Florida Administrative Code
59 - AGENCY FOR HEALTH CARE ADMINISTRATION
59A - Health Facility and Agency Licensing
Chapter 59A-3 - HOSPITAL LICENSURE
Section 59A-3.310 - Intensive Residential Treatment Facility Services
Universal Citation: FL Admin Code R 59A-3.310
Current through Reg. 50, No. 187; September 24, 2024
Services shall be designed to meet the needs of the emotionally disturbed patient and must conform to stated purposes and objectives of the program.
(1) Intake and Admission. Every IRTF shall develop written policies and procedures governing the facilities intake and admissions process.
(a) Acceptance of a child or adolescent for
inpatient treatment shall be based on the assessment, arrived at by the
multidisciplinary clinical staff involved and clearly explained to the patient
and the family. Whether the family voluntarily requests services or the patient
is referred by the court, the special hospital shall involve the family's
participation to the fullest extent possible. Discharge planning shall begin at
the time of intake and admission.
(b) Acceptance of the child or adolescent for
treatment shall be based on the determination that the child or adolescent
requires treatment of a comprehensive and intensive nature and is likely to
benefit by the programs that the facility has to offer.
(c) Admission shall be in keeping with stated
policies of the special hospital and shall be limited to those patients for
whom the special hospital is qualified by staff, program and equipment to give
adequate care.
(d) Staff members
who will be working with the patient, but who did not participate in the
initial assessment shall be oriented regarding the patient and the patient's
anticipated admission prior to meeting the patient. When the patient is to be
assigned to a group, the other patients in the group shall be prepared for the
arrival of the new member. There shall be a specific staff member assigned to
the new patient to observe him and help with the unit orientation
period.
(e) The admission procedure
shall include documentation concerning:
1.
Responsibility for and amount of financial support;
2. Responsibility for medical and dental
care, including consent for medical and surgical care and treatment;
3. Arrangements for appropriate family
participation in the program, phone calls and visits when indicated;
4. Arrangements for clothing, allowances and
gifts; and
5. Arrangements
regarding the patient's leaving the facility with or without medical
consent.
(f) Decisions
for admission shall be based on the initial assessment of the patient made by
the appropriate multidisciplinary clinical staff. This assessment must be
documented on the record of treatment on admission.
(g) The admission order must be written by a
staff or consultant physician.
(2) Assessment and Treatment Planning Including Discharge. Every IRTF shall develop written policies and procedures to ensure an initial assessment of the patient's physical, psychological and social status, appropriate to the patient's developmental age, is completed to determine the need and type of care or treatment required, and the need for further assessment. These policies and procedures shall include the assessment process as well as treatment planning including discharge planning, and include methods for involving family members or significant others (i.e., guardians, counselors, friends) in assessment, treatment, discharge, and follow-up care plans.
(a) Assessment. The facility is
responsible for a complete assessment of the patient, some of which may be
required just prior to admission, by professionals acceptable to the facility's
staff. The complete assessment shall include:
1. Physical. Subparagraphs a., b. and c. must
be completed by a physician, APRN or PA on the staff of the facility prior to
admission or within 24 hours after admission.
a. Complete medical history, including
history of medications;
b. General
physical examinations;
c.
Neurological assessment;
d. Motor
development and functioning;
e.
Dental assessment;
f. Speech,
hearing and language assessment;
g.
Vision assessment;
h. Review of
immunization status;
i. Laboratory
workup including routine blood work and analysis;
j. Chest x-ray and/or tuberculin
test;
k. Serology; and,
l. Urinalysis.
m. If any of the physical health assessments
indicate the need for further testing or definitive treatment, arrangements
shall be made to carry out or obtain the necessary evaluations or treatment by
clinicians, physicians, APRNs or PAs trained as applicable, and plans for these
treatments shall be coordinated with the patient's overall treatment
plan.
2.
Psychiatric/Psychological.
a. The assessment
includes direct psychiatric evaluation and behavioral appraisal, evaluation of
sensory, motor functioning, a mental status examination appropriate to the age
of the patient and a psychodynamic appraisal. A psychiatric history, including
history of any previous treatment for mental, emotional or behavioral
disturbances shall be obtained, including the nature, duration and results of
the treatment, and the reason for termination.
b. The psychological assessment includes
appropriate testing.
3.
Developmental/Social.
a. The developmental
history of the patient includes the prenatal period and from birth until
present, the rate of progress, developmental milestones, developmental
problems, and past experiences that may have affected the development. The
assessment shall include an evaluation of the patient's strengths as well as
problems. Consideration shall be given to the healthy developmental aspects of
the patient, as well as to the pathological aspects, and the effects that each
has on the other shall be assessed. There shall be an assessment of the
patient's current age, appropriate developmental needs, which shall include a
detailed appraisal of his peer and group relationships and
activities.
b. The social
assessment includes evaluation of the patient's relationships within the
structure of the family and with the community at large, and evaluation of the
characteristics of the social, peer group, and institutional settings from
which the patient comes. Consideration shall be given to the patient's family
circumstances, including the constellation of the family group, their current
living situation, and all social, religious, ethnic, cultural, financial,
emotional and health factors. Other factors that shall be considered are past
events and current problems that have affected the patient and family;
potential of the family's members meeting the patient's needs; and their
accessibility to help in the treatment and rehabilitation of the patient. The
expectations of the family regarding the patient's treatment, the degree to
which they expect to be involved, and their expectations as to the length of
time and type of treatment required shall be assessed.
4. Nursing. The nursing assessment shall be
performed by a person, who at a minimum, is duly licensed in the State of
Florida to practice as a registered nurse and shall include the evaluation of:
a. Self-care capabilities including bathing,
sleeping, eating;
b. Hygienic
practices such as routine dental and physical care and establishment of healthy
toilet habits;
c. Dietary habits
including a balanced diet and appropriate fluid and calorie intake;
d. Response to physical diseases (e.g.,
acceptance by the patient of a chronic illness as manifested by his compliance
with prescribed treatment);
e.
Responses to physical handicaps (e.g., the use of prostheses for coping
patterns used by the visually handicapped); and,
f. Responses to medications (e.g., allergies
or dependence).
5.
Educational/Vocational. The patient's current educational/vocational needs in
functioning, including deficits and strengths, shall be assessed. Potential
educational impairment and current and future educational vocational potential
shall be evaluated using, as indicated, specific educational testing and
special educators or others.
6.
Recreational. The patient's work and play experiences, activities, interests
and skills shall be evaluated in relation to planning appropriate recreational
activities.
(b) Treatment
Planning. An initial treatment plan shall be formulated, written and
interpreted to the staff and patient within 72 hours of admission. The
comprehensive treatment plan shall be developed for each child by a
multidisciplinary staff, within 14 days of admission. This plan must be
reviewed at least monthly, or more frequently if the objectives of the program
indicate. Review shall be noted in the record. A psychiatrist as well as
multidisciplinary professional staff must participate in the preparation of the
plan and any major revisions.
1. The treatment
plan shall be based on the assessment and shall include clinical consideration
of the physical, developmental, psychological, chronological age, family,
education, social and recreational needs. The reason for admission shall be
specified as shall specific treatment goals, stated in measurable terms,
including a projected time frame, treatment modalities to be used, staff who
are responsible for coordinating and carrying out the treatment, and expected
length of stay and designation of the person or agency to whom the child will
be discharged.
2. The degree of the
family's involvement (parent or parent surrogates) shall be defined in the
treatment planning program.
3.
Collaboration with resources and significant others shall be included in
treatment planning, when the treatment team determines it will not interfere
with the child's treatment.
4.
Procedures that place the patient at physical risk or pain shall require
special justification. The rationale for their use shall be clearly set forth
in the treatment plan and shall reflect the prior involvement and specific
review of the treatment plan by a child psychiatrist. When potentially
hazardous procedures or modalities are contemplated for treatment, there shall
be additional program specific policies governing their use to protect the
rights and safety of the patient. The facility shall have specific written
policies and procedures governing the use of electroconvulsive therapy or other
forms of convulsive therapy. If such procedures are to be used they shall be
carried out in a setting with emergency equipment available and shall be
administered only by medical personnel who have been trained in the use of such
equipment. Policies and procedures shall insure that:
a. Electroconvulsive therapy or other forms
of convulsive therapy shall not be administered to any patient unless, prior to
the initiation of treatment, two child psychiatrists with training or
experience in the treatment of adolescents, who are not affiliated with the
treating facility, have examined the patient, consulted with the responsible
child psychiatrist and have written and signed reports which show concurrence
with the administration of such treatment. Such reviews shall be carried out
only by American Board of Psychiatry certified or American Board of Psychiatry
eligible child psychiatrists;
b.
All signed consultation reports, either recommending or opposing the
administration of such treatment, shall be made a part of the patient's
clinical record;
c. Written
informed consent of members of the family authorized to give consent, and where
appropriate the patient's consent shall be obtained and made a part of the
patient's clinical records. The person who is giving such consent may withdraw
consent at any time;
d. Lobotomies
or other surgical procedures for intervention or alterations of a mental,
emotional or behavioral disorder shall not be performed on
patients.
(c)
Discharge. Discharge planning begins at the time of admission. A discharge date
shall be projected in the treatment plan. Discharges shall be signed by a staff
physician of the facility. A discharge summary shall be included in the
records. Discharge planning shall include input from the multidisciplinary
staff and will include family participation.
1. Discharge planning shall include a period
of time for transition into the community (e.g., home visits gradually
lengthened) for those patients who have been in the program for six months or
longer. There must be a written plan for follow-up services, either by the
facility or by another agency.
(3) Staff Coverage. Every IRTF shall develop written policies and procedures to ensure the program is staffed with appropriately trained and qualified individuals to meet the needs of the patients. There shall be a master clinical staffing pattern which provides for adequate clinical staff coverage at all times.
(a) There shall be at least one registered
nurse on duty at all times. Services of a registered nurse shall be available
for all patients at all times.
(b)
A physician shall be on call twenty-four (24) hours a day and accessible to the
facility within forty-five (45) minutes.
(c) Special attention shall be given to times
which probably indicate the need for increased direct care (e.g., weekends,
evenings, during meals, transition contained herein, and substantiated by the
results between activities, and waking hours).
(d) Staff interaction shall insure that there
is adequate communication of information regarding patients (e.g., between
working shifts or change of personnel) with consulting professional staff for
routine planning and patient review meetings. These interactions shall be
documented in writing.
(4) Program Activities. Every IRTF must develop an organizational chart with a description of each unit or department and its services, goals, policies and procedures, its relationship to other services and departments and how these are to contribute to the priorities and goals of the program, and ways in which the program carries out any community education consultation programs. Program goals of the facility shall include those activities designed to promote the physical and emotional growth and development of the patients, regardless of pathology or age level. There should be positive relationships with general community resources, and the facility staff shall enlist the support of these resources to provide opportunities for patients to participate in normal community activities as they are able. All labeling of vehicles used for transportation of patients shall be such that it does not call unnecessary attention to the patients.
(a) Group Size. The size and composition of
each living group shall be therapeutically planned and depend on the age,
developmental level, sex and clinical conditions. It shall allow for
staff-patient interaction, security, close observation and support.
(b) Routine Activities. Basic routine shall
be delineated in a written plan which shall be available to all personnel. The
daily program shall be planned to provide a consistent well structured yet
flexible framework for daily living and shall be periodically reviewed and
revised as the needs of the individual patient or the living group change.
Basic daily routine shall be coordinated with special requirements of the
patient's treatment plan.
(c)
Social and Recreation Activities. Program of recreational and social activities
shall be provided for all patients for daytime, evenings and weekends, to meet
the needs of the patients and goals of the program. There shall be
documentation of these activities as well as schedules maintained of any
planned activities.
(d) Religious
Activities. Opportunity shall be provided for all patients to participate in
religious services and other religious activities within the framework of their
individual and family interests and clinical status. The option to celebrate
holidays in the patient's traditional manner shall be provided and
encouraged.
(e) Education. The
facility shall arrange for or provide an educational program for all patients
receiving services in that facility.
1. The
particular educational needs of each patient shall be considered in both
placement and programming.
2.
Children or adolescents placed in the special hospital by a public agency or at
the expense of a public agency shall receive education consistent with the
requirements of Chapter 6A-6, F.A.C., as applicable.
(f) Vocational Programs. The facility shall
arrange for, or provide, vocational or prevocational training for patients in
the facility for whom it is indicated.
1. If
there are plans for work experience developed as part of the patient's overall
treatment plan, the work shall be in the patient's interest with payment where
appropriate, as determined by the treatment facility and the vocational
program, and never solely in the interest of the facility's goals or
needs.
2. Patients shall not be
solely responsible for any major phase or institutional operation or
maintenance, such as cooking, laundering, housekeeping, farming or repairing.
Patients shall not be considered as substitutes for employed
staff.
(g) Nutrition and
Standards. There shall be a provision of planning and preparation of special
diets as needed (e.g., diabetic, bland, high calorie). Menus shall be evaluated
by a consultant dietitian relative to nutritional adequacy at least monthly,
with observation of food intake and changes seen in the
patient.
(5) Physical Care. The facility shall have available, either within its own organizational structure or by written agreements or contracts with outside health care clinicians or facilities, a full range of services for the treatment of illnesses and the maintenance of general physical health.
(a) The facility shall develop a written plan
for medical services which delineates the ways the facility obtains or provides
all general and specialized medical, surgical, nursing, pharmaceutical and
dental services.
1. Insofar as rules
59A-3.300 through
59A-3.310, F.A.C., are intended
to establish minimum requirements for intensive residential treatment
facilities for children and adolescents that have a primary purpose of treating
emotional and mental disorders, such facilities are not required to establish
and maintain medical buildings and equipment required of general or specialty
hospitals as specified in rules
59A-3.080 through
59A-3.281, F.A.C. Services which
require such specialized buildings and equipment may be obtained from outside
health care providers by written agreement or contract. This shall not preclude
the facility from maintaining a medical services area or building which does
not meet the requirements of rules
59A-3.065 through
59A-3.281, F.A.C., for the
purpose of isolating patients with contagious diseases, conducting physical
examinations, providing preventive medical care services, or providing first
aid services.
2. If the facility
chooses to establish and operate a specialty or general hospital for the
purposes of offering medical care more intensive than those specified in
subsection 59A-3.065(32),
F.A.C., the plans for construction shall be submitted for review in accordance
with rule 59A-3.080, F.A.C., and such
facilities shall be required to be licensed, built and operated in accordance
with rules 59A-3.065 through
59A-3.281,
F.A.C.
(b) Patients who
are physically ill may be cared for on the grounds of the facility if medically
feasible as determined by a physician, ARNP or PA. If medical isolation is
necessary, there shall be sufficient and qualified staff available to provide
care and attention.
(c) Provisions
shall be made in writing for patients from the facility to receive care from
outside health care providers and hospital facilities, in the event of serious
illness which the facility cannot properly handle. Such determinations shall be
made by a licensed physician.
(d)
Every patient shall have a complete physical examination annually and more
frequently if indicated. This examination shall be as inclusive as the initial
examination. Efforts shall be made by the institution to have physical defects
of the patients corrected through proper medical care. Immunization shall be
kept current (DT, polio, measles, mumps, M-M-R).
(e) Each member of the program staff shall be
trained to recognize common symptoms of the illnesses of patients, and to note
any marked dysfunctions of patients.
(f) Staff shall have knowledge of basic
health needs and health problems of patients, such as mental health, physical
health and nutritional health. Staff shall teach attitudes and habits conducive
to good health through daily routines, examples and discussion, and shall help
the patients to understand the principles of health.
(g) Each program shall have a planned program
of dental care and dental health which shall be consistently followed. Each
patient shall receive a dental examination by a qualified dentist and
prophylaxis at least once a year. Reports of all examinations and treatment
shall be included in the patient's clinical record.
(6) Emergency Services. All clinical staff shall have training in matters related to handling emergency situations.
(a) Policies and procedures shall be written
regarding handling and reporting of emergencies and these shall be reviewed at
least yearly thereafter by all staff.
(b) There shall be a physician on call
twenty-four (24) hours a day; his/her name and where he/she can be reached
shall be clearly posted in accessible places for program staff.
(c) All staff providing direct patient care
must maintain current first aid certificate.
(d) An emergency medication kit shall be made
available and shall be constituted to meet the needs of the facility. The
emergency medication kit shall contain items selected by the staff or
consultant medical doctor and staff or consultant pharmacist which shall be
maintained and safeguarded in accordance with federal and state laws and
regulations pertaining to the specific drug items included.
(e) There shall be an adequate number of
first aid kits available to program staff at all times. Contents of the first
aid kits shall be selected by the staff or consultant medical personnel and
shall include items designed to meet the needs of the facility.
(f) The program shall have written policies
and procedures of obtaining emergency diagnosis and treatment of dental
problems. The program shall have written agreement with a licensed dentist(s)
who is a consultant or a member of the staff for emergency dental
care.
(g) The facility shall have a
written plan to facilitate emergency hospitalization in a licensed medical
facility. The facility shall make available a written agreement from a licensed
hospital verifying that routine and emergency hospitalization will be
provided.
(h) The special hospital
shall have a written plan for providing emergency medical and psychiatric care.
1. There shall be a written posted plan which
shall clearly specify who is available and authorized to provide necessary
emergency psychiatric or medical care, or to arrange for referral or transfer
to another facility to include ambulance arrangements, when
necessary.
2. There shall be a
written plan regarding emergency notification to the parents or legal guardian.
This plan and arrangements shall be discussed with all families or guardians of
patients upon admission.
(7) Pharmaceutical Services. Pharmaceutical services, if provided, shall be maintained and delivered as described in the applicable sections of chapters 465 and 893, F.S.
(8) Laboratory and Pathology Services.
(a) The facility shall provide clinical and
pathology services within the institution, or by contractual arrangement with a
laboratory commensurate with the facility's needs and which is registered under
the provisions of chapter 483, F.S.
1.
Provision shall be made for the availability of emergency laboratory services
24 hours a day, 7 days a week, including holidays.
2. All laboratory tests shall be ordered by a
licensed practitioner in accordance with section
483.041(7),
F.S.
3. All laboratory reports
shall be filed in the patient's medical record.
4. The facility shall have written policies
and procedures governing the collection, preservation and transportation of
specimens to assure adequate stability of specimens.
(b) Where the facility depends on an outside
laboratory for services, there shall be a written contract detailing the
conditions, procedures and availability of work performed. The contract shall
be reviewed and approved by the medical staff, administrator and the governing
board.
(9) Patients' Rights. Every effort shall be made to safeguard the legal and civil rights of patients and to make certain that they are kept informed of their rights, including the right to legal counsel and all other requirements of due process.
(a) Individual dignity and human rights are
guaranteed to all clients of mental health facilities in Florida by the Florida
Mental Health Act, known as the "Baker Act, " chapter 394, F.S.
(b) Each facility shall be administered in a
manner that protects the client's rights, his life, and his physical safety
while under treatment.
1. The special
hospital's space and furnishings should be designed and planned to enable the
staff to respect the patient's right to privacy and, at the same time, provide
adequate supervision according to the development and clinical needs of the
patients. Provisions for an individual patient's rights regarding privacy shall
be made explicit to the patient and family. A written policy concerning
patient's rights shall be provided to the patient of authentic research or
studies, or innovations of client's record.
2. The special hospital center's policies
shall allow patient visitation and communication with all members of the family
and other visitors as clinically indicated and when such visits are consistent
with the facility's program. When therapeutic considerations recommended by the
responsible licensed psychologist or physician necessitate restriction of
communication or visits, as set forth in the programs policies and procedures,
these restrictions shall be evaluated at least weekly by the clinical staff for
their continuing effectiveness. These restrictions shall be documented and
signed by the responsible psychologist or physician and be placed in the
patient's record. The special hospital shall make known to the patient, the
family and referring agency its policies regarding visiting privileges on and
off the premises, correspondence and telephone calls. These policies shall be
stated in writing and shall be provided to the patient and family and updated
when change in policy occurs. When limitations on such visits, calls or other
communications are indicated by practical reason, e.g., the expense of travel
or telephone calls, such limitations shall be determined with participation of
the patient's family or guardian.
3. Patients shall be allowed to request an
attorney through their parents or guardians. This shall be established as
written policy, and the policy shall be provided to families and
patients.
4. Patient's opinions and
recommendations shall be considered in the development and continued evaluation
of the therapeutic program. The special hospital shall have written policies to
carry out appropriate procedures for receiving and responding to patient
communications concerning the total program.
5. The special hospital shall have written
policies regarding methods used for control of patients' behavior. Such written
policies shall be provided to the appropriate staff and to the patient and his
family. Only staff members responsible for the care and treatment of patients
shall be allowed to handle discipline. Patients shall not be subject to cruel,
severe, unusual or unnecessary punishment. Patients shall not be subjected to
remarks which ridicule them or their families, or others.
6. Protective restraint consists of any
apparatus or condition which interferes with the free movement of the patient.
Only in an emergency shall physical holding be employed unless there are
physician's orders for a mechanical restraint. Physical holding or mechanical
restraints, such as canvas jackets or cuffs, shall be used only when necessary
to protect the patient from injury to himself or others. Use of mechanical
restraints reflect a psychiatric emergency and must be ordered by the
responsible staff/consultant physician, be administered by trained staff and be
documented in the patient's clinical records. The need for the type of
restraint used and the length of time it was employed and condition of the
patient shall be recorded in the patient's record. An order for a mechanical
restraint shall designate the type of restraint to be used, the circumstance
under which it is to be used and the duration of its use. A patient in a
mechanical restraint shall have access to a staff member at all times during
the period of restraint.
7. The
facility shall have written policies and procedures which govern the use of
seclusion. The use of seclusion shall require clinical justification and shall
be employed only to prevent a patient from injuring himself or others, or to
prevent serious disruption of the therapeutic environment. Seclusion shall not
be employed as punishment or for the convenience of staff. A written order from
a physician shall be required for the use of seclusion for longer than one
hour. Written orders for seclusion shall be limited to twenty-four (24) hours.
The written approval of the medical director or the director of psychiatrist
services shall be required when seclusion is utilized for more than twenty-four
(24) hours. Staff who implement written orders for seclusion shall have
documented training in the proper use of the procedures. Appropriate staff
shall observe and visually monitor the patient in seclusion every fifteen (15)
minutes, documenting the patient's condition and identifying the time of
observation. A log shall be maintained which will record on a quarter- hour
basis the observation of the patient in seclusion, and will also indicate when
the patient was taken to the bathroom, when and where meals were served, when
other professional staff visited, etc., and shall be signed by the observer.
The need or reason for seclusion shall be made clear to the patient and shall
be recorded in the patient's clinical record. The length of time in seclusion
shall also be recorded in the clinical record, as well as the condition of the
patient. A continuing log shall be maintained by the facility that will
indicate by name the patients placed in seclusion, date, time, specified reason
for seclusion and length of time in seclusion. In an emergency, orders may be
given by a physician over the telephone to a registered professional nurse.
Telephone orders must be reviewed within twenty-four (24) hours by the director
of psychiatric services.
8. The
special hospital shall not exploit a patient or require a patient to make
public statements to acknowledge his gratitude to the treatment
center.
9. Patients shall not be
required to perform at public gatherings.
10. The special hospital shall not use
identifiable patients' pictures without written consent. The signed consent
form shall be on file at the facility before any such pictures are used. A
signed consent form must indicate how pictures shall be used and a copy shall
be placed in the patient's clinical record.
(10) Records. The form and detail of the clinical records may vary but shall minimally conform to the following standards:
(a) Content. All clinical records
shall contain all pertinent clinical information and each record shall include:
1. Identification data and consent forms;
when these are not obtainable, reason shall be noted;
2. Source of referral;
3. Reason for referral, example, chief
complaint, presenting problem;
4.
Record of the complete assessment;
5. Initial formulation and diagnosis based
upon the assessment;
6. Written
treatment plan;
7. Medication
history and record of all medications prescribed;
8. Record of all medication administered by
facility staff, including type of medication, dosages, frequency of
administration, persons who administered each dose, and route of
administration;
9. Documentation of
course of treatment and all evaluations and examinations, including those from
other facilities, for example, emergency rooms or general hospitals;
10. Periodic treatment summaries; updated at
least every 90 days;
11. All
consultation reports;
12. All other
appropriate information obtained from outside sources pertaining to the
patient;
13. Discharge or
termination summary report; and,
14. Plans for follow-up and documentation of
its implementation.
(b)
Identification data and consent form shall include the patient's name, address,
home telephone number, date of birth, sex, next of kin, school and what grade,
date of initial contact or admission to the program, legal status and legal
document, and other identifying data as indicated.
(c) Progress Notes. Progress notes shall
include regular notations at least weekly by staff members, consultation
reports and signed entries by authorized identified staff. Progress notes by
the clinical staff shall:
1. Document a
chronological picture of the patient's clinical course;
2. Document all treatment rendered to the
patient;
3. Document the
implementation of the treatment plan;
4. Describe each change in each of the
patient's conditions;
5. Describe
responses to and outcome of treatment; and,
6. Describe the responses of the patient and
the family or significant others to significant inter-current
events.
(d) Discharge
Summary. The discharge summary shall include the initial formulation and
diagnosis, clinical resume, final formulation and final primary and secondary
diagnoses, the psychiatric and physical categories. The final formulation shall
reflect the general observations and understanding of the patient's condition
during appraisal of the fundamental needs of the patients. Records of
discharged patients shall be completed following discharge within a reasonable
length of time, and not to exceed 15 days. In the event of death, a summation
statement shall be added to the record either as a final progress note or as a
separate resume. This final note shall take the form of a discharge summary and
shall include circumstances leading to death. All discharge summaries must be
signed by a staff or consultant physician.
(e) Recording. Entries in the clinical
records shall be made by staff having pertinent information regarding the
patient, consistent with the facility policies, and authors shall fully sign
and date each entry. When mental health trainees are involved in patient care,
documented evidence shall be in the clinical records to substantiate the active
participation of supervisory clinical staff. Symbols and abbreviations shall be
used only when they have been approved by the clinical staff and when there is
an explanatory notation. Final diagnosis, both psychiatric and physical, shall
be recorded in full, and without the use of either symbols or
abbreviations.
(f) Policies and
Procedures. The facility shall have written policies and procedures regarding
clinical records which shall provide that:
1.
Clinical records shall be confidential, current and accurate;
2. The clinical record is the property of the
facility and is maintained for the benefit of the patient, the staff and the
facility;
3. The facility is
responsible for safeguarding the information in the record against loss,
defacement, tampering or use by unauthorized persons;
4. The facility shall protect the
confidentiality of clinical information and communication between staff members
and patients;
5. Except as required
by law, the written consent of the patient, family, or other legally
responsible parties, is required for the release of clinical record
information;
6. Records may be
removed from the facility's jurisdiction and safekeeping only according to the
policies of the facility or as required by law; and,
7. That all staff shall receive training, as
part of new staff orientation and with periodic update, regarding the effective
maintenance of confidentiality of the clinical record. It shall be emphasized
that confidentiality refers as well to discussions regarding patients inside
and outside the facility. Verbal confidentiality shall be discussed as part of
all employee training.
(g) Maintenance of Records. Each facility
shall provide for a master filing system which shall include a comprehensive
record on each patient's involvement in every program aspect.
1. Appropriate records shall be kept on the
unit where the patient is being treated or be directly and readily accessible
to the clinical staff caring for the patient;
2. The facility shall maintain a system of
identification and coding to facilitate the prompt location of the patient's
clinical records;
3. There shall be
policies regarding the permanent storage, disposal or destruction of the
clinical records of disclosure of confidential information later in
life;
4. The clinical record
services required by the facilities shall be directed, staffed and equipped to
facilitate the accurate processing, checking, indexing, filing, retrieval and
review of all clinical records. The clinical records service shall be the
responsibility of an individual who has demonstrated competence and training or
experience in clinical record administrative work. Other personnel shall be
employed as needed, in order to effect the functions assigned to the clinical
record services;
5. There shall be
adequate space, equipment and supplies, compatible with the needs of the
clinical record service, to enable the personnel to function effectively and to
maintain clinical records so that they are readily
accessible.
(11) Program and Patient Evaluation. The staff shall work towards enhancing the quality of patient care through specified, documented, implemented and ongoing the designing professions having as their purpose processes of clinical care evaluation studies and utilization review mechanisms.
(a) Individual Case
Review.
1. There shall be regular staff
meetings or unit meetings to review and monitor the progress of the individual
child or adolescent patient. Each patient's case shall be reviewed within a
month after admission and at least monthly during residential treatment. This
shall be documented. This meeting may also be used for review and revision of
treatment plans.
2. The facility
shall provide for a follow-up review on each discharged patient to determine
effectiveness of treatment and disposition.
(b) Program Evaluation.
1. Clinical Care Evaluation Studies. There
shall be evidence of ongoing studies to define standards of care consistent
with the goals of the program effectiveness of the program, and to identify
gaps and inefficiencies in service. Evaluation shall include follow-up studies.
Studies shall consist of the following elements:
a. Selection of an appropriate
design;
b. Specification of
information to be included;
c.
Collection of data;
d. An analysis
of data with conclusions and recommendations;
e. Transmissions of findings; and,
f. Follow-up on
recommendations.
2.
Utilization Review. Each facility shall have a plan for and carry out
utilization review. The review shall cover the appropriateness of admission to
services, the provision of certain patterns of services, and duration of
services. There shall be documentation of utilization review meetings either in
minutes or in individual clinical records. The improvement of patient care,
shall receive special consideration following a request and documentation of
the proposed project by the individual
sponsor.
Rulemaking Authority 395.1055 FS. Law Implemented 395.1055 FS.
New 1-1-77, Formerly 10D-28.92, 10D-28.110, Amended 9-4-95, 10-16-14, Formerly 59A-3.110.
Disclaimer: These regulations may not be the most recent version. Florida may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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