Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) Written policies and procedures shall be developed and maintained by the person responsible for the service in consultation with other appropriate health professionals and administration. Policies shall be approved by the governing body. Procedures shall be approved by the administration and medical staff where such is appropriate.
(b) The responsibility and the accountability of the psychiatric service to the medical staff and administration shall be defined.
(c) The psychiatric unit shall be used for patients with he diagnosis of a mental disorder requiring hospital care. For purposes of these regulations "mental disorder" is defined as any psychiatric illness or disease, whether functional or of organic origin.
(d) Medical services.
(1) Psychiatrists or clinical psychologists, acting within the scope of their licensure and subject to the rules of the facility, shall be responsible for the diagnostic formulation for their patients and the development and implementation of each patient's treatment plan.
(2) Medical examinations shall be performed as often as indicated by the medical needs of the patient. Reports of all medical examinations shall be on file in the patient's medical record.
(3) A psychiatrist shall be available at all times for psychiatric emergencies.
(4) An appropriate committee of the medical services shall:
(A) Identify and recommend to administration the equipment and supplies necessary for emergency medical problems.
(B) Develop a plan for handling and/or referral of patients with emergency medical problems.
(C) Determine the circumstances under which electroconvulsive therapy may be administered.
(D) Develop guidelines for the administration of a drug when given in unusually high dosages or for purposes other than those for which the drug is customarily used.
(e) Psychological services shall be provided by clinical psychologists within the scope of their licensure and subject to the provisions of Section 1316.5 of the Health and Safety Code. Staff physicians shall assume responsibility for those aspects of patient care which may be provided only by physicians.
(f) Provision shall be made for the rendering of social services by social workers at the request of a patient's attending physician or psychologist.
(g) Therapeutic activity program.
(1) Every unit shall provide and conduct organized programs of therapeutic activities in accordance with the interests, abilities and needs of the patients.
(2) Individual evaluation and treatment plans which are correlated with the total therapeutic program shall be developed and recorded for each patient.
(h) Education.
(1) No hospital shall accept children of school age who are educable or trainable and who are expected to be a patient in the unit for one month or longer unless an educational or training program can be made available for such children in accordance with their needs and conditions.
(2) Educational programs provided in the facility shall follow those programs established by law, and shall be under the direction of teachers with California teaching credentials.
(3) If children attend community schools, supervision to and from school shall be provided in accordance with the needs and conditions of the patients.
(4) Transportation to and from school shall be provided where indicated.
(i) The medical records of all patients admitted to the unit shall contain a legal authorization for admission. Release of information or medical records concerning any patient shall be only as authorized under the provisions contained in Article 7 (commencing with Section 5325; and Section 5328 in particular) Part 1, Division 5 of the Welfare and Institutions Code.
(j) Restraint of patients.
(1) Restraint shall be used only when alternative methods are not sufficient to protect the patient or others from injury.
(2) Patients shall be placed in restraint only on the written order of the licensed healthcare practitioner acting within the scope of his or her professional licensure. This order shall include the reason for restraint and the type of restraint to be used. In a clear case of emergency, a patient may be placed in restraint at the discretion of a registered nurse and a verbal or written order obtained thereafter. If a verbal order is obtained it shall be recorded in the patient's medical record and be signed by the licensed healthcare practitioner on his or her next visit.
(3) Patients in restraint by seclusion or mechanical means shall be observed at intervals not greater than 15 minutes.
(4) Restraints shall be easily removable in the event of fire or other emergency.
(5) Record of type of restraint including time of application and removal shall be in the patient's medical record.
(k) Patients' rights.
(1) All patients shall have rights which include, but are not limited to, the following:
(A) To wear his own clothes, to keep and use his own personal possessions including his toilet articles; and to keep and be allowed to spend a reasonable sum of his own money for canteen expenses and small purchases.
(B) To have access to individual storage space for his private use.
(C) To see visitors each day.
(D) To have reasonable access to telephones, both to make and receive confidential calls.
(E) To have ready access to letter writing materials, including stamps, and to mail and receive unopened correspondence.
(F) To refuse shock treatment.
(G) To refuse lobotomy.
(H) To be informed of the provisions of law regarding complaints and of procedures for registering complaints confidentially, including but not limited to, the address and telephone number of the complaint receiving unit of the Department.
(I) All other rights as provided by law or regulations.
(2) The licensed health care practitioner acting within the scope of his or her professional licensure who has overall responsibility for the unit or his or her designee, may for good cause, deny a person any of the rights specified in (1) above, except those rights specified in subsections (F), (G) and (I) above and the rights under subsection (F) may be denied only under the conditions specified in Section 5326.4, Welfare and Institutions Code. The denial, and the reasons therefore, shall be entered in the patient's medical record.
(3) These rights, written in English and Spanish, shall be prominently posted.
(l) Psychiatric unit staff shall be involved in orientation and in-service training of hospital employees.
(m) Periodically, an appropriate committee of the medical staff shall evaluate the services provided and make appropriate recommendations to the executive committee of the medical staff and administration.
1. Amendment filed 2-8-83; designated effective 3-2-83 (Register 83, No. 7).
2. Amendment of subsection (d)(1) filed 11-1-85 as an emergency; effective upon filing (Register 85, No. 44). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 3-3-86.
3. Certificate of Compliance transmitted to OAL 2-28-86 and filed 3-26-86 (Register 86, No. 13).
4. Change without regulatory effect amending subsection (e), repealing subsections (e)(1)-(2), amending subsection (j)(2) and amending NOTE filed 3-24-2005 pursuant to section 100, title 1, California Code of Regulations (Register 2005, No. 12).
5. Change without regulatory effect amending subsection (e), adding new subsections (e)(1)-(2) and amending subsection (j)(2) and NOTE filed 4-20-2006 pursuant to section 100, title 1, California Code of Regulations (Register 2006, No. 16).
6. Amendment of subsections (d)(1)-(2) and (e), repealer of subsections (e)(1)-(2) and amendment of subsections (f), (j)(2) and (k)(2) and NOTE filed 3-3-2010; operative 4-2-2010 (Register 2010, No. 10).
Note: Authority cited: Sections 1275, 100275 and 131200, Health and Safety Code. Reference: Sections 1255, 1276, 1316.5, 131050, 131051 and 131052, Health and Safety Code.
