Operating Manual v0.1 DRAFT

AHD-CLINICAL-001 — Operating Manual v0.1

Avina Home Detox LLC Status: DRAFT v0.1 (Avina version, recreated from scratch in our voice; replaces the MD Detox baseline reference) Date: 24/04/2026 Owner: Medical Director (Elizabeth Mortazavi MD) + Director of Nursing (TBA)

Preamble

This Operating Manual governs the day-to-day clinical and operational delivery of Avina Home Detox engagements. It is the operating standard, authored by the Medical Director and ratified by the Director of Nursing. Every nurse, every clinician, every operations staff member commissioned by the Company is trained against this Manual before a first deployment.

The Manual is reviewed quarterly and audited annually. Changes require Medical Director sign-off. Field deviations require written justification and Medical Director ratification within 24 hours.

I. INTAKE

A. Inbound Channels

Inbound enquiries arrive through one of three channels:

  1. The Avina Wellness website enquiry form
  2. The Avina Home Detox direct enquiry form (avinahomedetox.com)
  3. Direct contact with Kelly Mortazavi, the Medical Director, or Elizabeth’s clinical referral network

Every enquiry is logged in the CRM within 30 minutes of receipt. Every enquiry receives a response from Kelly Mortazavi or her senior operator within 48 hours. No automated replies. No booking systems.

B. The First Conversation

The first conversation is a one-hour phone call held by Kelly Mortazavi or the Medical Director. The conversation establishes:

  1. The presenting clinical condition
  2. The principal’s history with detox or treatment
  3. The principal’s current medical state (medications, comorbidities, recent hospitalisations)
  4. The residence environment (geography, household composition, security needs)
  5. The family or family-office context
  6. Timeline urgency
  7. The family-office contact authorised to receive briefings

No clinician is on the first call. No clinical advice is given. No commitments are made. The call is qualification.

C. Clinical Information Collected (post-first-call)

Once a case advances past the first conversation, the following is gathered for the Medical Director’s case review:

D. Email Alert (within Avina)

When a case is approved by the Medical Director, an internal alert is dispatched to the operations channel:

Case files are stored in the encrypted Vault, not in email. Email alerts contain no PHI. Case files reference Case IDs only.

II. APPROVAL

A. Medical Director Case Review

The Medical Director reviews every prospective case before clinical work begins. The Medical Director:

  1. Reads the full intake file
  2. Conducts a 30-60 minute clinical phone interview with the principal
  3. Reviews any available medical records the principal authorises
  4. Reaches a written approval / decline decision within 24-48 hours of intake completion

Approval criteria. Cases approved are those where: - Withdrawal can be safely managed in the residence under Avina protocols - The principal is medically stable enough for in-residence care - The residence environment supports safe care delivery - No immediate hospitalisation is medically indicated - The principal consents to the engagement

Decline criteria. Cases declined include: - Severe alcohol withdrawal with prior history of seizure or DT requiring hospitalisation - Polysubstance withdrawal with cardiac history or QT prolongation risk - Active suicidal ideation requiring inpatient psychiatric admission - Pregnancy (refer to OB/Gyn-supervised inpatient detox) - Cardiac, hepatic, or renal compromise beyond the safety threshold - Residence environment unsuitable for clinical care delivery

A declined case receives a warm referral to a more appropriate care setting. The referral is not transactional and no fee is paid or accepted.

B. Documentation of Approval

Every approval is documented in the EMR, signed by the Medical Director, and stored in the Vault. The approval includes:

III. ONBOARDING

A. Documents Issued to the Principal

Once approved, the principal (or the family-office contact authorised to act on their behalf) receives:

  1. Engagement Letter — names the Medical Director, the practices commissioned (Detox + IV Recovery Course where applicable), the engagement state, the rhythm of family briefing, the boundary of confidentiality between principal and family
  2. Consent for Treatment — covers the medical detox protocol, the IV protocols where applicable, emergency response authorisation, communication with the principal’s outside providers
  3. HIPAA Notice of Privacy Practices — Avina’s HIPAA disclosures
  4. 42 CFR Part 2 Notice — additional confidentiality protections for substance use treatment records
  5. Credit Card Authorisation — payment terms per the engagement letter
  6. Avina Home Detox Brochure — for principal and family

All documents executed via DocuSign. Originals stored in the Vault.

B. Payment

Collected after Medical Director approval and before Day 1 of the engagement. Payment by wire transfer (preferred) or credit card. Avina invoices through Mercury Bank’s invoicing system or via the engagement letter directly.

C. Pre-Arrival Logistics

Director of Nursing schedules: - Primary nurse and rotating nurses for the case duration - Pharmacy briefing and medication preparation - Equipment delivery to the residence (or pre-positioned by Day 0) - Family-office briefing call to align on cadence and contacts

IV. NURSING — DAY 1 ARRIVAL

A. On Arrival

The arriving nurse:

  1. Confirms identity of the principal against the case file
  2. Conducts the consent process: signs all consents the principal has not yet executed
  3. Disposes of all drugs and alcohol in the residence appropriately, with the principal’s consent and witnessed
  4. Conducts the baseline assessment (Section IV.B)
  5. Sends the baseline report to the case group thread (within the encrypted comms platform), tagging the Medical Director

B. Baseline Assessment (every case)

The baseline assessment goes into the EMR as the H&P (History and Physical) for the engagement.

C. Safety Posture

V. NURSING — ONGOING SHIFT WORKFLOW

A. Cadence

B. Documentation

Every nursing entry includes: - Timestamp - Vital signs - Withdrawal score - Subjective: principal’s report - Objective: nurse’s clinical observations - Medications administered (with dose, route, time) - Plan for the next 4-hour window - Any escalations to MD

C. Group Thread Reporting

A written shift report is sent to the encrypted case group thread at every shift change. The report contains:

The Medical Director reads the group thread daily and is alerted in real time on any flagged event.

D. Refusal of Vitals

If the principal declines vital signs, the refusal is documented as: “Principal declined vital signs at [time]. Nurse explained clinical purpose; principal acknowledged. Will reattempt at next medication administration.” The Medical Director is notified.

E. Change in Condition Escalation

The nurse contacts the Medical Director immediately on any of: - Significant change in mental status - Hemodynamic instability (SBP <90 or >180; HR <50 or >120) - Respiratory distress or SpO2 <92% - Seizure activity - Loss of consciousness - Severe nausea / vomiting / diarrhoea producing dehydration risk - Signs of severe alcohol withdrawal (delirium tremens) - Suicidal ideation expressed - Any concern in the nurse’s clinical judgement

If an emergency, the nurse calls 9-1-1 first and notifies the Medical Director second.

VI. CHARTING — EMR

A. EMR System

DrChrono Pro is the system of record. All clinical notes are entered in the EMR. Paper MAR is used for medication administration tracking and reconciled to the EMR daily.

B. Visit Documentation

Each shift is documented as one SOAP note in the EMR: - Subjective: the principal’s report - Objective: clinical observations and vitals - Assessment: the nurse’s clinical assessment - Plan: next-window plan

The visit is signed by the nurse at end of shift. The Medical Director co-signs within 24 hours.

C. Medication Administration Record (MAR)

Every medication administered is documented on the paper MAR (with timestamp, dose, route, signature) and entered in the EMR. The paper MAR is reconciled against the EMR by the DON or Medical Director on every Day 3 and at case close.

D. Case Closure

At case close, the Medical Director writes a case summary in the EMR including: indication, protocol used, day-by-day course, any complications, medications dispensed and remaining, recommended aftercare, recommended IV maintenance schedule (where applicable), recommended therapeutic follow-up.

VII. CLINICAL — DETOX MEDICATIONS

A. Reference

Full medication detail by indication is in AHD-PROTOCOL-LIBRARY-v0.1.md. The Operating Manual references the library; the library is the source of truth for medication, dose, route, frequency, and contraindications.

B. Medication Authority

All medications are administered under standing or specific orders from the Medical Director. The MAR is co-signed by the MD on every Day 3 and at case close.

C. Controlled Substance Handling

Schedule II/III/IV substances are couriered from the pharmacy to the residence by an authorised person on the day of administration. Storage in the residence is in a locked container with the nurse holding the key. Unused doses are returned to the pharmacy at case close and reconciled.

VIII. CLINICAL — IV PROTOCOLS

A. Reference

Full IV protocol detail is in AHD-IV-LIBRARY-v0.1.md (under research, pending NEXUS clinical brief). The Operating Manual references the library; the library is the source of truth.

B. IV Authority

Every IV protocol is prescribed by the Medical Director on a case-specific basis. Standing orders cover hydration and thiamine repletion; all NAD, glutathione, and other infusions require case-specific written orders.

C. IV Workflow

The nurse places the IV under standard sterile technique. Vital signs are taken before infusion start, every 15 minutes during NAD infusion (which is delivered slowly over 4-6 hours), at infusion end, and 30 minutes post-infusion.

Common adverse reactions (NAD-specific): chest pressure during infusion (slow the rate), niacin flush, GI discomfort. The nurse pauses the infusion for any patient discomfort and contacts the Medical Director.

IX. POST-CASE — DISCHARGE AND AFTERCARE

A. Discharge Workflow

At case close (typically Day 5 standard, Day 7-10 extended): 1. Final assessment by the closing nurse 2. Final medication reconciliation 3. Discharge summary written by the Medical Director 4. Aftercare plan (IV course schedule where applicable, telehealth therapy schedule, family-office briefing schedule) 5. Family-office contact briefed on aftercare 6. Equipment removal from residence 7. Vault file finalised

B. Aftercare Coordination

The Medical Director (or a designated case manager) holds an aftercare check-in with the principal: - Day 7 post-discharge (phone) - Day 14 post-discharge (phone) - Day 28 post-discharge (phone or in person) - Monthly thereafter (per engagement letter)

X. DISCRETION

A. NDA Cascade

Every clinician on a case has signed a master NDA covering the principal, the family, the residence, and the contents of every conversation. Vendors engaged on a case sign before retention.

B. Communications Standards

C. Pharmacy and Courier Discretion

D. Family-Office Briefing Discipline

XI. INCIDENT MANAGEMENT

A. Adverse Event

Any clinical adverse event (medication reaction, injury, fall, deviation from expected course): 1. Stabilise the principal 2. Contact the Medical Director immediately 3. Document in the EMR within 1 hour 4. Family-office briefed per engagement letter 5. Internal incident report filed within 24 hours 6. Quarterly M&M review

B. Emergency

Any emergency: 1. Call 9-1-1 2. Provide care to the limit of clinical scope until EMS arrives 3. Notify Medical Director immediately 4. Notify Director of Nursing 5. Notify Kelly Mortazavi 6. Document fully in the EMR 7. Family-office contact briefed by the Medical Director or Kelly within 1 hour

C. Confidentiality Breach

Any suspected breach of confidentiality (intentional or accidental): 1. Investigate immediately 2. Contain 3. Notify the principal and the family-office contact within 24 hours per HIPAA breach notification rules 4. Document and report to counsel within 48 hours

XII. STAFF — NURSING

A. Recruitment

All nursing staff are 1099 contractors, licensed in the jurisdiction of the engagement, with documented current licensure, current BLS, and (preferred) ACLS certification. Substance use disorder nursing experience preferred.

B. Onboarding

Every new nurse completes: 1. Background check (criminal, professional) 2. Reference check (3 minimum, all clinical) 3. License verification 4. NDA execution 5. Avina Home Detox Nursing Curriculum (12 modules, ~40 hours) 6. Supervised first deployment with the Director of Nursing

A first-deployment validation is required before any solo deployment.

C. Ongoing Performance

Quarterly clinical performance review by the Director of Nursing. Annual review by the Medical Director. Continuing education requirements per state law.

XIII. M&M REVIEW

The Medical Director and the Director of Nursing convene a quarterly Morbidity and Mortality review to: - Review every adverse event - Review every protocol deviation - Review every case escalation - Identify training gaps - Update the protocol library and the Operating Manual

XIV. AMENDMENTS

This Manual is a living document. Amendments are proposed by any clinician, reviewed by the DON, and ratified by the Medical Director. All amendments are dated, version-controlled, and stored in the Vault.

End of v0.1. Refresh quarterly. Annual audit by external healthcare compliance auditor scheduled Y2.