This chapter establishes minimum program requirements for Tennessee-licensed Mental Health Adult Residential Treatment programs, which provide 24-hour intensive, structured mental health services for adults in a non-permanent therapeutic milieu. Operators must meet staffing ratios, arrange 24/7 medical and emergency psychiatric access, complete assessments and plans of care within specified timeframes, and maintain detailed individual records. Additional requirements cover medication administration, management of disruptive behavior, service recipient rights, recreational activities, and health/hygiene assistance.
View official sourceDecember, 2022 (Revised) 1 RULES OF THE TENNESSEE DEPARTMENT OF MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES CHAPTER 0940-05-17 MINIMUM PROGRAM REQUIREMENTS FOR MENTAL HEALTH ADULT RESIDENTIAL TREATMENT SERVICES TABLE OF CONTENTS 0940-05-17-.01 Definition 0940-05-17-.07 Assessment Requirements 0940-05-17-.02 Application of Rules for Mental Health Adult 0940-05-17-.08 Plan of Care Requirements Residential Treatment Program 0940-05-17-.09 Management of Disruptive Behavior 0940-05-17-.03 Personnel and Staffing Requirements 0940-05-17-.10 Service Recipient Rights 0940-05-17-.04 Other Services 0940-05-17-.11 Medication Administration 0940-05-17-.05 Emergency Services 0940-05-17-.12 Recreational Activities 0940-05-17-.06 Individual Record Requirements 0940-05-17-.13 Health, Hygiene, and Grooming 0940-05-17-.01 DEFINITION. (1) “Adult Residential Treatment Program” means a mental health treatment program that offers 24 hour intensive, coordinated, and structured services for adult service recipients within a non-permanent therapeutic milieu that focuses on enabling a service recipient to move to a less restrictive setting. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33-2-302. Administrative History: Original rule filed May 26, 1988; effective July 11, 1988. Amendment filed December 30, 2002; effective March 15, 2003. 0940-05-17-.02 APPLICATION OF RULES FOR MENTAL HEALTH ADULT RESIDENTIAL TREATMENT PROGRAM. (1) The governing body of an adult residential treatment program must comply with the following rules: (a) Rule 0940-05-04-.02 (2) Life Safety Board and Care Occupancy (b) Chapter 0940-05-05 Adequacy of Program Environment and Ancillary Services; (c) Chapter 0940- 05-06 Minimum Program Requirements for All Mental Health Services (new rules to be filed), (d) Chapter 0940-05-17 Minimum Program Requirements for Mental Health Adult Residential Treatment Program Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33- 2-302. Administrative History: Original rule filed May 26, 1988; effective July 11, 1988. Amendment filed December 30, 2002; effective March 15, 2003. 0940-05-17-.03 PERSONNEL AND STAFFING REQUIREMENTS. (1) Treatment and rehabilitation services must be provided by mental health professionals or mental health personnel and under the direct clinical supervision of a licensed mental health professional. MINIMUM PROGRAM REQUIREMENTS FOR MENTAL HEALTH CHAPTER 0940-05-17 ADULT RESIDENTIAL TREATMENT SERVICES (Rule 0940-05-17-.03, continued) December, 2022 (Revised) 2 (2) The program must provide access to medical services via a written agreement or employment of a licensed physician. (3) If the physician is not a psychiatrist, the program must arrange for the regular, consultative, and emergency services of a licensed psychiatrist; (4) During normal waking hours, all programs must provide a least one (1) on- duty/on-site staff person for every ten (10) service recipients present in the program. Staff persons counted in the staff -to-service recipie nt ratio may only be persons who are assigned to provide direct program services as described by written job description. Support staff such as clerical, housekeeping, van and b us driver staff; students involved in an on- site practicum for academic credit; and volunteers may not be counted in the staff -to-recipient ratio. During normal sleeping hours, all programs must provide one (1) on- duty/on-site staff in each building where service recipients are housed; and in any building housing more than ten (10) service recipients, programs must provide one (1) additional on- duty/on-site staff for each additional ten (10) service recipients. (5) The program must provide a ratio of one (1) on -site, on-duty direct-treatment staff member to ten (10) service recipients for not less than three (3) hours of treatment/rehabilitation services on site per week day. (6) The program must provide at all times at least one (1) on- duty staff member certified in cardiopulmonary resuscitation (CPR) and trained in First aid, and the Heimlich maneuver. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33- 2-302. Administrative History: Original rule filed May 2 6, 1988; effective July 11, 1988. Amendment filed December 30, 2002; effective March 15, 2003. 0940-05-17-.04 OTHER SERVICES. (1) The program must arrange access to qualified dental, medical, nursing, and pharmaceutical care for service recipients of t he program on a twenty -four (24) hours per day and seven (7) days a week basis. Service recipients or their families may choose a personal professional for non-emergency services. (2) The program must insure that each service recipient has had a physical examination within the six (6) months prior to admission or within thirty (30) days after admission. Such examinations should include routine screenings (such as vision and hearing) and laboratory examinations (such as Pap smear and blood work), as determi ned necessary by the physician, and special studies where the index of suspicion is high and thereafter as ofte n as indicated by the service recipient’s physician. (3) In consultation with the service recipient/guardian/conservator, the program must arran ge access for each service recipient for ongoing mental health services not provided by the program and assist the service recipient in keeping appointments and participating in such treatment programs. Documentation of such referrals must be kept in the s ervice recipient’s record. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33- 2-302. Administrative History: Original rule filed May 26, 1988; effective July 11, 1988. Amendment filed December 30, 2002; effective March 15, 2003. MINIMUM PROGRAM REQUIREMENTS FOR MENTAL HEALTH CHAPTER 0940-05-17 ADULT RESIDENTIAL TREATMENT SERVICES December, 2022 (Revised) 3 0940-05-17-.05 EMERGENCY SERVICES. (1) Program must arrange care for emergency services on a twenty-four (24) hours per day and seven (7) days a week basis. (2) The program must provide direct or telephone access to at least one (1) Tennessee licensed mental health professional twenty -four (24) hours a day seven (7) days a week. If the professional is not a psychiatrist, the program must also arrange for the regular, consultative, and emergency services of a psychiatrist. (3) The program must provide back -up coverage by staff trained to handle acute psychiatric problems on a twenty-four (24) hours per day and seven (7) days per week on-call basis. (4) The program must secure emergency services for service recipients who pose an imm inent physical danger to themselves or others. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33- 2-302. Administrative History: Original rule filed May 26, 1988; effective July 11, 1988. Amendment filed December 30, 2002; effective March 15, 2003. 0940-05-17-.06 INDIVIDUAL RECORD REQUIREMENTS. (1) The record maintained for each service recipient must include the following information: (a) Progress which must include written documentation of progress and c hanges which have occurred within the Plan of Care and, at a minimum, must be recorded daily. Progress notes must be dated and minimally include the signature, with title or degree, of the person preparing the note; (b) A list of each service recipient’s personal property valued at one hundred ($100.00) or more, including its disposition if no longer in use; (c) Narrative summary review of all medications prescribed at least every six (6) months, which includes specific reasons for continuation of each medication. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33- 2-302. Administrative History: Original rule filed May 26, 1988; effective July 11, 1988. Amendment filed December 30, 2002; effective March 15, 2003. 0940-05-17-.07 ASSESSMENT REQUIREMENTS. (1) The facil ity must ensure that the following assessments are completed prior to the development of the service recipient's Plan of Care: (a) Current assessment of functioning according to presenting problem(s), including a history of the presenting problem, and assessments in the following areas: 1. Community living skills, 2. Educational level; 3. Independent living skills, and 4. Emotional psychological health; (b) Current diagnosis and DSM axis (I-V); MINIMUM PROGRAM REQUIREMENTS FOR MENTAL HEALTH CHAPTER 0940-05-17 ADULT RESIDENTIAL TREATMENT SERVICES (Rule 0940-05-17-.07, continued) December, 2022 (Revised) 4 (c) A six (6) month history of prescribed medications, f requently used over -the-counter medications, and alcohol and other drug use. (d) History of prior mental health and alcohol and drug treatment episodes. (e) Basic medical history and information. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33- 2-302. Administrative History: Original rule filed May 26, 1988; effective July 11, 1988. Amendment filed December 30, 2002; effective March 15, 2003. 0940-05-17-.08 PLAN OF CARE REQUIREMENTS. (1) A plan must be developed for each service recipient. The plan must be based on initial and on-going assessment of needs and strengths and must be completed within seventy -two (72) hours of admission. Documentation of the plan must be made in the individual's record and must include the following: (a) The service recipient’s name. (b) The date of plan of care development. (c) Standardized diagnostic formulation(s) including, but not limited to, the current Diagnostic and Statistical Manual (DSM) Axes I-V and/or ICD-9. (d) Needs and strengths of the recipient that are to be addressed within the particular service/program component. (e) Observable and measurable individual goals that are related to specific needs identified and which are to be addressed by the particular service/program component. (f) Interventions that address specific goals and objectives, identify staff responsible for interventions, and planned frequency of contact. (g) Signatures(s) of treatment staff who develop the plan and the primary staff responsible for its implementation, including physician when appropriate. (h) Signature of service recipient (and/or conservator legal custodian, or attorney in -fact). Reasons for refusal to sig n and/or inabil ity to participate in Plan of Care development must be documented. (i) Discharge planning that includes a projected discharge date and anticipated post discharge needs including documentation of resources needed in the community. (j) A review of the Plan of Care must occur at least every thirty days after development of the Plan of Care and every thirty days thereafter and must include the following documentation: 1. Dated signature(s) of appropriate treatment staff, including physician; and 2. An asses sment of progress toward each treatment goal and/or objective with revisions as indicated; and MINIMUM PROGRAM REQUIREMENTS FOR MENTAL HEALTH CHAPTER 0940-05-17 ADULT RESIDENTIAL TREATMENT SERVICES (Rule 0940-05-17-.08, continued) December, 2022 (Revised) 5 3. A statement by the staff psychiatrist or physician of justification for the level of services(s) needed; and 4. An assessment of suitability for treatment i n a less restrictive environment must be part of the review process. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33- 2-302. Administrative History: Original rule filed May 26, 1988; effective July 11, 1988. Amendment filed December 30, 2002; effective March 15, 2003. 0940-05-17-.09 MANAGEMENT OF DISRUPTIVE BEHAVIOR. (1) Policies addressing the methods for managing service recipients’ disruptive behavior must include the following: (a) Post incident debriefing for staff and service recipient. (b) Service recipient Program Plan modification as indicated. (c) Teaching the adaptive or desirable behavior to the service recipient in conjunction with the implementation of the procedures. (d) Physical holding must be implemented in such a way as to minimize any physical harm to the service recipient and may only be used when the service recipient poses an immediate danger to self or others. Physical holding may be used only until the service recipient is calm. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33- 2-302. Administrative History: Original rule filed May 26, 1988; effective July 11, 1988. Amendment filed December 30, 2002; effective March 15, 2003. 0940-05-17-.10 SERVICE RECIPIENT RIGHTS. (1) Service recipients must be allowed to use their personal funds directly or allow the service recipient’s representative payee or other legally authorized person acting on behalf of the service recipient to purchase incidentals and special needs items. (2) Each service recipient must be allowed to possess and use his/her own money unless otherwise indicated by the service recipient's Plan of Care. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33- 2-302. Administrative History: Original rule filed May 26, 1988; effective July 11, 1988. Amendment filed December 30, 2002; effective March 15, 2003. 0940-05-17-.11 MEDICATION ADMINISTRATION. (1) The service recipient’s ability and training must be taken into consideration when supervising the self-administration of medication. (2) Prescription medications are to be taken only by service recipients for whom they are prescribed, and in accordance with the directions of a physician. (3) Medications must be stored in a locked container which ensures proper conditions of security and sanitation and prevents accessibility to any unauthorized persons. MINIMUM PROGRAM REQUIREMENTS FOR MENTAL HEALTH CHAPTER 0940-05-17 ADULT RESIDENTIAL TREATMENT SERVICES (Rule 0940-05-17-.11, continued) December, 2022 (Revised) 6 (4) Discontinued and outdated medications and containers with worn, illegible, or missing labels must be disposed. (5) It must be documented and reported to practitioners who prescribed the medication, all medication errors, drug reactions, or suspected overmedication. (6) Evidence of the current prescription of each medication taken by a service recipient must be maintained by the program. (7) All direct -service staff must be trained about medications used by service recipients. This training must include information about the purpose and function of the medicati ons, their major side effects and contraindications, and ways to recognize signs that medication is not being taken or is ineffective. (8) Staff must have access to medications at all times. (9) All medications must be administered by licensed medical or licensed nursing personnel or by other qualified personnel. (Qualified personnel under these rules means a certified or registered respiratory therapist, a radiological technologist, a nuclear medicine technolog ist, or a certified physician assistant prac ticing pursuant to a protocol approved by the medical staff.) Such qualified service personnel may only administer medication within the scope of an established protocol. (10) Schedule II drugs must be stored within two (2) separately locked compartments at all times and be accessible only to staff in charge of administering medication. (11) All medications and other medical preparations intended for internal or external human use must be stored in medicine cabinets or drug rooms. Such cabinets or drug rooms must be kept securely locked when not in use and the key must be in the possession of the supervising nurse or other authorized staff. Locks in doors to medicine cabine ts and drug rooms must be such that they require an action on the part of staff to lock and unlock. (12) Staff must document each time a service recipient self -administers medication or refuses a medication. This documentation must include the date, time, medication name, dosage as well as over the counter medication. This documentatio n must be made on the medication log sheet in the service recipient's chart. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33- 2-302. Administrative History: Original rule filed May 26, 1988; effective July 11, 1988. Amendment filed December 30, 2002; effective March 15, 2003. 0940-05-17-.12 RECREATIONAL ACTIVITIES. (1) The program must ensure that opportunities are provided for recreational activities which are appropriate to and adapted to the needs, interests, and ages of the service recipients being served. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33- 2-302. Administrative History: Original rule filed May 26, 1988; effective July 11, 1988. Amendment f iled December 30, 2002; effective March 15, 2003. 0940-05-17-.13 HEALTH, HYGIENE, AND GROOMING. (1) The program must assist service recipients in the independent exercise of health, hygiene, and grooming practices. MINIMUM PROGRAM REQUIREMENTS FOR MENTAL HEALTH CHAPTER 0940-05-17 ADULT RESIDENTIAL TREATMENT SERVICES (Rule 0940-05-17-.13, continued) December, 2022 (Revised) 7 (2) The program must assist each servi ce recipient in securing an adequate allowance of personally-owned, individualized, clean, and seasonal clothes that are the correct size. (3) The program must assist and encourage service recipients in the use of dental, physical prosthetic appliances and visual aids. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33- 2-302. Administrative History: Original rule filed May 26, 1988; effective July 11, 1988. Amendment filed December 30, 2002; effective March 15, 2003.