Testing Associated with Detoxification from Alcohol or Drugs

Behavioral Health Services, Inc.

Subject: Residential SUD Treatment Policy#: 4.11.6.3
Title: Incidental Medical Services – Testing Associated with Detoxification from Alcohol or Drugs

Effective Date: February 21, 2023

POLICY:
BHS residential treatment facilities that are licensed by DHCS shall provide IMS – Testing associated with detoxification from alcohol or drugs 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 – Testing associated with detoxification from alcohol or drugs in their facilities.

PROCEDURES:
Assessment of resident’s health status to determine safest course of managing detoxification Who determine the course of detoxification treatment - the Medical Director or alternate HCP determines the safest course of detoxification treatment for the resident, based on the assessment, physical exam and screenings or laboratory testing ordered.
How is the course of treatment determined – the Medical Director or alternate HCP evaluates all conditions from the assessment, including the resident’s age, drug of choice, length of use, adverse medical conditions and screening/testing results obtained during admission and prior to implementing an appropriate drug protocol for detoxification/withdrawal management. The Medical Director or alternate HCP may also review outside medical records when appropriate, with patient signed consent.

Types of testing
Specify all testing performed for residents in detoxification treatment – Testing for detox patients at the residential treatment facilities includes all of the following: Alcohol & Drug (Urinalysis) Screening (Point of Care and Laboratory-based) – conducted on site by qualified staff acting within scope, depending upon the staffing at the facility.
Tuberculosis (TB) Screening Mantoux Skin test (PPD) or Quantiferon TB– placed by qualified staff and read by qualified staff.
Urine-based pregnancy test (for women in detox) – conducted on site, by qualified staff acting within scope, depending on the staffing at the facility.
Testing for Chronic Diseases that may affect their course of treatment and ability to undergo detoxification.
On occasion, blood tests may also be ordered by the Medical Director or alternate HCP. Blood tests ordered may include but are not limited to tests for red and white blood cell counts, electrolytes, organ function, liver enzymes and nutrient deficiencies. These tests may have the blood draw at the facility and sent to an outside laboratory or the resident is referred and transferred to a laboratory for blood draw if this test is deemed necessary by the Medical Director or alternate HCP for a safe detoxification. Residents whose medical condition or detoxification/withdrawal management protocol requires extensive laboratory testing beyond what is offered at the facility, may be referred to a higher level of care (e.g. 3.7-WM or 4.0-WM) where the testing may be provided on site. This will be determined by the Medical Director or alternate HCP at the time of physical exam.
Blood test for hepatic panel may be conducted on site to determine appropriate level of detoxification (3.2-WM or 3.7-WM) required for the patient. Blood sample drawn is sent to an outside lab for analysis.

Administration of Tests
Who administers the tests and Where they are administered –
Alcohol & Drug (Urinalysis) Screening (Point of Care and Laboratory-based) – conducted on site by qualified staff acting within scope, , depending upon the staffing at the facility.
Tuberculosis (TB) Screening Mantoux Skin test (PPD) – placed by qualified staff and read by qualified staff.
Urine-based pregnancy test (for women in detox) – conducted on site, by qualified staff acting within scope, depending on the staffing at the facility.
Blood test for hepatic panel or Chronic Disease – blood drawn in the physical exam room, by LVN, RN or MA.
How tests are administered
Collection / Disposal Procedures for Alcohol and Drug Urinalysis Screening
Staff members performing alcohol and drug screening must be trained, authorized by the supervisor, and know urine drug screen procedures before being permitted or assigned to perform drug screening tests. The trained staff member (aka witness/collector) is responsible for instructing the donor in the drug screen procedures. The witness/collector shall follow BHS testing procedures ensure a valid test and result. When urine testing is performed, the resident’s emission of urine should be collected and observed by a witness/collector with the same gender as the patient whenever possible when congruent with patient’s gender identity. A nurse may serve as witness/collector for either gender.
All staff must be respectful of the patient and patient’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 (Redi-Cup) Tests

Action Taken Procedure/Forms

Witness/Collector = SUD Counselor, MA, LVN, RN (depending on staffing at facility)
Any trained staff member (SUD counselor, MA, LVN, RN) may serve as the witness/collector for drug screen analysis, 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. Witness/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 witness/collector, the donor and the paperwork must remain together from this point forward until the chain of custody is complete. Both witness/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 witness/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.
Witness/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 witness/collector void into specimen cup and screw on the lid. A minimum of 30 ml of urine is required.
Witness/Collector Carefully observe the donor voiding into specimen cup or bottle and, if applicable, transferring urine from cup to bottle.
The witness/collector must have a clear view of the donor. For example, with the door of the toilet stall completely open, the witness/collector stands just outside the stall facing the donor.
Ascertain that the specimen is not substituted or adulterated in any way.

Witness/Collector Instruct donor to hold up bottle so that witness/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.
Witness/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 Redi-Cup 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 designee Place the copy of the chain of custody form in the client’s file. Enter results into EHR.
Review lab invoice and code each charge by cost center for payment. Pass coded invoice to Accounts Receivable.

Procedures - Laboratory Based Tests Action Taken Procedure/Forms
Witness/Collector Any trained staff member may serve as the witness/collector for drug screen analysis, 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. Witness/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 witness/collector, the donor and the paperwork must remain together from this point forward until the chain of custody is complete. Both witness/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 witness/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.
Witness/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 witness/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.
Witness/Collector Carefully observe the donor voiding into specimen cup or bottle and, if applicable, transferring urine from cup to bottle.
The witness/collector must have a clear view of the donor. For example, with the door of the toilet stall completely open, the witness/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.
Witness/Collector Instruct donor to hold up bottle so that witness/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. 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.
Witness/Collector The witness/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.
Witness/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 witness/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.
Witness/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 labratory 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 EHR.
Review lab invoice and code each charge by cost center for payment. Pass coded invoice to Accounts Receivable.

Collection / Disposal Procedures for TB Screening Action Taken Procedure/Forms
Collector = LVN or RN (depending on staffing of facility) Wash hands

Confirm patient’s identity using 2 patient identifiers prior to performing the test

Explain procedure to patient

Place gloves on

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 patient’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 patient to return within 48 to 72 hours after administration for reading

Document procedure in patient’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 staff. No medical assistant will read PPD test results.

The staff member reading the result will document the result in the patient 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 patients
• Persons with fibrotic changes on chest radiograph consistent with prior TB
• Patients with organ transplants and other
immunosuppressed patients (Receiving the equivalent of ⊃ 3.5 mg/d of prednisone for
1 month or more. Risk of TB in patients 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
• Residents and employees† of the following high-risk congregate settings: prisons and jails, nursing homes and other long-term facilities for the elderly, hospitals and
other health care facilities, residential facilities for patients 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

3) Testing Procedures for Urine-based Pregnancy Test

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

Procedures/Forms

• Wash hands
• Confirm patient’s identity using 2 patient identifiers prior to performing the test
• Explain procedure to patient
• Verify provider order
• Hand patient a specimen container and direct patient to void in the restroom
• Label specimen container with patient’s name if needed
• Put on gloves
• 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 patient’s chart

4) Testing procedures for blood draw

Collector = LVN or RN

• Universal precautions shall be followed at all times as outlined in the policies entitled, “Infection Control”
• Wash hands with soap and water before and after contact with the patient
• Confirm patient’s identity using two (2) patient identifiers
• Put on gloves
• Explain procedure to patient
• Ensure patient confidentiality during procedure
• Check Medical Director or alternate HCP’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 notes

• Review of test results (who, how, when) – The staff member who administers the
test shall read and document test results, in accordance with the procedures above.
The Medical Director or alternate HCP will review these test results as part of his/her
evaluation of the resident’s health status and to determine the safest course of detoxification. The Medical Director or alternate HCP makes the final determination
of test results as soon as they are available for evaluation.
Point of care urine drug screening results are considered preliminary. Positive results will be discussed with the patient. Patient admission of drug use will be considered confirmation of the result. For patients who deny drug use, the sample will be sent to the laboratory for confirmation. The patient will be retained in the program pending confirmation of the results.
• Documentation of tests and results (who, how, where) – The staff member who
administered the test will record the tests conducted and their results in the resident’s health record immediately upon completion of the test, in accordance with the procedures outlined above.