902 KAR 20:160. Chemical dependency treatment services and facility specifications.
RELATES TO: KRS 202A.241, 216B.010, 216B.015, 216B.030, 216B.105, 216B.990, 311.560(4), 314.011(8), 314.042(8), 320.210(2)
STATUTORY AUTHORITY: KRS 216B.010, 216B.042(1)
NECESSITY, FUNCTION, AND CONFORMITY: KRS 216B.042 and 216B.105 require the Cabinet for Health Services to regulate health facilities and health services. This administrative regulation establishes licensure requirements for the operation, services, and facility specifications of chemical dependency treatment programs.
Section 1. Definitions. (1) "Aftercare" means the process of providing continued services following primary chemical dependency treatment, in order to support and increase gains made during treatment.
(2) "Governing authority" means the individual, agency, partnership or corporation that directs and establishes policy concerning the management and operation of a chemical dependency treatment program.
(3) "Interdisciplinary team" means a group of at least four (4) professionals including a physician, registered nurse, certified chemical dependency counselor and a person with a master's degree in psychology, social work or counseling.
(4) "Qualified dietician" means:
(a) A person who has a Bachelor of Science degree in foods and nutrition, food service management, institutional management or related services and has successfully completed a dietetic internship or coordinated undergraduate program accredited by the American Dietetic Association (ADA) and is a member of the ADA or is registered as a dietician by ADA; or
(b) A person who has a Masters Degree in nutrition and is a member of ADA or is eligible for registration by ADA; or
(c) A person who has a Bachelor of Science degree in home economics and three (3) years of work experience with a registered dietician.
(5) "Restraint" means a physical or mechanical device used to restrict the movement of the patient or a portion of the patient's body.
Section 2. Scope of Operation and Services. (1) A chemical dependency treatment service shall have a structured inpatient program to provide medical, social, diagnostic and treatment services to persons who suffer from illness related to the misuse or abuse of alcohol and other drugs.
(2) Chemical dependency treatment services shall:
(a) Have a duration of less than thirty (30) days;
(b) Be hospital based or freestanding;
(c) Have eight (8) or more patient beds;
(d) Be under the medical direction of a physician; and
(e) Provide continuous nursing services.
Section 3. Administration and Operation. The licensee shall be responsible for compliance with federal, state and local law pertaining to chemical dependency treatment programs.
(1)(a) The governing authority shall appoint a program administrator who shall have a:
1. Bachelor's degree in a health or human services field;
2. Bachelor's degree in another field supplemented with one (1) year of work experience in the field of chemical dependency; or
3. High school diploma and four (4) years experience in the field of chemical dependency.
(b) The governing authority shall establish, in writing:
1. Program goals and objectives; and
2. An evaluation plan for annual assessment of the attainment of the goals and objectives.
(2) Program administrator.
(a) The program administrator shall be responsible for the daily management of the facility and shall provide liaison between the governing authority and staff members.
(b) The program administrator shall keep the governing authority informed of the operations of the facility through periodic reports and attendance at meetings of the governing authority.
(3) Administrative records and reports.
(a) A medication error, drug reaction, accident, or other incident involving a patient, visitor, or staff member, shall be reported in writing, signed by the program administrator and any witness to the event, and placed in an incident file.
(b) Licensure inspection reports, plans of correction and program evaluations shall be available to the public, upon request, at the facility.
(a) Administrative policies. The program shall have a written administrative policy to cover each aspect of the facility's operation, as follows:
1. A description of the organizational structure, staffing, and allocation of responsibility and accountability;
2. A description of referral linkages with other facilities and providers;
3. A description of the services included in the program;
4. An expense and revenue accounting system following generally accepted accounting procedures;
5. A volunteer program; and
6. Program evaluation and quality assurance review.
(b) Patient care policy. A written patient care policy shall be developed and shall include a description of:
1. Actions to be taken when a patient is lost, unaccounted for, or otherwise absent without authorization;
2. Provisions for patient visitation and use of telephones;
3. Provision of emergency medical services; and
4. Patient admission and discharge criteria, including the categories of individuals accepted and not accepted by the program.
(c) Patient rights policy. A written policy to enhance patient dignity and to protect human rights. The policy shall assure that each patient is:
1. Informed of rules and regulations governing patient conduct and responsibilities, including the procedure for handling grievances;
2. Informed, prior to admission for rehabilitation, of services available and charges for treatment, including charges not covered under Medicare, Medicaid, or other third-party payor;
3. Encouraged and assisted to:
a. Understand and exercise patient rights;
b. Voice grievances; and
c. Recommend changes in policies and services. If a patient so requests, a grievance or recommendation shall be conveyed to that body within the organization with authority to take corrective action.
4. Presented with the opportunity to participate in the planning of his treatment;
5. Informed of the right to refuse to participate in experimental research;
6. Assured confidential treatment of records and presented with the opportunity to approve or refuse release of records to any individual not involved in his care, except as required by Kentucky law or third party payment contract; and
7. Treated with consideration, respect, and recognition of personal dignity and individuality, including privacy in treatment and personal health needs.
(a) The governing authority shall establish a personnel policy which the governing authority shall review and update on an annual basis.
(b) There shall be a personnel record for each person employed by the facility, which shall include the following:
1. Evidence of the results of a tuberculosis test, performed either prior to or within the first week of employment and annually thereafter;
2. Evidence of education, training, and experience, and a copy of current license or certification credentials, if applicable;
3. Evidence that the employee received orientation to the facility's written policies within the first week of employment; and
4. Evidence of regular in-service training which corresponds with job duties and includes a list of training and dates completed.
(6) Staffing requirements. The program shall have personnel sufficient to meet patient needs on a twenty-four (24) hour basis. The number and classification of personnel required shall be based on the number of patients and the individual treatment plans.
(a) Responsibility for the medical aspect of the program shall reside with a qualified physician, in the post of medical director. The duties of the medical director shall include:
1. Patient admission;
2. Approval of patient treatment plans;
3. Participation in the quality assurance review; and
4. Provision of medical services, personally or by a designated physician, either in-house or on-call, on a twenty-four (24) hour basis.
(b) Interdisciplinary team. There shall be an interdisciplinary team responsible for:
1. Developing individual treatment plans;
2. Developing aftercare plans; and
3. Conducting quality assurance reviews.
(c) Treatment director. The program shall have a full time treatment director responsible for:
1. Coordinating the interdisciplinary team in developing individual treatment plans;
2. Initiating a periodic review of each patient's treatment plan;
3. Supervising the maintenance of patient records; and
4. Coordinating the interdisciplinary team in developing an aftercare plan for each patient to provide continuity of care.
(d) Nursing services. Nursing services shall be available on a twenty-four (24) hour basis. The program shall have at least one (1) full-time registered nurse. When a registered nurse is not on duty there shall be a licensed practical nurse present who is responsible for the nursing care of patients during her tour of duty. When a licensed practical nurse is on duty, a registered nurse shall be on call.
(e) Medical supervision. A physician, or registered nurse under the direction of a physician, shall supervise implementation of the medical aspects of the treatment plan and all staff directly involved in patient medical care.
(f) In-service training. All personnel shall participate in ongoing in-service training programs relating to their respective job activities. These programs shall include thorough job orientation for new personnel and regular in-service training programs emphasizing professional competence and the human relationship necessary for effective health care.
(7) Patient records.
(a) An individual record shall be maintained for each patient. Each entry shall be signed and dated by the person making the entry.
(b) At the time of admission the following information shall be entered into the patient's record:
1. Name, date of admission, birth date and place, marital status and Social Security number;
2. Person to contact in case of emergency;
3. Next of kin; and
4. Type and place of employment.
(c) The record shall contain documentation of medical services provided during detoxification and rehabilitation, including the results of physical examinations.
(d) The record shall contain the patient's treatment plan outlining goals and objectives for the individual during treatment. The record shall also contain documentation of how the plan was implemented and of patient progress in meeting the goals and objectives outlined in the treatment plan.
(e) The record shall contain notation of medication administered, stating the date, time, dosage, and frequency of administration and the name of the person administering each dose.
(f) The record shall contain a discharge summary and a plan for aftercare.
(g) The discharge summary shall be entered in the patient's record within seven (7) days after discharge and shall include:
1. The course and progress of the patient with regard to the individual treatment plan;
2. General observations of the patient's condition initially, during treatment and at discharge; and
3. The recommendations and arrangements for further treatment including prescribed medications and aftercare.
(h) If the patient is referred to another service provider after discharge, and if the patient executes a written release, a copy of the discharge summary shall be with the patient's permission sent to the provider with the patient's permission.
(i) After a patient's death or discharge the completed record shall be placed in an inactive file and retained for five (5) years or in case of a minor, three (3) years after the patient reaches the age of majority under state law, whichever is longest.
(8) Linkage agreements. The program shall have linkages through written agreements with providers of other levels of care which may be medically indicated to supplement the services available in the program. These linkages shall include a hospital and an emergency medical transportation service in the area.
(9) Quality assurance. The service shall have a quality assurance program that includes an effective mechanism for reviewing and evaluating patient care on a regular basis by the interdisciplinary team.
(a) A prescription or nonprescription medication administered to a patient shall be noted in the patient's records with the date, time and dosage, and signed by the person administering the medication.
(b) Each prescription medication shall be plainly labeled with the patient's name, the name of the drug, strength, name of pharmacy, date, physician name, caution statement and directions for use.
(c) A prescription or nonprescription medication shall not be administered to a patient except on the written order of a physician or other practitioner acting within his statutory scope of practice. A medication shall be administered by licensed personnel.
(d) Medication shall be kept in a locked storage area which shall be well lighted and of sufficient size to permit storage without crowding. Medication requiring refrigeration shall be kept in a separate locked box in a refrigerator. Medication for external use shall be stored separately from medication administered by mouth or injection.
(e) A medication error or drug reaction shall be reported immediately to the medical director and treatment coordinator and an entry shall be made in the patient's record.
(f) An emergency medical kit, with contents approved by a physician, shall be maintained at the facility. It shall be inspected after use or at least monthly to remove deteriorated and outdated drugs and to ensure completeness of content.
(11) Restraints. Requirements for the use of restraints shall be met pursuant to KRS 202A.241 and 908 KAR 3:010(9).
(12) Activities schedule. A daily schedule of program activities shall be posted in the facility.
Section 4. Provision of Services. (1) Detoxification. Medical detoxification services pursuant to the requirements of 902 KAR 20:111 shall be available directly or through another licensed provider, for a patient who requires detoxification.
(2) Rehabilitation. The program shall provide:
(a) Medical services as needed, under the supervision of a physician;
(b) Scheduled individual, group, and family counseling;
(c) Psychological testing and evaluation as needed;
(d) Education of the patient on the subject of chemical dependency and related lifestyle issues, including nutrition and communication skills;
(e) Recreational activities with facilities and equipment, consistent with the patient's needs and the therapeutic program;
(f) Referral to other rehabilitative or community service agencies providing services not available through the program; and
(g) Aftercare services provided directly or through arrangement with another agency.
(3) Physical examinations. Within ten (10) days prior to or three (3) days after admission for rehabilitation a patient shall have a physical examination with tests ordered by physician.
(4) Psychosocial history. A patient shall have a psychosocial history and assessment interview within seventy-two (72) hours after admission for rehabilitation. The following data shall be collected and recorded in the patient record:
(a) History of alcohol and drug use;
(b) A determination of current emotional state;
(c) Vocational history;
(d) Familial relationships; and
(e) Educational background.
(5) Treatment plan. The interdisciplinary team, with the participation of the patient, shall develop an individual treatment plan within four (4) days after admission for rehabilitation, based on the patient's medical evaluation and psychosocial history and assessment. The treatment plan shall:
(a) Specify the services required for meeting the patient's needs;
(b) Identify goals necessary for the patient to achieve, maintain or reestablish physical health and adaptive capabilities;
(c) Establish goals with both long-term and short-term objectives and the anticipated time expected to meet these goals; and
(d) Identify the location and frequency of treatment procedures, including referrals for a required service not provided by the program.
(6) The treatment plan shall be reviewed and updated at least weekly for the duration of the inpatient treatment.
(7) The patient's family or significant others shall be involved in the treatment process, if approved by the patient. An attempt to involve family members or significant others shall be reported in the patient's medical record.
(8) Aftercare plan.
(a) Prior to completion of treatment, the interdisciplinary team, the patient and, with the patient's permission, the patient's family or significant others shall develop a written aftercare plan. The plan shall be designed to establish continued contact for the support of the patient.
(b) The aftercare plan shall include methods and procedures to meet patient needs through direct contact or with assistance from other community human services organizations.
(c) When aftercare services are provided directly, a periodic review and updating of the aftercare plan shall be conducted with the frequency of review determined by the interdisciplinary team, the patient, and with the patient's permission, the patient's family or significant others. If the patient is referred to another agency for aftercare services, follow-up shall be conducted to determine if services are being provided.
Section 5. Compliance with Building Codes, Ordinances and Regulations. (1) Nothing stated herein shall relieve the licensee from compliance with building codes, ordinances, and regulations which are enforced by city, county, or state jurisdictions.
(2) The following shall apply:
(a) Requirements for safety pursuant to the National Fire Protection Association 101, Life Safety Code adopted by the Kentucky Department of Housing, Buildings and Construction;
(b) Requirements for plumbing pursuant to 815 KAR 20:010 through 20:191;
(c) Requirements for making buildings and facilities accessible to and usable by persons with disabilities.
(3) The facility shall be approved by the Fire Marshal's Office before a license or license renewal is granted.
(4) The facility shall receive necessary approval from appropriate agencies prior to occupancy and licensure.
(5) Physical and sanitary environment.
(a) The physical plant and overall facility environment shall be maintained to protect the safety and well-being of patients, personnel and visitors.
(b) A person shall be designated responsible for services and for the establishment of practices and procedures in each of the following areas:
1. Plant maintenance;
2. Laundry operations, either on site or off site; and
(c) The facility buildings, equipment, and surroundings shall be kept in good repair, neat, clean, free from accumulation of dirt and rubbish and free from foul, stale or musty odors.
1. An adequate number of housekeeping and maintenance personnel shall be provided.
2. Written housekeeping procedures shall be established for each area and copies shall be available to personnel.
3. Equipment and supplies shall be provided for cleaning surfaces. The equipment shall be maintained in a safe, sanitary condition.
4. A hazardous cleaning solution, compound, or substance shall be labeled, stored in an approved container, and kept separate from nonhazardous cleaning materials.
5. The facility shall be free from insects, rodents, and their harborage.
6. Garbage and trash shall be stored in closed containers in an area separate from an area used for the preparation or storage of food. The garbage and trash area shall be cleaned regularly and shall be in good repair.
(d) The facility shall have available at all times a quantity of linen essential to the proper care and comfort of residents.
1. Clean linen and clothing shall be stored in clean, dry, dust-free areas designated exclusively for this purpose.
2. Soiled linen and clothing shall be placed in suitable bags or closed containers and stored in a separate area ventilated to the exterior of the building.
Section 6. Facility Requirements and Special Conditions. (1) Patient rooms. Each patient room shall meet the following requirements:
(a) The maximum room capacity shall be six (6) patients.
(b) The minimum room area, exclusive of toilet room, closet, locker, wardrobe, or vestibule, shall be:
1. 100 square feet for a one (1) bed room; and
2. Eighty (80) square feet per bed for multibed rooms.
(c) Partitions, cubicle curtains, or placement of furniture shall be used to provide privacy in a multiperson room. Ample closet and drawer space shall be provided for the storage of each patient's personal property.
(d) The placement of a patient in a multibed room shall be appropriate to the age and program needs of the patient.
(2) Lavatory. In a single or multibed room with a private toilet room, the lavatory may be located in the toilet room. If two (2) or more patients share a common toilet a lavatory shall be provided in each patient room.
(3) Centralized toilet area. If a centralized toilet area is used, the facility shall provide, for each gender on each floor, one (1) toilet for each eight (8) residents or a major fraction thereof. Toilets shall be separated by a permanent partition and at least one (1) toilet for each gender shall be designed for wheelchair use.
(4) Patient baths. There shall be one (1) shower stall or one (1) bathtub for each fifteen (15) patients not individually served. Each bathtub or shower shall provide space for the private use of the fixture and for dressing.
(5) The patient shall be encouraged to take responsibility for maintaining his own living quarters and for other day-to-day housekeeping activities of the program, as appropriate to his clinical status.
(6) Dietary service.
(a) The facility shall have a dietary department, organized, directed, and staffed to provide quality food service and optimal nutritional care.
1. The dietary service shall be directed on a full-time basis by an individual who, by education or specialized training and experience, is knowledgeable in food service management.
2. The dietary service shall have at least one (1) qualified dietician to supervise the nutritional aspects of patient care and to approve menus on at least a consultative basis.
3. If food service personnel are assigned a duty outside the dietary department, a duty shall not interfere with the sanitation, safety, or time required for regular dietary assignments.
(b) A menu shall be planned, written, and rotated to avoid repetition. Nutritional needs shall be met in accordance with recommended dietary allowances of the Food and Nutrition Board of the National Research Council of the National Academy of Sciences, and in accordance with physician orders.
(c) A meal served shall correspond with the posted menu. When a change in the menu is necessary, substitution shall provide equal nutritive value, and the change shall be recorded on the menu. A menu shall be kept on file for thirty (30) days.
(d) Food shall be prepared by methods that conserve nutritive value, flavor and appearance, and shall be served at the proper temperature.
(e) At least three (3) meals shall be served daily with not more than a fifteen (15) hour span between a substantial evening meal and breakfast. Each meal shall be served at a regular time and a nourishing between-meal or bedtime snack offered.
(f) The facility shall comply with relevant provisions of 902 KAR 45:005. (9 Ky.R. 1078; Am. 10 Ky.R. 38; eff. 8-3-83; 11 Ky.R. 478; eff. 10-9-84; 18 Ky.R. 828; eff. 10-16-91; 23 Ky.R. 2870; eff. 2-19-97; 25 Ky.R. 2967; 26 Ky.R. 763; eff. 10-20-99.)