate settings and for professional
  purposes that demonstrably relate to the case.
  Confidential information acquired during delivery
  of services shall be safeguarded from illegal or
  inappropriate use, access and disclosure or from
  loss, destruction or tampering. These safeguards
  shall protect against verbal disclosure, prevent
  unsecured maintenance of records, or recording of
  an activity or presentation without appropriate
  releases.
• 148.211. Environment.
• The provider shall provide an appropriate, safe,
  clean, and well-maintained environment.

27
Chapter 148 Required of All Programs

• 148.212. Communications.
• The provider shall inform the individual
  receiving services about all relevant and
  important aspects of the service relationship.
• 148.213. Exploitation.
• The provider shall not exploit relationships
  with individuals receiving services for personal
  or financial gain of the provider or its
  personnel. The provider shall not charge
  exorbitant or unreasonable fees for any service.
  The provider shall not pay or receive any
  commission, consideration, or benefit of any kind
  related to the referral of an individual for
  services.
• 148.214. Duty to Report.
• When a provider or its personnel have knowledge
  of unethical conduct or practice on the part of a
  person or provider, they have a responsibility to
  report the conduct or practices to appropriate
  funding or regulatory bodies or to the public.
  Any provider or provider personnel who receive an
  allegation or have reason to suspect that an
  individual has been, is, or will be subject to
  abuse, neglect or exploitation by any provider
  shall immediately inform TCADA's investigations
  division. The provider shall also take immediate
  action to prevent or stop the abuse, neglect, or
  exploitation and provide appropriate care and
  treatment. The provider shall report allegations
  of child abuse or neglect to the Texas Department
  of Protective and Regulatory Services as required
  by the Tex. Fam. Code Ann. 261.101 (Vernon 2002
  Supp. 2004). The provider shall report
  allegations of abuse, neglect or exploitation of
  elderly or disabled individuals to the Texas
  Department of Protective and Regulatory Services
  as required by the Tex. Hum. Res. Code Ann.
  48.051 (Vernon 2001 Supp. 2004). If the
  allegation involves sexual exploitation, the
  service provider shall comply with reporting
  requirements listed in the Tex. Civ. Prac. Rem.
  Code Ann. 81.006 (Vernon 1997 Supp. 2004).

28
Chapter 148 Required of All Programs

• 148.215. Impaired Providers.
• Providers should recognize the effect of
  impairment on professional performance and should
  be willing to seek needed treatment. Where there
  is evidence of impairment in a colleague, a
  provider should be supportive of assistance or
  treatment. An employer shall provide access to
  information regarding available services to
  impaired employees.
• 148.216. Ethics.
• Providers shall adhere to established
  professional codes of ethics. These codes of
  ethics define the professional context within
  which the provider works, in order to maintain
  professional standards and safeguard the client
  or participant. Provider and all of its
  personnel shall protect consumers and act in an
  ethical manner at all times.

29
Chapter 148 Required of All Programs

• 148.217. Specific Acts Prohibited.
• Providers shall not enter into a personal or
  business relationship of any type with an
  individual receiving services until at least two
  years after the last date an individual receives
  services from the provider.
• Providers shall not allow unqualified persons or
  entities to provide services.
• Provider shall not hire or utilize known sex
  offenders in adolescent programs or programs that
  house children.
• Providers shall prohibit adolescent clients and
  participants from using tobacco products on the
  program site. Staff and other adults (volunteers,
  clients, participants and visitors) shall not use
  tobacco products in the presence of adolescent
  clients or participants.

30
Chapter 148 Required of All Programs

• 148.218. Standards of Conduct.
• The facility and all of its personnel shall
  protect clients' rights and provide competent
  services.
• Any person associated with the facility that
  receives an allegation or has reason to suspect
  that a person associated with the facility has
  been, is, or will be engaged in illegal,
  unethical, or unprofessional conduct shall
  immediately inform the Commission's
  investigations division and the facility's chief
  executive officer or designee. If the allegation
  involves the chief executive officer, it shall be
  reported to the Commission and the facility's
  governing body.
• The facility and its personnel shall comply with
  Tex. Health Safety Code Ann. ch. 164 (Vernon
  2001 Supp. 2003)(relating to Treatment
  Facilities Marketing and Admission Practices).
• The facility shall have written policies on
  staff conduct that complies with this section.

31
Chapter 148 Prevention Requirements

• What evidenced based programs that addresses the
  listed criteria.
• Want family included
• Want input from stakeholders
• Want program evaluation

32
Chapter 148Licensure Information

• For new applicants must submit
• Application
• Operational Plan
• Policies and Procedures
• Proof of Liability Insurance
• Inspection will occur within 45 days
• Applying 60 days for inactive status- no services
  for 60 days retire license- can request inactive
  status, but only good for 60 days

33
Chapter 148 Facility Requirements

• 148.502 Operational Plan, Policies Procedures
• The facility shall operate according to an
  operational plan. The operational plan shall
  reflect
• program purpose or mission statement
• services and how they are provided
• description of the population to be served and
• goals and objectives of the program.
• The facility shall adopt and implement written
  policies and procedures as deemed necessary by
  the facility and as required herein. The
  policies and procedures shall contain sufficient
  detail to ensure compliance with all applicable
  Commission rules.
• The policy and procedure manual shall be current,
  consistent with program practices, individualized
  to the program, and easily accessible to all
  staff at all times.

34
Chapter 148 Facility Requirements

• 148.503. Reporting Measures
• Facilities shall submit the following information
  annually, electronically or in paper form, in a
  format provided by the Commission, unless a
  current contract with TCADA is in effect
• total number of clients served by diagnosis
• gender of clients served
• ethnicity of clients served
• ages of clients served
• primary and secondary drug at admission
• discharge reason per treatment episode, including
  length of stay at time of discharge and
• average percent of occupancy for each residential
  program.

35
Chapter 148 Facility Requirements

• 148.504. Quality Management.
• The facility shall develop procedures and
  implement a quality management process. The
  procedures shall address at a minimum
• goals and objectives that relate to the program
  purpose or mission statements
• methods to review the progress toward the goals
  and a documented process to implement corrections
  or changes
• a mechanism to review and analyze incident
  reports, monitor compliance with rules and other
  requirements, identify areas where quality is not
  optimal and procedures to analyze identified
  issues, implement corrections, and evaluate and
  monitor their ongoing effectiveness
• methods of utilization review to ensure
  appropriate client placement, adequacy of
  services provided and length of stay and
• documentation of the activities of the quality
  management process.

36
Dream a little Dream

• For a woman to dream of going to a hairdresser
  shows she will soon be entangled in some family
  scandal concerning the morals of a member of her
  family. Should she have her hair dyed, she will
  narrowly escape imprisonment.
• For a man to dream of a hairdresser will presage
  much gossip or a need to dominate a beautiful
  woman.

37
Chapter 148 Facility Requirements

• 148.505. General Environment.
• The facility shall have a certificate of
  occupancy from the local authority that reflects
  the current use by the occupant or documentation
  that the locality does not issue occupancy
  certificates.
• 148.507. General Documentation Requirements.
• Authentication of electronic records shall be by
  a digital authentication key.
• 148.508. Client Records.
• The facility shall protect all client records
  and other client-identifying information from
  destruction, loss, tampering, and unauthorized
  access, use or disclosure.
• (1) All active client records shall be stored
  at the facility. Inactive records, if stored
  off-site, shall be fully protected. All
  original client records shall be maintained in
  the State of Texas.
• (2) Information that identifies those seeking
  services shall be protected to the same degree
  as information that identifies clients.
• (3) Electronic client information shall be
  protected to the same degree as paper records
  and shall have a reliable backup system.
• Client records shall be maintained for at least
  six years. Records of adolescent clients shall be
  maintained for at least five years after the
  client turns 18.

38
Chapter 148 Facility Requirements

• 148.509. Incident Reporting
• All incident reports shall be stored in a
  single, separate file.
• The facility shall have a designated individual
  responsible for reviewing incident reports and
  all incidents should be evaluated through the
  quality management process to determine
  opportunities to improve or address program and
  staff performance.

39
Chapter 148 Personnel Practices

• 148.601. Hiring Practices.
• A facility whose personnel includes counselor
  interns shall be registered with the Commission
  as a clinical training institution and comply
  with all applicable requirements.
• The facility shall verify by Internet, telephone
  or letter and document the current status of all
  required credentials with the credentialing
  authority.
• The facility shall be aware of its obligations
  under Tex. Civ. Prac. Rem. Code Ann. 81.003.
  Reference Checks
• The facility shall obtain and assess the results
  of a criminal background check from the
  Department of Public Safety on all staff within
  four weeks of the hiring date. Individuals hired
  may not have any client contact until the results
  of the criminal background check are assessed.
  The facility shall use the criteria listed in
  Tex. Occ. Code Ann. 53.022, 53.023 (Vernon
  2004) to evaluate criminal history reports and
  make related employment decisions.
• The facility shall not hire an individual who has
  not passed a pre-employment drug test that meets
  criteria established by the Commission. The
  facility shall develop a job description which
  outlines job duties and minimum qualifications
  for all personnel.
• The facility shall maintain a personnel file for
  each employee, and all contractors, students and
  volunteers with any direct client contact which
  contains documentation demonstrating compliance
  with this section.

40
Chapter 148 Personnel Practices

• 148.603. Training.
• Prior to performing their duties and
  responsibilities, the facility shall provide
  orientation to staff, volunteers, and students.
  This orientation shall include information
  addressing
• TCADA rules
• facility policies and procedures
• client rights
• client grievance procedures
• confidentiality of client-identifying information
  (42 C.F.R. pt. 2 HIPAA)
• standards of conduct and
• emergency and evacuation procedures.

41
Chapter 148 Personnel Practices

• Training Continued
• The following initial training must be received
  within the first 90 days of employment and must
  be completed before the employee can perform a
  function to which the specific training is
  applicable. Subsequent training must be
  completed as specified.
• (1) Abuse, Neglect, and Exploitation.
• (2) HIV, Hepatitis B and C, Tuberculosis and
  Sexually Transmitted Diseases.
• (3) Cardio Pulmonary Resuscitation (CPR)
• (4) Nonviolent Crisis Intervention.
• (5) Restraint and/or Seclusion.
• (6) Intake, Screening and Admission
  Authorization.
• (7) Self-administration of Medication.

42
More dreams.

• To dream of a monkey denotes that you have
  deceitful friends who will flatter you to advance
  their own interests.

43
Chapter 148 Client Rights

• 148.701 Bill of Rights
• Revised and includes residential
• No changes to Client Grievance
• No changes to Abuse, Neglect Exploitation
• No change to Program Rules
• 148.705 Client Labor
• No client labor allowed, falls under
  relationships clause
• No Changes to Restraint and Seclusion
• No changes to Responding to Emergencies
• 148.708 Searches
• Clarified that must be documented in client file.

44
Chapter 148 Screening Assessment

• 148.801 Screening
• DSM-IV
• TDI Placement Criteria
• Financial Resources Insurance
• Validated Assessment Instruments
• Documentation to Justify-Supported
• LVN can do detox screening w/ conditions

45
Chapter 148 Screening Assessment

• 148.802 Admission Consent
• Consolidation of consent and orientation

46
Chapter 148 Screening Assessment

• 148.803 Assessment
• Comprehensive Psychosocial Assessment

47
Chapter 148 Screening Assessment

• 148.804 Treatment Planning
• Discharge on TP, use TDI criteria, but
  individualize
• Projected length of stay
• No change to reviews
• Transfers must be justified
• No change to progress notes

48
Chapter 148 Screening Assessment

• 148.805 Discharge
• Individualized discharge plan
• Updated as client progresses through treatment
• Address continuity of services
• No changes to written plan design
• Clarification on follow-up, no sooner than 60 and
  no later than 90 upon DC from FACILITY, not
  program.

49
Chapter 148 Treatment Program Services

• 148.901 Requirements for All Treatment Providers
• Follow written curriculum
• Education must include client participation
• Education related to HIV, STD, TB Hep
• Education related to nicotine addition and
  tobacco
• Access to screening and testing and referral if
  positive
• Maintain and adequate number of staff
• Residential- one counselor 8 hours, six days a
  week
• Director QCC, 2 years post licensure experience
• 148.902 Requirements for Detoxification Programs
• Medical Director or designee shall approve all
  medical policies, guideline, tools and medical
  content of all forms
• Detox training requirements
• Screening instrument recommendation
• Specifies required counseling
• Documentation requirement for crisis
  stabilization

50
Chapter 148 Treatment Program Services

• 148.903 Requirements for Residential Programs
• Intensive Residential- 30 hours of counseling (10
  CD counseling, 10additional counseling 10
  planned, structured activities monitored by
  staff.)
• 116 day and 132 night
• Counselor caseloads can not exceed ten
• Supportive Residential- 6 hours per week ( three
  CD counseling- one individual per month and three
  of additional counseling)
• 120 day and 150 night
• Program sets caseload limit
• 148.904 Requirements for Outpatient Programs
• Ensure access to full continuum of care
• Intensity appropriate to client needs

51
Chapter 148 Treatment Program Services

• 148.905 Requirements for Adolescent Programs
• Provide education within 3 days if admission
  expected to last beyond 14 days.
• 15 hours of planned structured activities
  (includes school)
• 18 day and 116 night
• Involve family
• Training requirement

52
Chapter 148 COSPD

• 148.906 Access to services
• May not include the following in determining
  eligibility for any service
• Mental Illness
• Medications
• Presumption of inability to benefit
• Success of prior episodes
• If a client refuses a service, this can not
  preclude them from accessing other MH and CD
  services
• Establish and implement procedures to ensure
  continuity between screening, assessment,
  treatment and referral services.

53
Chapter 148 COSPD

• 148.907 Additional requirements for programs
• Address both MH and CD
• Best Practices
• Facilitate accessing services they need and
  choose
• Provided by competent staff (as defined in
  148.908)
• 148.909 Competencies for staff
• Staff must demonstrate competencies within 90
  days
• Knowledge Competencies
• Technical Competencies
• Interpersonal Competencies

54
Chapter 148 COSPD

• 148.909 Treatment Planning
• Identify services
• Measurable outcomes
• Family members need for education and support
  services
• Facilitation of families education and support
  services
• Client and family (if requested) get a copy of
  treatment plan

55
Chapter 148 Women and Children

• 148.910 Treatment Services for Women and Children
• Has been significantly condensed
• Requirements related to minimum standards for
  child care centers (www.tdprs.state.tx.us)
• Adoption of rules related to child care

56
Chapter 148 Electronic Services (Internet
Therapy)

• 148.911 Treatment Services Provided by Electronic
  Means
• May only be outpatient services
• Adults only
• QCC Only
• Verification of client required
• Security as detailed in HIPAA required
• Transfer of info using 128 bit-encryption
• No e-mail with client identification
• Toll-free number for technical support

57
Chapter 148 Electronic Services (Internet
Therapy)

• Contingency plan for problems
• Description of all services
• Referral for those who do not meet criteria
• Grievance procedure
• Provide potential risks to client
• Emergency contact for client
• Program reside and performed in Texas
• Make ADA accommodation

58
Chapter 148 Food and Nutrition

• No significant changes
• Each dose of prescription and OTC medication must
  be recorded in client record

59
Chapter 148 Food and Nutrition

• No significant changes

60
Chapter 148 Physical Plant

• 148.1202 Inspections
• annual inspection by the local certified fire
  inspector or the State fire marshal
• annual inspection of the alarm system by the fire
  marshal or an inspector authorized to install and
  inspect such systems
• annual kitchen inspection by the local health
  authority or the Texas Department of Health
• gas pipe pressure test once every three years by
  the local gas company or a licensed plumber
• annual inspection and maintenance of fire
  extinguishers by personnel licensed or certified
  to perform those duties and
• annual inspection of liquefied petroleum gas
  systems by an inspector certified by the Texas
  Railroad Commission.

61
Chapter 148 Physical Plant

• 148.1205 Space, Furniture and Supplies
• 80 usable square feet per individual in
  single-occupancy rooms
• 60 usable square feet per individual in
  multiple-occupancy rooms (or 50 square feet per
  individual if bunk beds are used) and
• 40 usable square feet for each child 18 months
  and older and 30 usable square feet per infant
  under 18 months.
• 148.1206 Fire Systems
• A fire detection, alarm, and communication system
  required for life safety shall be installed,
  tested, and maintained in accordance with the
  facility's occupancy and capacity
  classifications.

62
Chapter 148 Court Commitment

• No significant changes to this section

63
Chapter 148 Therapeutic Communities

• A TC methodology to treatment is distinguished
  from other models of care by the following
• TCs are highly structured residential programs
  intended to treat criminal and antisocial
  behaviors occurring with substance abuse or
  dependence.
• This model views recovery from these disorders as
  a developmental learning process in which the
  social and psychological characteristics of the
  client must be changed to one of "right living"
  and the client must adopt appropriate morals and
  values promoted by the program as opposed to
  solely recovering from an illness.
• The model utilizes the community itself and TC
  specific group-type meetings as the primary
  modality of change. Confrontation amongst clients
  regarding their behaviors, a carefully
  orchestrated consequence-reward system and
  hierarchical privilege system are the primary
  approaches utilized instead of the counseling and
  therapy utilized in other models of treatment.
• Counselors act primarily as role models and
  rational authorities rather than as counselors or
  therapists.
• The model expects the client length of stay to be
  a minimum of 90 days in order to achieve positive
  outcomes.
• The program is divided into 3 phases The
  Orientation Phase (Information Dissemination),
  Primary Treatment Phase (Personal Application),
  and Re-Entry/Relapse Prevention Phase (Social
  Application).

64
Chapter 148 Therapeutic Communities

• Treatment programs using the TC methodology are
  required to comply with Screening and Assessment
• If the comprehensive psychosocial assessment
  identifies a potential mental health problem, the
  program shall arrange for the client to obtain a
  mental health evaluation by a Qualified Mental
  Health Professional.
• If the mental health evaluation reflects the
  client currently has a diagnosis, or has been
  diagnosed during the last year with an Axis I
  diagnosis or post traumatic stress disorder,
  and/or moderate to severe mental retardation, the
  program shall obtain written authorization from a
  licensed psychiatrist or licensed physician
  experienced in treating chemical dependency, for
  the client to receive TC treatment services prior
  to providing TC program services.
• A QCC, with at least one year documented
  experience in treating individuals with mental
  illness, shall act as the primary counselor and
  confer at least monthly with the authorizing
  psychiatrist or physician.
• The client shall voluntarily agree to participate
  in the TC program.
• If the client is pregnant at the time of
  admission, the program shall obtain written
  authorization from a licensed physician for the
  client to receive TC treatment services prior to
  providing TC program services. If the pregnancy
  is determined after admission, the program shall
  obtain written authorization from a licensed
  physician for the client to receive TC treatment
  services.
• A physician or physician assistant shall monitor
  the pregnant clients response to treatment at
  least monthly or more often as needed.

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Chapter 148 Therapeutic Communities

• The TC Program shall ensure that all staff
  receive training in the TC methodology. All
  staff members shall receive 16 hours of training
  in TC theory, TC methods, and TC intervention
  techniques. This training is in addition to the
  applicable training requirements outlined in
  148.603 of this title (relating to Training),
  and must take place within the first ninety days
  of employment.
• Intensive residential TC programs shall provide a
  minimum of 20 hours of services per week, which
  shall include
• Six hours of counseling (which shall include two
  hours of individual counseling per month)
• Six hours of additional counseling, CD education,
  and life skills training and
• Eight hours of TC groups, such as cognitive
  restructuring, AM/PM development, and
  encounter-confrontation groups. A counselor
  shall be present to supervise or monitor the
  activity and maintain structure in the TC groups.
• In addition to the 20 hours outlined above, the
  program shall provide ten additional hours of
  peer driven activities, such as community
  meetings, house meetings, peer support,
  recreation, seminars, and self help groups.
• Attendance shall be documented for peer driven
  activities. Documentation shall contain date,
  duration and type of activity. There is no size
  limitation or staffing requirement for peer
  driven activities.
• Ten hours of the above services shall be in
  provided in the evenings and on weekends.

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Chapter 148 Therapeutic Communities

• Adult Supportive TC Residential Programs shall
  provide at least six hours of treatment services
  per week for each client, comprised of at least
• two hours of chemical dependency counseling (one
  hour per month of which shall be individual
  counseling)
• two hours of additional counseling, chemical
  dependency education, and life skills training
  and
• two hours of TC groups such as cognitive
  restructuring, AM/PM development, and encounter-
  confrontation groups. A counselor shall be
  present to supervise or monitor the activity and
  maintain structure in the TC groups.
• Group counseling size is limited to 16 clients.
  Chemical dependency education and life skills
  classes are limited to 35 clients.
• The TC program shall set limits on counselor
  caseload size that ensures effective,
  individualized treatment. The TC program shall
  justify the caseload size in writing based on the
  program design, characteristics and needs of the
  population served, and the minimum client service
  hours as indicated in this section.

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Chapter 148 Therapeutic Communities

• In intensive residential TC programs the direct
  care staff to client ratio shall be 116 while
  awake and 132 during sleeping hours.
• In supportive residential TC programs the direct
  care staff to client ratio shall be 120 while
  awake and 150 during sleeping hours.
• In addition to the other requirements of this
  subchapter, the TC programs policy and procedure
  manual shall contain the following
• written program description explaining how the
  therapeutic community functions
• program structure, including rules, methods, and
  service schedule
• overview of the TC treatment process
• description of consequences and rewards system
  and
• policy stating that interventions are not used as
  punishment and that access to medical and
  psychiatric care will not be denied.

68
Chapter 148 Faith Based Programs

• No significant changes other than moved from its
  own chapter to Standards of Care.

69
September 2004

• Welcome State Health Services
• Licensing
• Audit
• Investigation

70
HHSC Organizational Chart6/15/2004