Tenn. Comp. R. & Regs. 0940-05-31-.01

Current through June 10, 2024

Section 0940-05-31-.01 - POLICIES AND PROCEDURES FOR MENTAL HEALTH THERAPEUTIC NURSERY PROGRAM FACILITIES

The facility must maintain a written policy and procedures manual which includes the following elements:

(1) An agency quality assurance procedure which assess the quality of care at the facility. This procedure must ensure appropriate treatment has been delivered according to acceptable clinical practice.

(2) A written program description which must be available to staff, clients, and members of the public. This program description must be on file with the Children and Adolescent (C&

A) Services Section of the Division of Mental Health Services, Tennessee Department of Mental Retardation. The description must include but need not be limited to the following:

(a) A comprehensive statement of the philosophy that guides the program services, structure, and practices,

(b) Services offered by the facility, availability of staff to provide services, and hours of operation,

(c) Characteristics of the person(s) to be served,

(d) Process of referral into the program,

(e) Admission criteria,Facility rules for clients,

(f) Referral mechanisms for services outside the facility (both medical and non-medical),

(g) Emergency and non-emergency transportation of clients, and

(h) Discharge criteria;

(3) Policies and procedures which address the methods for managing disruptive behavior,

(4) If restrictive procedures are used to manage disruptive behaviors, written policies and procedures must govern their use and must minimally include and/or ensure the following:

(a) The range and order of use of all restrictive procedures will be written out in the program's procedures plan. The plan must state that restrictive procedures will be used by the facility only on a gradually increasing continuum and only after all non-restrictive interventions for dealing with the problem behavior have been tried or considered.

(b) The child's parent or guardian must have given overall written consent to any restrictive measures taken with him/her by the clinical staff,

(c) Use of restrictive procedures(s) must be noted in the child's chart and be justifiable as part of the child's program plan,

(d) Only mental health professionals or mental health personnel may use restrictive procedures and must be adequately trained in their use, and

(e) The adaptive or desirable behavior should be taught to the client in conjunction with the implementation of the restrictive procedures.

(5) A policy which states physical holding must be implemented in such a way as to minimize any physical harm to the client.

(6) A policy that requires that a first aid chart must be posted, and caregivers and helpers must be familiar with its contents.

(7) A policy that requires that a first aid kit containing at least a thermometer, bandage compresses, adhesive tape, and gauze pads must be available to the staff.

(8) A policy that prohibits firearms on the premises and that requires that kitchen knives and other potentially dangerous utensils or tools must be secured so that they are inaccessible to children.

(9) A policy that requires that emergency telephone numbers must be posted next to the telephone and readily available to any staff member as follows: hospital, ambulance, parent, parent contact, guardian or conservator, and physician.

Tenn. Comp. R. & Regs. 0940-05-31-.01

Original rule filed January 11, 1996; effective March 26, 1996.

Authority: T.C.A. §§ 4-4-103, 33-2-504 and 33-1-203(b)(5).