Section 2.
Clinically Managed Residential Withdrawal Management.
(1) In addition to the licensing requirements
of
908
KAR 1:370, a program offering clinically managed
residential withdrawal management shall accept and provide services only to
clients meeting the:
(a) Diagnostic criteria
for substance-related disorder as established by the most recent version of the
Diagnostic and Statistical Manual of Mental Disorders (DSM) for alcohol,
tobacco, and other drug use; and
(b) Dimensional criteria for clinically
managed residential withdrawal management as established in the most recent
version of The American Society of Addiction Medicine (ASAM)
Criteria.
(2) Clinically
managed residential withdrawal management services shall:
(a) Be delivered by staff who:
1. Are qualified to meet the needs of
clients; and
2. Provide twenty-four
(24) hour supervision, observation, and support for clients who are intoxicated
or experiencing withdrawal;
(b) Include care for clients whose
intoxication and withdrawal signs and symptoms require twenty-four (24) hour
structure and support without the need for medically monitored inpatient
withdrawal management services; and
(c) Include:
1. Use of established clinical protocols to
identify clients who are in need of:
a.
Medical services beyond the capacity of the facility; and
b. Transfer to an appropriate level of
care;
2. Availability of
specialized clinical consultation and supervision for biomedical, emotional,
behavioral, and cognitive problems;
3. Protocols that shall be developed and
supported by a physician knowledgeable in addiction medicine for use in
determining the nature of any medical or nursing interventions required if a
client's condition deteriorates and the client appears to need the care of a
physician or nurse;
4. Availability
of medical evaluation and consultation twenty-four (24) hours per
day;
5. Affiliation with other
levels of care; and
6. Ability to
arrange for appropriate laboratory and toxicology tests.
(3) Staff shall include clinical
staff trained and competent to implement physician-approved protocols for:
(a) Patient observation and
supervision;
(b) Determination of
appropriate level of care; and
(c)
Facilitation of the client's transition to continuing care.
(4) Each clinician who is
responsible for assessing and treating clients shall be able to obtain and
interpret information regarding the needs of the clients, including:
(a) The signs and symptoms of alcohol and
other drug intoxication and withdrawal;
(b) Appropriate treatment and monitoring of
intoxication and withdrawal; and
(c) How to facilitate entry into ongoing
care.
(5) A program
providing clinically managed residential withdrawal management that supervises
self-administration of medication shall have written policies and procedures on
the steps involved for self-administration, including:
(a) Identification in the client record of
medication that requires physician approval prior to use; and
(b) The name of the staff person who
monitored the self-administration of the medication.
(6) Therapies offered by a program providing
clinically managed residential withdrawal management shall include:
(a) Daily clinical services to assess and
address the needs of each client, including the following if needed:
1. Medical services, including:
a. Medically assisted withdrawal;
or
b. Medication assisted treatment,
provided onsite or through referral;
2. Individual counseling;
3. Group counseling; or
4. Withdrawal support;
(b) A range of cognitive, behavioral,
medical, mental health, and other therapies as needed to enhance a client's
understanding of:
1. Addiction;
2. Co-occurring disorders;
3. Completion of the withdrawal management
process; and
4. Referral to an
appropriate level of care for continuing treatment;
(c) Withdrawal rating scale tables and flow
sheets that include tabulation of vital signs if needed;
(d) Interdisciplinary individualized
assessment and treatment;
(e)
Health education services; and
(f)
Services to families and significant others.
(7) Elements of the assessment and treatment
planning shall include:
(a) An individualized
treatment plan established in accordance with
908
KAR 1:370, Section 19, including:
1. Problem identification in dimensions two
(2) through six (6) of the most recent version of the ASAM criteria;
2. Development of treatment goals and
measurable treatment objectives; and
3. Activities designed to meet the treatment
objectives and management of withdrawal symptoms;
(b) Daily assessment of:
1. Progress during withdrawal management;
and
2. Any treatment
changes;
(c) Transfer
and discharge planning, beginning at the point of admission; and
(d) Referral and linkage arrangements for:
1. Counseling;
2. Medical care, including medication
assisted treatment if not provided onsite;
3. Psychiatric care; and
4. Continuing care.
(8) Progress notes shall:
(a) Be maintained in the client record in
accordance with
908
KAR 1:370, Section 17(4)(h);
(b) Reflect implementation of the treatment
plan;
(c) Document the client's
response to treatment; and
(d)
Include each amendment of the treatment plan.
(9) A client shall continue with clinically
managed residential withdrawal management until:
(a) Withdrawal signs and symptoms are
sufficiently resolved so that the client can be safely managed at a less
intensive level of care;
(b) The
client's signs and symptoms of withdrawal have:
1. Failed to respond to treatment;
or
2. Intensified so that transfer
to a more intensive level of withdrawal management is indicated; or
(c) The client is unable to
complete clinically managed residential withdrawal management despite an
adequate trial, due to increasing depression, suicidal impulses, or other
severe complication.
Section 3. General Residential Treatment
Programs.
(1) In addition to the licensing
requirements in
908
KAR 1:370, a residential treatment program:
(a) Shall evaluate the client's need for each
of the following at admission:
1. Alcohol and
other drug abuse services;
2.
Employment services;
3. Vocational
education, training, or rehabilitation services;
4. Disability services;
5. Other health and human services;
and
6. Assistance in developing
daily living skills;
(b)
Shall establish and implement a policy for off-site supervision and
transportation of clients to services provided outside of the facility, which
shall:
1. Indicate the method of
transportation;
2. Address the
security and accountability for each client and his or her personal
possessions;
3. Address the
transfer of client information to and from the provider of services;
4. Ensure that a copy of current registration
and current insurance information is maintained on file for each vehicle used
to transport clients;
5. Ensure
that the name of each driver responsible for transporting clients is maintained
on file;
6. Identify the employee
who accompanies the client, if appropriate; and
7. Identify the destination for each client;
and
(c) May provide
clinically managed residential withdrawal management as established in Section
2 of this administrative regulation.
(2) A residential treatment program shall
provide each client with education regarding:
(a) The disease of addiction;
(b) The client's diagnosis;
(c) The effects of alcohol and other drug
abuse;
(d) The risks of exposure to
human immunodeficiency virus (HIV), hepatitis, and other health consequences of
substance use disorder;
(e) Family
issues related to substance use disorder;
(f) Recovery support groups specific to
addiction recovery;
(g) Medication
assisted treatment; and
(h)
Understanding the interactions between mental health and addiction, including
the most common types of co-occurring disorders.
(3) Information or education about alcohol
and other drug abuse, including recovery shall be made available to a client's
family or significant other.
(4) A
client shall have access to printed materials, appropriate to the client's
literacy level, and audio and video materials that are:
(a) Presented multi-lingually on the basis of
client composition of the facility; and
(b) Related to the treatment of alcohol and
other drug abuse.
(5) A
residential treatment program client shall receive at least six (6) hours each
day in structured activities, including participation in any of the following
activities:
(a) Alcohol and other drug abuse
education;
(b) Individual, group,
or family counseling in which the client shall participate a minimum of ten
(10) hours each week;
(c) On-site
or off-site recovery support meetings;
(d) Life skills training;
(e) Vocational training or an educational
activity; or
(f)
Recreation.
(6) If
counseling is provided in a group, there shall be a maximum of twelve (12)
clients per clinician.
(7)
(a) A residential treatment program shall
provide a planned, diversified program of organized recreational activities
that allow clients to participate on an individual or group basis as specified
in the client treatment plan and coordinated with other client care
services.
(b) Recreational
activities shall be provided under the direction of staff as part of the
client's schedule.
(8)
(a) Progress notes shall be recorded in the
client's record following the delivery of a clinical service or individual
counseling session and shall include:
1. The
type of service provided, including the:
a.
Date of the service; and
b. Length
of the service;
2. A
description of the client's response to the service; and
3. Clinical impressions including the
clinician's assessment of the client's progress or lack of progress toward
achieving the objectives established in the treatment plan.
(b) In addition to paragraph (a)
of this subsection, a progress note shall be made each week to document the
client's progress in:
1. Employment;
2. Pursuing employment;
3. Participation in vocational education,
training, or rehabilitation activities;
4. Participation in recovery support
groups;
5. Training in daily living
and recovery supports; and
6.
Following through on referrals to services, if needed.
(9) A written recovery plan shall
be:
(a) Developed by the client and the
treatment team to identify and promote aspects of continuing care for substance
use disorder that are associated with success in recovery;
(b) Provided to the client after he or she
has achieved the initial stabilization goals of treatment; and
(c) Based on the client's needs at discharge,
including activities and any referrals to support recovery.
(10) A discharge summary shall be completed
within thirty (30) calendar days of discharge, including the client's:
(a) Date of admission;
(b) Date of discharge;
(c) Presenting problem;
(d) Evaluation of alcohol and other drug
abuse or dependency;
(e) Summary of
treatment;
(f) Response to
treatment;
(g) Referrals made to
other organizations or providers; and
(h) Reason for discharge.
(11) Other than a personal care or
housekeeping task, if a client performs work in the residential treatment
program that is part of a therapeutic activity, the work shall be voluntary and
consistent with the treatment plan.
(12) A residential treatment program shall
have written policies and procedures on the use of medication, including:
(a) Documentation in the client record of any
medications the client is currently prescribed and taking;
(b) Documentation in the client record of any
over-the-counter medication the client is taking;
(c) Steps involved for self-administration of
over-the-counter medication, including identification in the client record of
medication that requires physician approval prior to use;
(d) Documentation that any medications
brought into the facility by a resident are not administered or allowed to be
self-administered unless the medication has been identified and a written order
to administer or allow for self-administration of the specific drug is given by
the responsible prescribing practitioner;
(e) Documentation of the physician's
verification in the client's record;
(f) Storage of all medications to ensure that
all medications be kept in a locked, secure location inaccessible to
clients;
(g) Administration of
medication, including establishment of the times for administration of
medication;
(h) Documentation in
the client's record of self-administration of prescription or over-the-counter
medication, including the:
1. Name of the
medication;
2. Date and time of
self-administration;
3. Dosage and
amount of medication; and
4. Name
of the staff person who monitored the self-administration of the
medication.
(13) A residential treatment program shall
have a first-aid kit with supplies necessary for use in responding to minor
injury or illness.
(14)
(a) If the program prepares meals on-site for
a client, food services shall be provided in accordance with
902 KAR
45:005.
(b) A copy of the food service permit shall
be maintained on site.
(c) There
shall be documentation that meal planning is approved by a registered
dietician.
(d) If clients prepare
their own meals on-site or are otherwise responsible for their meals, a food
service permit shall not be required.
(e) Drinking water shall be freely available
throughout the day, including mealtime.
(15) A residential treatment program shall be
staffed twenty-four (24) hours per day, seven (7) days per week and have:
(a) A program manager, supervisor, or
coordinator, including a designated staff person responsible for managing a
program in the absence of the manager, supervisor, or coordinator;
(b) A sufficient number of personnel to meet
client needs based on the:
1. Number of
clients;
2. Need for assistance;
and
3. Services delivered;
and
(c) At least one (1)
staff person on duty and awake at all times who is trained in:
1. Crisis intervention;
2. Cardiopulmonary resuscitation;
and
3. Standard first
aid.
(16) A
residential treatment program shall ensure that in addition to the clients'
rights established by
908
KAR 1:370, Section 16, the following clients' rights
shall be fully protected:
(a) The right to
visitation with family and friends, subject to written visiting rules and hours
established by the program, except as provided in subsections (17) and (18) of
this section;
(b) The right to
conduct private telephone conversations, subject to written rules and hours
established by the program, except as provided in subsections (17) and (18) of
this section;
(c) The right to send
and receive uncensored and unopened mail;
(d) The right to wear his or her own clothing
subject to written program rules;
(e) The right to bring personal belongings,
subject to limitation or supervision by the program;
(f) The right to communicate with his or her
personal physician; and
(g) The
right to practice his or her personal religion or attend religious services,
within the program's policies and written policies for attendance at outside
religious services.
(17)
The administrator, program manager, or designee may impose limitations on any
of the visitation or phone call procedures if limitations are:
(a) Therapeutically necessary; and
(b) Recorded in the client's
record.
(18) The
residential treatment program may require the client to open mail or packages
in the presence of program staff for inspection.
(19) If more than one (1) type of residential
AODE program operates in the same facility, staff may provide services in each
program.
Section 5. Residential Transitional Living
Program.
(1) In addition to the licensing
requirements of
908
KAR 1:370, a residential transitional living program
that provides counseling services on-site shall:
(a) Comply with the requirements established
for general residential treatment programs in Section 3(1), (6), and (8) to
(17) of this administrative regulation;
(b) Ensure that each client participates in
counseling and planned clinical program activities a minimum of five (5) hours
per week. Client participation in any combination of individual, group, or
family counseling shall be scheduled for no less than two (2) of the five (5)
hours of weekly program activities; and
(c) Enable each client to attend recovery
support meetings.
(2) A
residential transitional living program that does not provide counseling
services on-site shall:
(a) Comply with the
requirements established for general residential treatment programs in Section
3(1)(a) and (b) and (d) through (f), and (8) through (17) of this
administrative regulation;
(b)
Ensure that a comprehensive biopsychosocial assessment is obtained on behalf of
the client;
(c) Ensure that each
client participates in counseling and planned clinical program activities a
minimum of five (5) hours per week. Client participation in any combination of
individual, group, or family counseling shall be scheduled for no less than two
(2) of the five (5) hours of weekly program activities;
(d) Enable each client to attend recovery
support meetings;
(e) Have a
program manager who may be responsible for more than one (1) facility and
shall:
1. Be responsible for the day-to-day
management of the program, including:
a.
Supervising caseworkers; and
b.
Monitoring the implementation of program policies and procedures;
2. Complete training in accordance
with
908
KAR 1:370, Section 10(1); and
3. Meet the education and experience
requirements of a clinical services supervisor in accordance with
908
KAR 1:370, Section 10(3), or have at least a
bachelor's degree from an accredited college or university, in addition to:
a. 4,000 hours of work experience in the
alcohol and other drug treatment field post degree; and
b. Eighty (80) hours of alcohol and other
drug abuse training within four (4) years immediately prior to the date of
assuming responsibility as a program manager or no longer than two (2) years
immediately after assuming responsibility as a program manager;
(f) Have sufficient
staff to ensure that a staff person that meets the minimum requirements of a
program manager is responsible for managing a program in the absence of the
program manager; and
(g) Have
caseworkers who:
1. Shall be responsible for:
a. Coordinating clinical services in
accordance with a client's treatment plan;
b. Monitoring a client's progress in relation
to the treatment plan;
c.
Conducting training on daily living and recovery supports; and
d. Making referrals; and
2. Meet the training, education, and
experience requirements of
908
KAR 1:370, Section 11(2) to (5).
Section 6. Adolescent
Residential Treatment Program.
(1) An
adolescent residential treatment program shall be a freestanding residential
facility or a distinct part of a facility in which care is provided to two (2)
or more adolescent clients who are:
(a) Under
eighteen (18) years of age; or
(b)
Eighteen (18) to twenty-one (21) years of age, if placement in an adolescent
program is determined to be the appropriate level of care upon completion of
the assessment described by
908
KAR 1:370, Section 18(1) and (2).
(2) In addition to the requirements of
908
KAR 1:370 and Section 3 of this administrative
regulation, an adolescent residential treatment program:
(a) Shall admit adolescents only to areas
within the facility approved by the cabinet for adolescent occupancy;
(b) Shall ensure that areas for adolescents
are physically separated from any part of a facility occupied by or accessible
to adult clients;
(c) Shall ensure
that adolescent clients in the facility be separated if the age range is more
than five (5) years;
(d) Shall have
no fewer than two (2) staff members present and on site at all times:
(e) Shall have at least one (1) staff member
within sight and sound and responsible for the supervision of no more than:
1. Ten (10) adolescent clients during waking
hours; and
2. Twenty (20)
adolescent clients during sleeping hours;
(f) Shall provide or coordinate the provision
of educational services; and
(g)
May provide clinically managed residential withdrawal management as established
in Section 2 of this administrative regulation.
(3) An adolescent residential treatment
program shall:
(a) Make every effort to
identify the resident's family dynamics, including family structure and
patterns of relating, or interactions between family members;
(b) Engage and include the family in the
resident's treatment as early as possible in accordance with
908
KAR 1:370, Section 9(9);
(c) Provide single family therapy,
multi-family group therapy, and parental education sessions as clinically
appropriate and as specified in the client's treatment plan;
(d) Assist the resident in developing a
support system to help reinforce behavioral gains made during treatment;
and
(e) Provide ongoing support
with an emphasis on recovery supports.
(4) Educational services shall be provided
by:
(a) The local school district in which the
facility is located;
(b) An
accredited private educational institution in the community; or
(c) An on-site school that:
1. Is operated by the facility and approved
by the Kentucky Department of Education;
2. Is designed to maintain the educational
and intellectual development of the adolescent;
3. If indicated, provides opportunities to
remedy deficits in the educational level of an adolescent who has fallen behind
as a result of involvement with substance use; and
4. Includes at least three (3) hours of
instruction on days that education services are provided.
(5) Regardless of the method by
which the educational services are delivered to clients, staff of the
adolescent residential treatment program shall:
(a) Confer with teachers or their principals
on the progress of each client; and
(b) If appropriate, encourage clients to
become active in extracurricular school activities and make arrangements
necessary to enable the client to participate.
(6) The adolescent residential treatment
program shall ensure that any adolescent who legally is not attending school
participates in a training program that provides:
(a) Necessary life skills;
(b) Vocational training; and
(c) Training on methods of job
acquisition.
(7) Each
resident shall be limited to no more than two (2) hours of entertainment-based
screen time per day.
(8) Structured
activities shall be developmentally appropriate to the resident.
(9) Food shall be served to residents in a
common eating area and shall:
(a) Include at
least three (3) meals per day, served with not more than a fifteen (15) hour
span between the substantial evening meal and breakfast;
(b) Include between-meal and unscheduled
snacks;
(c) Not be withheld as
punishment and shall not be used as a reward;
(d) Take into account the special dietary
needs and tastes of residents, such as diabetes and allergies;
(e) Be served in an amount appropriate to the
age of the resident and include second servings, if requested; and
(f) Not be served while viewing television or
using electronics.
(10)
The following practices shall be expressly forbidden:
(a) Corporal punishment;
(b) Use of restraints of any sort;
(c) Use of a behavior management room;
and
(d) Sanctions that include
verbal, mental, or physical abuse.
(11)
(a)
Computer and internet usage shall be monitored.
(b) Blocking software or other controls shall
be used to restrict access to inappropriate web sites.
(12) A resident shall receive assistance with
personal care and hygiene based upon his or her developmental skills.
Section 8. Physical Environment.
(1) Each type of residential AODE program
shall:
(a) Comply with building codes,
ordinances, and administrative regulations that are enforced by city, county,
or state jurisdictions;
(b) Be
approved by the State Fire Marshal's office:
1. Prior to initial licensure; or
2. If the AODE changes locations;
(c) Within the program's total
square footage, have at least 120 square feet of space for each client residing
in the facility;
(d) Have at least
one (1) toilet and one (1) sink per eight (8) clients;
(e) Have at least one (1) shower or tub per
fifteen (15) clients;
(f) Provide
space for a client to store clothing, linens, and personal belongings,
including a receptacle that may be locked for the storage of personal property;
and
(g) Have separate rooms for the
following:
1. Sleeping;
2. Dining;
3. Bathing and toileting;
4. Living and recreation;
5. Laundry;
6. Visiting; and
7. Private consultation and counseling, which
shall be conducted in an area where a client is assured privacy and
confidentiality.
(2) A client's bed shall have:
(a) A clean mattress; and
(b) Two (2) sheets, a pillow, and bed
covering of sufficient quality to maintain resident comfort.
(3) The premises shall be well
kept and in good repair and meet the following requirements:
(a) The facility shall ensure that the
grounds are well kept and the exterior of the building, including the
sidewalks, steps, porches, ramps, and fences are in good repair;
(b) The interior of the building including
walls, ceilings, floors, windows, window coverings, doors, plumbing, and
electrical fixtures shall be in good repair; and
(c) Garbage and trash shall be stored in
areas separate from those used for the preparation and storage of food and
shall be removed from the premises regularly.
Section 9. Client Care Environment.
(1) Each type of residential AODE program
shall meet the following housekeeping and sanitation conditions and implement
policies that reflect the following:
(a) The
facility and its contents shall be clean to sight and touch and free of dirt
and debris;
(b) All rooms shall be
free of condensation, mold growth, and noxious odors;
(c) All equipment and materials necessary for
cleaning, disinfecting, and sterilizing shall be available in the facility at
all times, except as provided in subsection (3)(b) of this section;
(d) Thermometers, which are accurate to
within three (3) degrees Fahrenheit shall be kept in a visible location in
refrigerators, freezers, and storerooms used for perishable and other items
subject to deterioration;
(e)
Articles in storage shall be elevated from the floor and away from walls,
ceilings, and air vents;
(f) Aisles
in storage areas shall be kept unobstructed;
(g) Pest control methods that are safe for
clients and staff shall be used to:
1.
Minimize and eliminate the presence of rodents, flies, roaches, and other
vermin in the facility; and
2.
Prevent the breeding, harborage, or feeding of vermin;
(h) All openings to the outer air shall be
effectively protected against the entrance of insects and other
vermin;
(i) Toilet tissue, soap,
and disposable towels or air driers shall be provided in each bathroom at all
times, with soap and disposable towels or air driers provided at each hand
washing sink;
(j) Bathrooms with
multiple hand washing sinks shall provide at least one (1) soap dispenser and
one (1) disposable towel dispenser or air drier for every two hand washing
sinks;
(k) Except as provided in
paragraph (j) of this subsection, a soap dispenser and towel dispenser shall be
provided by each hand washing sink and utility sink throughout the
facility;
(l) Mattresses, pillows,
blankets, draperies, upholstery, and other fabrics or decorations shall be
fire-resistant and flameproof;
(m)
Latex foam pillows shall be prohibited;
(n) Equipment requiring drainage shall be
drained to a sanitary connection;
(o) The temperature within client areas of
the facility shall:
1. Be maintained at a
minimum of seventy-two (72) degrees Fahrenheit; and
2. Not exceed eighty-two (82) degrees
Fahrenheit;
(p) The
facility shall maintain adequate ventilation in all areas used by clients;
and
(q) The facility shall
establish a written heat emergency action plan to be implemented if the indoor
air temperature is eighty-two (82) degrees Fahrenheit or higher for four (4)
consecutive hours.
(2)
Each type of residential AODE program shall meet the following safety
conditions and implement policies that reflect the following:
(a) Non-skid wax shall be used on all waxed
floors;
(b) Throw rugs or scatter
rugs shall not be used;
(c) All
equipment shall be located in an unobstructed space that has been provided for
operation;
(d) All household and
cleaning products in the facility shall be identified, labeled, and securely
stored in a cabinet, closet, or room that is inaccessible to clients;
(e) All furnishings shall be clean and in
good repair, and mechanical equipment shall be in good working order;
and
(f) All smoke detectors shall
be fully operational.
(3) Each family residential program shall
meet the following safety conditions in addition to the provisions set forth in
subsections (1) and (2) of this section:
(a)
Children shall not be exposed to lead-based paint hazards;
(b) Toxic chemicals, including cleaning
agents shall be stored in locked cabinets or enclosed in areas not accessible
to the children;
(c) All electrical
outlets shall have protective covers;
(d) All fluorescent and incandescent light
bulbs shall have protective covers or shields;
(e) All windows and other glass surfaces that
are not made of safety glass and that are located three (3) feet above the
floor or lower shall have protective guards;
(f) Non-permanent safety barriers shall be
installed if the facility has stairs, ramps, balconies, porches, or elevated
play areas;
(g) Materials and
furniture for indoor and outdoor use shall be of sturdy and safe construction,
be easy to clean and free of hazards;
(h) Children shall be kept away from hot
stoves, irons and ironing boards, knives, glassware and other equipment within
the facility that may cause injury;
(i) Poisons, insect traps, rodent traps, and
similar products shall be kept out of reach of children; and
(j) All indoor and outdoor areas are
maintained in a safe and sanitary manner.