(1) At a minimum, the program is required to have written policies and procedures including supporting evidence of implementation on each of the following areas:

(a) staffing requirements to include assurance there is an identified clinical supervisor who is a licensed addiction counselor and oversees the implementation of services to assure quality and appropriateness of care rendered to clients;

(b) critical population requirements to include how pregnant woman resources and referral options will be made available so staff can make referrals as indicated by client needs including:

(i) ensuring a pregnant woman who is not seen by a private physician, physician assistant-certified, nurse practitioner, or advanced practice registered nurse is referred to one of these providers for determination of prenatal care needs; and

(ii) discussing pregnancy specific issues and resources.

(c) therapy service requirements to include but not limited to:

(i) ensuring utilization of the DSM and the ASAM admission, continued stay, and discharge criteria for patient placement decisions in the initial and the ongoing assessment of the client throughout the course of treatment;

(ii) ensuring a person needing detoxification will be immediately referred to a detoxification provider, if available, unless the person needs acute care in a hospital; and

(iii) limitations and requirements of group counseling sessions to include client/staff appropriate for the level of care being rendered.

(d) clinical policies addressing:

(i) the assignment of work to a client by a licensed addiction counselor when the assignment is part of the treatment program and has therapeutic value;

(ii) the use of self-help groups;

(iii) arranging for medical consultation when clinically needed;

(iv) arranging for psychiatric consultation when clinically indicated;

(v) how laboratory testing is to be done including but not limited to:

(A) testing methods (urine, saliva, blood, breath, etc.); and

(B) collection and storage.

(vi) how drug and alcohol screening testing is to be done including but not limited to:

(A) a guide how testing is used as part of the therapeutic process in a nonpunitive manner;

(B) requirements to ensure the use of drug testing becomes part of the clients treatment plan; and

(C) client refusal to submit for testing and confirmation testing.

(e) policies addressing a facility's ability to provide dual diagnosis services to include at a minimum the following:

(i) mental health screening; and

(ii) procedures to assure mental health treatment if identified as a co-occurring client.

(f) a description of services showing there are arrangements in place for coordination and collaboration to provide services with the following, at a minimum, if not provided on-site:

(i) mental health services;

(ii) pregnancy services;

(iii) human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) services;

(iv) tuberculosis (TB) services;

(v) Hepatitis B and C services; and

(vi) sexually transmitted diseases treatment services.

(g) case management services policies and procedures provided in conjunction with or as part of the client's substance use disorder treatment and recovery;

(h) treatment planning process policies and procedures including but not limited to:

(i) how a treatment plan will be jointly developed with the client and the staff who has responsibility for the client;

(ii) assurance the treatment plan is initiated by the third contact visit for outpatient services and within three days of admission for residential services;

(iii) a provision for review and signature by the client and the staff person providing treatment services to the client;

(iv) documentation of regular reviews of the treatment plan with the client in the progress notes;

(v) having measurable objectives and therapeutic interventions with target dates appropriate to the client's clinical needs;

(vi) the clinical problems identified in the client's biopsychosocial assessment;

(vii) when clinically appropriate, implementing a targeted case management plan;

(viii) the engagement or disengagement and documentation of family members and significant others involvement and participation in the treatment process including but not limited to:

(A) offering family sessions and regularly scheduled group and educational activities for family members and significant others; and

(B) how clinical decisions are made and documented regarding the need to involve or not to involve the family and significant others in the treatment process.

(ix) how the facility will conduct reviews as part of a multidisciplinary staffing and how documentation in the client record will reflect all staff who participated in the review;

(x) documenting patient response to treatment and achievement of the treatment plan objectives in the progress notes; and

(xi) a policy to assure the client has a continuing care plan prior to discharge which at a minimum addresses:

(A) support group recommendations;

(B) continuing care service provider's contact name, contact number, and initial appointment;

(C) healthcare and/or medication follow-up; and

(D) goals for continuing care.