Monitoring Health Status

Behavioral Health Services, Inc.

Subject: Residential SUD Treatment Policy#: 4.11.6.2
Title: Incidental Medical Services – Monitoring Health Status

Effective Date: 6/27/24

POLICY:
BHS residential treatment facilities that are licensed by DHCS shall provide IMS –Monitoring Health Status with approval of DHCS. DHCS-licensed BHS residential treatment facilities shall have and follow written protocol and procedures in accordance with relevant Health and Safety
codes and other regulatory requirements for the implementation of approved IMS – Monitoring Health Status in their facilities.
For the purposes of this Policy and Procedure “Toxicology” refers to the testing for substances of misuse or their metabolites only.

PROCEDURES:
Monitoring Health Status Throughout Treatment
• Who monitors clients – The physician, other qualified practitioner, registered or certified
SUD counselors, and, depending on the residential facility, Medical Assistant(s) (MA),
Licensed Vocational Nurse(s) (LVN), and/or Registered Nurse(s) (RN) will monitor the
health status of clients throughout the course of treatment.
• Type of Monitoring – Who conducts it and where it is conducted:
o Initial physical exam – conducted by the physician or alternate physician in the
physical exam office
o Physical, face-to-face observation, including check for breathing – conducted by
registered or certified SUD counselors, MAs, LVNs, or RNs, depending on the staffing at the facility. Conducted throughout facility.
o Toxicology1 Screening (Point of Care and Laboratory-based) – conducted in the
designated bathroom, by trained staff member.
o Tuberculosis (TB) Screening – conducted in the physical exam office by the LVN, RN, MA, or contracted lab facility, if no proof of current TB screening is provided by the client at intake, depending on the staffing at the facility.
o Urine-based pregnancy test (if applicable in Withdrawal Management) – conducted in the bathroom nearest to the counseling station, by MA, LVN, RN or registered or certified SUD counselor, depending on the staffing at the facility.

1“Toxicology” in this context is exclusive to drug and alcohol testing

o Vital signs – Blood pressure, heart rate is conducted in client the physical exam room, or the counseling station by trained SUD counselor, MA, LVN or RN, depending upon the staffing at the facility.
o Standardized rating scales - Clinical Institute Withdrawal Assessment for Alcohol (CIWA) or the Clinical Opiate Withdrawal Scale (COWS) is conducted in the physical exam room or counseling office by trained SUD counselor, LPHA, physician or RN, depending upon the staffing at the facility.

• How Monitoring is Conducted – The table below shows the types of monitoring, who
performs each, when they are performed, and the documentation requirements.

Type of Monitoring: Initial physical exam
Who conducts: Physician or alternate physician
When conducted: Within 30 days of admission
Where conducted: Physical exam office
Documentation: Documentation in client’s file within 24 hours of completion.

Type of Monitoring: Face-to-face observations (check for breathing and physical observation) for Withdrawal Management clients
Who conducts: RN, MA, LVN or SUD counselor (depending on staffing at facility)
When conducted: Every 30 minutes for the first 72 hours
Where conducted: In the client’s bedroom
Documentation: In a 30-minute rounds sheet for each client. These sheets are kept on a clip
board for staff doing rounds for the first 72
hours, then filed in client chart.

Type of Monitoring: Other face-to-face
interactions throughout treatment to identify
symptoms, if any, requiring medical attention
Who conducts: MA, LVN, RN or SUD counselor (depending on staffing at facility)
Physician is contacted about the incident and
action taken.
When conducted: Informal, throughout
treatment episode
Where conducted: Throughout treatment facility
Documentation: On incident report form and
note in client file within 24 hours of medical
incident

Type of Monitoring: Toxicology
Who conducts: Qualified staff member
When conducted: During intake/admission
process and at other times as determined on
treatment plan
Where conducted: In the designated client restroom
Documentation: Note in client file as soon as
completed, within 24 hours

Type of Monitoring: TB Screening
Who conducts: LVN, MA, RN, or contracted lab facility
When conducted: During intake/ admission
process, if no proof of current TB screening
provided
Where conducted: In the physical exam office
Documentation: Documentation of test result in client file as soon as completed,
within 24 hours of result

Type of Monitoring: Urine-based pregnancy test (if applicable in Withdrawal Mgmt)
Who conducts: MA, LVN, RN,LPHA/LEPHA,
or SUD counselor (depending on staffing at facility)
When conducted: At intake/admission
for applicable clients in Withdrawal Management
Where conducted: In the designated client restroom
Documentation: Note in client file as soon as
completed, with 24 hours

Type of Monitoring: Vital signs for Detoxification / Withdrawal Mgmt clients
Who conducts: MA, LVN, RN,LPHA/LEPHA,
or SUD counselor (depending on staffing at facility)
When conducted: As directed by physician’s order and the detox drug protocol the client is on. At minimum, every 8 hours
Where conducted: In the client’s bedroom or
physical exam office
Documentation: Note in client file as soon as
completed, within 24 hours

Type of Monitoring: Standardized rating scales (COWS, CIWA)
Who conducts: Physician, RN, LPHA/LEPHA,
SUD counselor, depending on staffing at facility
When conducted: At intake/admission,
to determine need for withdrawal mgmt.
services, and at other times depending on
drug protocol.
Where conducted: In physical exam office or
counseling office
Documentation: Completed scale in client’s file within 24 hours of completion

Administration Assessment
• Collection / Disposal Procedures for Toxicology Screening
o Staff members performing toxicology screening must be trained, authorized by the
supervisor, and know toxicology procedures before being permitted or assigned to perform toxicology screening tests. The trained staff member (AKA collector) is
responsible for instructing the donor in the toxicology screen procedures. The collector
shall follow BHS testing procedures exactly to help ensure a valid test and result. When
urine testing is performed, the client’s emission of urine should be collected and observed by a collector with the same gender as the client whenever possible. A nurse may serve as collector for either gender.
o All staff must be respectful of the client and client’s privacy during the specimen collection
process. Specimen collection shall occur in a private bathroom in the facility that includes
warm running water.
• Procedures – Point of Care Tests Action Taken Procedure/Forms Collector = Any trained staff member

Any trained staff member may serve as the collector for toxicology screen, when assigned to do so.
Wash hands with soap and water before and after drug screen.
Remind donor to wash hands.
Wear single-use gloves during drug screen. This is a precaution in case of accidental spillage. Collector does not handle specimen until it is tightly capped and sealed by donor.
On the Chain of Custody Form mark the name of the program where the test is being done.

Write in the Client ID number, check the reason for the test and check how the
donor identification is verified.
In Step 2 Remarks, print any medications taken by the donor within the last 30 days, including prescription drugs, over the counter medication, any medication dispensed by a doctor or dentist and intravenous drugs or injections. If there is not enough space in this section, the donor should continue the list in the blank space at the top of the chain of custody form.
The collector, the donor and the paperwork must remain together from this point forward until the chain of custody is complete. Both collector and donor must keep the specimen cup and specimen bottle in sight until donor has voided and transferred the urine from the cup to the bottle. Subsequently, both the collector and the donor must keep the specimen bottle in sight until chain of custody is complete.
Ask donor to select a urine collection kit. This may be done in the office before proceeding to the restroom for the actual specimen collection.

Collector and Donor Go together to the  restroom, taking along the urine collection kit and the partially completed chain of custody form.

Donor In the presence of the collector void into specimen cup and screw on the lid. A minimum of 30 ml of urine is required.

Collector Carefully observe the donor voiding into specimen cup or bottle and, if applicable, transferring urine from cup to bottle.
The collector must have a clear view of the donor. For example, with the door of the toilet stall completely open, the collector stands just outside the stall facing the donor.
Ascertain that the specimen is not substituted or adulterated in any way.
Collector Instruct donor to hold up bottle so that collector can observe the temperature
strip. This must be done within 4 minutes of collection. Check “Yes” if specimen is within indicated temperature range. Otherwise, check “No” and print “out of range.”
Visually check specimen for discoloration. If there is any discoloration, note on the chain of custody in the blank space

Donor Tightly cap bottle. Slowly turn the cup upside down so that the urine fills the testing unit in the lid. Turn the cup upright and wait 5 minutes.

Donor In Step 3 of the Chain of Custody, read certification, Print full name, sign full name and date as donor.

Collector In Step 4 of the Chain of Custody, read certification, print full name, sign full name, and enter date. Read the results on the point of care test lid and record the results in Step 5 of the Chain of Custody.

Donor If results are negative, or the donor admits to drug use, discard sample in the toilet and dispose of specimen cup. If the results are positive and the donor denies drug use, transfer sample to a lab-based specimen bottle and prepare Chain of Custody as described for lab- based testing.

Note: The Chain of Custody is now complete. The donor may leave. Do not open the specimen bag or write on the copy of the form after this point.
Program Director or Place the copy of the Chain of Custody form in Designee the
client’s file. Enter results into MyEvolv.
Procedures - Laboratory Based Tests
Action Taken Procedure/Forms Collector Any trained staff member may serve as the collector for toxicology screen, when assigned to do so.
▪ Wash hands with soap and water before and after drug screen.
▪ Remind donor to wash hands.
▪ Wear single-use gloves during drug screen. This is a precaution in case of accidental spillage. Collector does not handle specimen until it is tightly capped and sealed by donor
▪ Identifies the donor, using the client ID number.
▪ Pre-printed information on the Chain of custody form identifies the account number. Point out to the donor that the number on the labels matches the number on the NCR paper pages of the Chain of custody form. On the chain of custody form, fill in Chain of Custody, “Donor Identification” and “Reason for Test” sections.
▪ Fill in the date collected, client ID number on the peel off label.
▪ Make an “X” in appropriate box to indicate reason for test.
▪ On the label, make an “X” next to the desired profile.
▪ In the comments section print any medications taken by the donor within
the last 30 days, including prescription drugs, over the counter medication, any medication dispensed by a doctor or dentist and intravenous drugs or injections. If there is not enough space in this section, the donor should continue the list in the blank space at the top of the chain of custody form.
▪ The collector, the donor and the paperwork must remain together from this point forward until the chain of custody is complete. Both collector and donor must keep the specimen cup and specimen bottle in sight until donor has voided and transferred the urine from the cup to the bottle. Subsequently, both the collector and the donor must keep the specimen bottle in sight until chain of custody is complete.
▪ Ask donor to select a urine collection kit. This may be done in the office before proceeding to the restroom for the actual specimen collection.

Collector and Donor

Go together to the restroom, taking along the urine collection kit and the partially completed chain of custody form including the cover page.
Donor In the presence of the collector, open the urine collection kit. Void into specimen cup and transfer urine to bottle. The donor may elect to omit the specimen cup and void directly into the bottle. A minimum of 30 ml of urine is required.

Collector Carefully observe the donor voiding into specimen cup or bottle and, if applicable, transferring urine from cup to bottle.
The collector must have a clear view of the donor. For example, with the door of the toilet stall completely open, the collector stands just outside the stall facing the donor.
Ascertain that the specimen is not substituted or adulterated in any way.

Donor Dispose of used specimen cup. Collector Instruct donor to hold up bottle so that collector can observe the temperature strip. This must be done within 4 minutes of collection. Check “Yes” if specimen is within indicated temperature range. Otherwise, check “No” and print “out of range.”
Visually check specimen for discoloration. If there is any discoloration, note on the chain of custody in the blank space

Tightly cap bottle. In Step 3 of the chain of custody the donor places the specimen bottle label over the closed cap and down the sides of the bottle to seal. The donor shall initial the label.

Collector The collector dates and signs the specimen bottle label. Donor Read certification, Print full name and client ID number, sign full name and date as donor.

Collector Read certification, print full name, sign full name and enter phone number on chain of custody. Fold together original of the chain of custody and hand them to the donor to place in the specimen bag. Initial and date the specimen bottle label. Keep copy of the chain of custody. Make a copy of the form for the donor to keep.

Donor Place specimen bottle, absorbent packing material and the chain of custody
form in specimen bag and close it. Gives closed specimen bag to collector.

Note: The chain of custody is now complete. The donor may leave. Do not open the specimen bag or write on the copy of the form after this point. Collector Place Collection Site Copy of chain of custody form in the pending file to match with results when received. Place specimen bag in designated location for Airborne Express pick up.
If facility is not scheduled for daily service, call lab dispatch to arrange for a courier. Do not request “stat” pick up or “stat” test results unless the additional expenditure is authorized in advance by the Program Director. The Program Director will evaluate the need for the additional expense on a case-by-case basis.

Lab Report results to the program generally within two business days. It may take additional time to clear or confirm results if the possibility of drugs is detected. Results are obtained by fax or the lab web site.

Program Director or Designee

Place the copy of the chain of custody form and the original sheet of the lab results in the client’s file. Enter results into MyEvolv. Review lab invoice and code each charge by cost center for payment. Pass coded invoice to Accounts Receivable.

• Collection / Disposal Procedures for TB Screening Mantoux PP skin test Action Taken Procedure/Forms Collector = MA, LVN or RN
(depending on staffing of facility)

• Wash hands and place gloves
• Confirm client’s identity using 2 client identifiers prior to performing the test
• Explain procedure to client
• Verify provider order
• Gather all supplies (tuberculin syringe 26 – 27 gauge needle 1/2”, alcohol swab)
• Verify medication expiration date
• Wipe vial with alcohol
• Cleanse skin at the injection site with alcohol swab and allow to dry
• Draw up 0.1 ml of the PPD agent (Mantoux) in the appropriate syringe
• Place the client’s arm in a comfortable position on a flat surface
• Select site (inner forearm) 1/3 from elbow area avoiding any visible veins
• Stretch the skin tightly between thumb and index finger before inserting the needle
• Insert needle bevel side up, holding the syringe parallel to skin to ensure accurate intradermal puncture
• Inject PPD agent resulting in a visible wheal about 6 to 10 mm. in size
• Instruct client to return within 48 to 72 hours after administration for reading
• Document procedure in client’s medical record
• Dispose of used needle in Sharps container
• Interpretation of the results of the Mantoux (PPD) Test:
• All readings will be done by a licensed, qualified staff member. No medical assistant will read PPD test results.
• The staff member reading the result will document the result in the client health record immediately after the reading.
• The following three cut points should be used to determine whether the skin test reaction is positive. A measurement of 0 mm or anything below the defined cut point for each category is considered negative.

Induration of ≥ 5 mm is considered positive in

Human immunodeficiency virus (HIV)-positive persons
• Recent contacts of TB case clients
• Persons with fibrotic changes on chest radiograph consistent with prior TB
• Clients with organ transplants and other
immunosuppressed clients (Receiving the
equivalent of 3;5 mg/d of prednisone for 1 month or more. Risk of TB in clients with corticosteroids increases with higher dose
and longer duration).

Induration of ≥ 10 mm is considered positive in
Recent immigrants (i.e., within the last 5 years)
from high prevalence country
• Injection drug users
• Clients and employees† of the following high-risk congregate settings: prisons and jails, nursing homes and other longterm facilities for the elderly, hospitals and other health care facilities, residential facilities for clients with acquired immunodeficiency
syndrome (AIDS), and homeless shelters
Mycobacteriology laboratory personnel
Persons with the following clinical conditions that place them at high risk: silicosis, diabetes mellitus, chronic renal failure, some hematologic disorders (e.g., leukemia’s and
lymphomas), other specific malignancies (e.g.,
carcinoma of the head, neck, or lung),weight loss of 3;10% of ideal body weight, gastrectomy, and jejunoileal bypass Children <4 years of age, or infants, children or
adolescents exposed to adults at high risk.

Induration of ≥ 15 mm is considered positive in Persons with no known risk factors for TB.

Reference: Centers for Disease Control and Prevention Division of Tuberculosis  Elimination
Testing Procedures for Urine-based Pregnancy Test
Action Taken Procedures/Forms Collector = MA, LVN, RN, LPHA/LEPHA or SUD counselor
(depending on staffing at facility)

• Wash hands and put on gloves
• Confirm patient’s identity using 2 identifiers prior to performing the test
• Explain the procedure to client
• Verify provider order
• Hand client the specimen container and direct patient to void in the restroom
• Label specimen container with client’s name if needed
• Remove test device from the pouch
• Using the pipette, obtain enough urine from the specimen up to the fill line
• Transfer the urine into the specimen device
• Test result will be read in the result window
• Read the result within the product testing directions which should reveal whether it’s positive or negative
• Document result in client’s chart

• Procedures for Blood draw Collector = LVN or RN or Contracted Lab Service

• Universal precautions shall be followed at all times as outlined in policies entitled, “Infection Control” only)
• Wash hands with soap and water before and after contact with the client
• Confirm client’s identity using two (2) client identifiers
• Put on gloves
• Explain procedure to client
• Ensure client confidentiality during procedure
• Check physician’s order for blood tests required
• Assemble required materials (vacutainer, alcohol wipe, tourniquet, gloves, gauze sponge, needle, lab tubes)
• Locate venipuncture site (antecubital fossa, dorsal aspect of the hand, median cubital vein)
• Apply the tourniquet above the area of the venipuncture site
• Cleanse the venipuncture site with alcohol swab prior to injection
• Fix chosen vein with thumb and draw the skin taut immediately below the site before inserting needle to stabilize the vein. With the
bevel of the needle up, slowly insert the needle at an acute angle to the vein and watch for the blood flow. When the vein has been hit, hold the site and needle firmly and attach the syringe to the needle or if using a “vacutainer” insert lab tube into vacutainer
needle and collect blood.
• When the specimen has been obtained, withdraw the needle, place a 2x2 gauze or cotton ball on the puncture site after the procedure and apply immediate pressure at the site of the venipuncture
• Release the tourniquet
• Label specimen container and place in a clear plastic specimen transport bag with laboratory requisition slip and deliver to front
storage container at the reception desk for transport to off-site laboratory
• Rotate test tubes to decrease the likelihood of the blood specimen from clotting
• Document date and type of test in progress note
• Procedures for Vitals (blood pressure and heart rate monitoring)

Action Taken
Collector = MA, LVN, RN or SUD counselor
(depending on staffing at facility)

Procedure/Forms:
• Wash hands
• Confirm client’s identity using 2 identifiers
prior to taking BP
• Explain procedure to client
• Select appropriate cuff size
• Palpate brachial artery
• Place cuff on bare arm with arrow over
brachial artery. Wrap cuff smoothly and
snugly
• Ensure client’s arm is fully supported on
furniture (i.e., table, arm of chair) at heart
level
• Instruct client to sit still and relax with back
supported, feet flat on floor, legs uncrossed
• Make sure monitor is plugged in and battery charged. Turn digital monitor power on.
• Cuff will auto-inflate
• Instruct client not to move/talk during BP
measurement
• Digital monitors measure BP by detecting
small movements
• After cuff auto-deflates, note the monitor
readings. The top number on the monitor
is the systolic pressure and the bottom is
the diastolic pressure reading. The last
number is the pulse rate.
• Repeat BP for any readings that are
initially elevated at least one minute
• Document in client’s medical record result
of BP

Urgent or Emergent Care
• Who determines current health status of clients – The physician officially determines
current health status of clients.
• Who makes decision to refer client to urgent or emergent care – Any staff member may make a decision to contact 9-1-1 for urgent or emergency care based on presenting symptoms.
• Who determines if client health status warrants readmission2 –The Program
Director or designee shall ensure that the client arrives with discharge paperwork from
the medical facility, and review paperwork to ensure that client’s health status warrants
readmission per referring party
• Who determines if client is eligible for IMS services – The physician determines if clients are eligible for IMS services.
2 “Readmission” in this context means re-entry to the residential treatment facility after the client has been transferred to a medical facility to address urgent or emergency health care needs.
BHS residential programs may hold a client’s bed if the client is anticipated to return to treatment within seven (7) calendar days. Beyond 7 days would prompt a formal discharge of the client. If the client applies to reenroll in the program after discharge, the regular admission policies and procedures would apply.

Residential SUD Incidental Medical Services – Monitoring Policy # 4.11.6.2
Treatment Health Status
Reviewed by: Board of Directors Review Date: 5/24/24
Approved by: Board of Directors Approval Date: 6/27/24
Effective Date 6/27/24
Supersedes Policy/Date: 1/21/18