Current through Reg. 50, No. 187; September 24, 2024
(1)
Advisory or Governing Board. The CSU or SRT shall have either a formally
constituted advisory or governing board for the CSU or SRT or operate under a
provider board which has ultimate authority for establishing policy and
overseeing the operation of the CSU or SRT. The board shall operate under a
mission statement and a set of bylaws governing its operation.
(a) Selection and Terms of Office. If an
advisory or governing board exists, the method of selection of members and
terms shall be specified in the corporate bylaws of the corporation. The
membership of such an advisory or governing board shall include broad
representation from the professional disciplines and the community, including a
consumer and a consumer's family member, and shall meet quarterly.
(b) Records. Records of the CSU or SRT with
an advisory or governing board shall include the name, address, and terms of
office of members; written minutes of meetings; attendance; and specific
recommendations or decisions of the board.
(2) Personnel Policies. Personnel policies
shall be made available in writing to all personnel. Policies shall include
rules governing the ethical conduct of staff and volunteers, rights and
confidentiality of information regarding individuals receiving services.
(a) Performance Evaluation of Staff. An
annual performance evaluation of all personnel shall be conducted. The program
shall provide for the signature of the employee acknowledging receipt of the
evaluation.
(b) Personnel Records.
Records on all employees and volunteers shall be maintained by the CSU or SRT.
Each employee record, available for employee review shall contain:
1. The employee's current job description
with minimum qualifications for the position;
2. The employment application or resume with
evidence that references were checked prior to employment;
3. The employee's annual
evaluations;
4. A copy of the
employee's professional license, if applicable;
5. A receipt indicating that the employee has
been trained and understands program policies and procedures, patient rights as
stated in Section 394.459, F.S., ethical conduct,
and confidentiality of information regarding individuals receiving
services;
6. Documentation that the
employee has been trained and understands the legal mandate under Section
415.103, F.S., to report
suspected abuse and neglect as well as the use of the Florida Abuse Hotline;
and,
7. Documentation that the
employee or volunteer has been fingerprinted and screened, if appropriate, in
accordance with Section
394.4572, F.S.
8. Documentation of training as required by
Section 381.0035, F.S., for all
non-licensed staff.
(c)
Fingerprint Screening. All personnel, as defined in Section
394.4572, F.S. shall be screened
in accordance with Sections
394.4572 and
408.809, F.S. Each CSU and SRT
shall maintain fingerprint screening records as follows:
1. A current list which identifies, by
position title, all positions which require fingerprint screening.
2. A continuously updated record of all
active personnel which identifies for each person his position title, date of
hire, and the date of the most recent fingerprint
screening.
(3)
Staff Development and Training. Each CSU and SRT shall provide staff
development and training for all facility staff, including part-time,
temporary, and volunteers, and shall develop policies and procedures for
implementing these activities. Policies and procedures shall be reviewed
annually. There shall be a qualified and experienced staff person responsible
for staff development and training who is, under the supervision of, or
receives consultation from, a mental health professional licensed under Chapter
491, F.S. All staff development and training activities shall be documented and
shall include activity or course title; number of contact hours; instructor's
name; credentials; and, date. The participation of each employee shall be
documented in accordance with systemic procedures either in the employee's
personnel file or staff development and training file. Attendance at
professional workshops and conferences should also be documented
accordingly.
(4) Financial Records.
Financial records that identify all income by source, and report all
expenditures by category, shall be maintained in a manner consistent with
Chapter 65E-14, F.A.C.
(5)
Confidentiality and Clinical Records. Every CSU and SRT shall maintain a record
on each individual receiving services, assuring that records and identifying
information are maintained in a confidential manner, and securing valid lawful
consent prior to the release of information in accordance with Section
394.4615, F.S. Clinical records
may be stored on paper, magnetic material, film, or other media, including
electronic storage. All staff shall receive training as part of staff
orientation, with at least a triennial update on file, regarding the effective
maintenance of confidentiality of clinical records, including electronic
records. It shall be emphasized that confidentiality includes oral discussions
regarding individuals receiving services inside and outside the CSU or SRT and
shall be discussed as part of employee training.
(a) Clinical Record System. Each CSU and SRT
shall have policies and procedures, in accordance with Section
394.4615, F.S., for a clinical
record system. The clinical record is the focal point of treatment
documentation and is a legal document. Entries placed in the clinical record to
document the individual's progress or facility's actions must be objective,
legible, accurate, dated, timed when appropriate, and authenticated with the
writer's signature, title, and discipline. Electronic signatures, as defined in
Chapter 668, Part I, F.S., are permissible. The clinical record shall be
organized and maintained for easy access. Clinical record services shall be the
responsibility of an individual who has demonstrated competence and training or
experience in clinical record management. Adequate space shall be provided for
the storage and retrieval of the records. The records shall be kept secure from
unauthorized access, and each program shall adopt policies and procedures which
regulate and control access to and use of clinical records.
(b) Record Retention and Disposition. An
individual's complete clinical record shall be retained for a minimum period of
6 years following discharge. If any litigation claim, negotiation, audit, or
other action involving the records has been started before the expiration of
the six-year period, the records shall be retained until completion of the
action and resolution of all issues which arise from such actions.
(c) Content of Clinical Records. The required
signature of treatment personnel shall be original as opposed to the facsimile.
The required signature of treatment personnel shall be original as opposed to
the facsimile. Policies and procedures shall require the clinical record to
clearly document the extent of progress toward short-term objectives and
long-term view. Clinical record documentation for each order or treatment
decision shall include its respective basis or justification, actions taken,
description of behaviors or response, and staff evaluation of the impact of the
treatment on the individual's progress. Clinical records shall contain:
1. The name and address of the individual
receiving services;
2. Name,
address, and telephone number of guardian, representatives, or others as
specified by the individual receiving services;
3. The source of referral and relevant
referral information;
4. Intake
interview and initial physical assessment;
5. The signed and dated informed consent for
treatment as mandated under Sections
394.459(3) and
394.4615, F.S.;
6. Documentation of orientation to program
and program rules;
7. The medical
history and physical examination report with diagnosis;
8. The report of the mental status
examination and psychosocial, psychological, nursing, rehabilitation,
nutritional, and mental health assessments as appropriate;
9. The original service plan developed, dated
and signed by the individual receiving services and treatment staff. The plan
shall contain short-term treatment objectives that relate to crisis
stabilization and the description and frequency of services to be
provided;
10. The signed and dated
service plan reassessments and reviews;
11. Examination, diagnosis and progress notes
by physician, psychiatric nurses, treatment staff and other mental health
professionals that relate to the service plan objectives;
12. Laboratory and radiology results, if
applicable;
13. Documentation of
seclusion or restraint observations, if utilized;
14. A record of all contacts with medical and
other services;
15. A record of
medical treatment and administration of medication, if administered;
16. An original or original copy of all
physician or psychiatric nurse medication and treatment orders;
17. Signed consent for the release of
information, if information is released;
18. An individualized discharge
plan;
19. Forms CF-MH 3042a, CF-MH
3042b, and CF-MH 3084, as appropriate;
20. A current, originally authorized CF-MH
3084, Feb 2005, "Baker Act Service Eligibility," which is incorporated herein
by reference for all individuals receiving services and available at
http://www.flrules.org/Gateway/reference.asp?No=Ref-08945
and from the department's website at
https://eds.myflfamilies.com/DCFFormsInternet/Search/DCFFormSearch.aspx;
and,
21. If the individual
receiving services has a community case manager, documentation of contacts
between the community case manager and CSU or SRT staff and the person
receiving service.
(6) Consent to Treatment. Any CSU or SRT
rendering treatment for mental illness to any individual, pursuant to Chapter
394, F.S., and Chapter 65E-5, F.A.C., shall have on file a valid and signed
informed consent for treatment. Forms CF-MH 3042a, "General Authorization for
Treatment Except Psychotropic Medications," Feb 05 and CF-MH 3042b, "Specific
Authorization for Psychotropic Medications," Feb 05, or substantially similar
forms, may be used. Forms CF-MH 3042a and 3042b are incorporated by reference
and are available at
http://www.flrules.org/Gateway/reference.asp?No=Ref-09031
and http://www.flrules.org/Gateway/reference.asp?No=Ref-090312,
respectively, and from the department's website at
https://eds.myflfamilies.com/DCFFormsInternet/Search/DCFFormSearch.aspx.
(7) Admission and Discharge Criteria. Each
CSU and SRT shall develop and utilize policies and procedures pursuant to
Chapter 394, F.S., for the intake, screening, admission, referral, disposition,
and notification of the individual or their guardians, representatives, or
others as specified by the individual seeking treatment. There shall be
adequate intake procedures to ensure that individuals being received from an
emergency room, agency, facility, or other referral source shall have all the
required paperwork and documentation for admission. If an individual has a case
manager, the case manager shall be notified and shall provide appropriate
information and participate in the development of the discharge plan.
Individuals receiving services, guardians, or others as specified by the
individual receiving services shall be informed of their eligibility or
ineligibility status for publicly funded CSU or SRT services, either at
admission or shortly thereafter.
(a)
Admissions Criteria. All persons admitted shall meet the criteria defined under
Section 394.455(28),
394.4625, or
394.463, F.S.
(b) Supervisory Clinical Review. The program
policies and procedures shall specify administrative procedures for the ongoing
review of clinical decisions regarding admission, treatment, and disposition.
This shall include staffings, individual supervision, and record
reviews.
(c) Orientation to Program
and Abuse Reporting. Each CSU and SRT shall conduct and document an orientation
session with each individual receiving services, guardians, and others as
specified by the individual receiving services, regarding admission and
discharge standards, rules, procedures, activities and concepts of the program.
A written copy of the above shall be provided to individuals receiving services
and their guardians. Individuals receiving services shall be informed in
writing of rights, protection standards, possible searches and seizures,
in-house grievance protocol, function of the human rights advocacy committee
and current procedures for reporting abuse, neglect, or exploitation to the
Abuse Hotline as required by Section
415.1034, F.S. Programs shall
not discourage or prevent anyone from contacting the Abuse
Hotline.
(8) Protection
of Individuals Receiving Services. Unless abridged by a court of law, the
rights of individuals who are admitted to CSU and SRT programs shall be assured
as mandated under Chapter 394, Part I, F.S., and Chapter 65E-5, F.A.C. Each CSU
and SRT shall be operated in a manner that protects the individual's rights,
life, and physical safety while receiving evaluation and treatment. In addition
to all rights granted under Chapter 394, Part I, F.S., individuals receiving
services shall be:
(a) Assigned a primary
therapist or counselor; and,
(b)
Assured that any search or seizure is carried out in a manner consistent with
program policies and procedures to ensure safety and security and is consistent
with therapeutic practices.
1. Searches and
Seizures. Whenever there is a reason to believe that the security of a facility
or the health of anyone is endangered or that contraband or objects which are
illegal to possess are present on the premises, a search of an individual's
room, locker, or possessions shall be conducted if authorized by the program
director or designee, as defined in program policies and procedures.
2. Presence of Individual. Whenever feasible,
the individual receiving services shall be present during a search.
3. Absence of Individual. When it is
impossible for the individual to be physically present during the search, they
shall be given prompt written notice of the search and of any article
confiscated.
4. Documentation.
Written reports of all searches shall be documented in the individual's
clinical record. A written inventory of items confiscated shall be forwarded to
the program director or designee.
(c) Facility policy shall prohibit any
retaliation or reprisal against either the individual or against staff for
reporting suspected abuse, neglect or exploitation, or violations of the
individual's rights. A copy of this facility policy shall be posted in a common
area and provided to individuals receiving services upon
request.
(9) Quality
Assurance Program. Every CSU and SRT shall comply with the requirements of
Section 394.907, F.S.
(a) Inclusions. Every CSU and SRT shall have,
or be an active part of, an established multidisciplinary quality assurance
program and develop a written plan which addresses the minimum guidelines to
ensure a comprehensive integrated review of all programs, practices, and
facility services, including the following: facilities safety and maintenance;
care and treatment practices; resource utilization review; peer review;
infection control; records review; maintenance of clinical records;
pharmaceutical review; professional and clinical practices; curriculum,
training and staff development; and incidents with appropriate policies and
procedures. The quality assurance program must include:
1. Composition of quality assurance review
committees and subcommittees, purpose, scope, and objectives of the quality
assurance committee and each subcommittee, frequency of meetings, minutes of
meetings, and documentation of meetings;
2. Procedures to ensure selection of both
difficult and randomly selected cases for review;
3. Procedures to be followed in reviewing
cases and incident reports;
4.
Criteria and standards used in the review process and procedures for their
development;
5. Procedures to be
followed to assure dissemination of the results and verification of corrective
action;
6. Tracking capability of
incident reports, pertinent issues and actions; and,
7. Procedures for measuring and documenting
progress and outcome of individuals receiving services.
(b) Process. The quality assurance program
shall conduct two separate complementary review processes on a monthly basis to
include peer review and utilization review. The effects of the peer and
utilization reviews shall ensure the following.
1. The admission is necessary and
appropriate.
2. The services are
the least restrictive means of intervention.
3. Rights are being protected.
4. Family or significant others are involved
in the treatment and discharge planning process as much as feasible with the
consent of the individual receiving services.
5. The service plan is comprehensive,
relative to the full range of the needs of the individual receiving services at
the CSU or SRT.
6. Minimal
standards for clinical records and consent to treatment are being met as
required by subsections
65E-12.106(5) and
(6), F.A.C., of this rule.
7. Medication is prescribed and administered
appropriately. All medication errors shall be reported under the CSU or SRT's
incident reporting system and subject to internal review by the quality
assurance program.
8. There has
been appropriate handling of medical emergencies.
9. Special treatment procedures, for example,
seclusion and restraints, emergency treatment orders, and medical emergencies,
are conducted according to facility policy.
10. High risk situations and special cases
are reviewed within 24 hours. These shall include suicide attempts, death,
serious injury, violence, sexual assaults, and abuse of any
individual.
11. All incident
reports are reviewed by the facility director within 3 working days.
12. The length of stay is supported by
clinical documentation.
13.
Supportive services are ordered and obtained as needed.
14. Continuity of care is provided through
care coordination activities.
15.
Delay in receiving services is minimal.
(c) The quality assurance committee shall
submit a quarterly report to the CSU or SRT director and board of directors for
their review and appropriate action.
(10) Critical Incident Reporting.
(a) Every CSU and SRT shall develop policies
and procedures for submitting critical incidents into the Department's
statewide designated electronic system specific to critical incident
reporting.
(b) Every CSU and SRT
shall report critical events within one (1) business day of the incident
occurring.
1. Adult Death. An individual 18
years old or older whose life terminates:
a.
While receiving services, or
b.
When it is known that an adult died within thirty (30) days of discharge from a
CSU or SRT.
c. The final
classification of an adult's death is determined by the medical examiner. In
the interim, the manner of death shall be reported as one of the following:
(I) Accident. A death due to the unintended
actions of one's self or another.
(II) Homicide. A death due to the deliberate
actions of another.
(III) Natural
Expected. A death that occurs, because of, or from complications of, a
diagnosed illness for which the prognosis is terminal.
(IV) Natural Unexpected. A sudden death that
was not anticipated and is attributed to an underlying disease either known or
unknown prior to the death.
(V)
Suicide. The intentional and voluntary taking of one's own life.
(VI) Undetermined. The manner of death has
not yet been determined.
(VII)
Unknown. The manner of death was not identified or made
known.
2. Child
Arrest. The arrest of a child.
3.
Child Death. An individual who is less than 18 years of age whose life
terminates:
a. While receiving services,
or
b. When it is known that a child
died within 30 days of discharge from a CSU or SRT;
c. The final classification of a child's
death is determined by the medical examiner. In the interim, the manner of
death will be reported as one of the following:
(I) Accident. A death due to the unintended
actions of one's self or another.
(II) Homicide. A death due to the deliberate
actions of another.
(III) Natural
Expected. A death that occurs, because of, or from complications of, a
diagnosed illness for which the prognosis is terminal.
(IV) Natural Unexpected. A sudden death that
was not anticipated and is attributed to an underlying disease either known or
unknown prior to the death.
(V)
Suicide. The intentional and voluntary taking of one's own life.
(VI) Undetermined. The manner of death has
not yet been determined.
(VII)
Unknown. The manner of death was not identified or made
known.
4.
Child-on-Child Sexual Abuse. Any sexual behavior between children less than 18
years of age which occurs without consent, without equality, or because of
coercion.
5. Elopement. An
unauthorized absence of any individual.
6. Employee Arrest. The arrest of an employee
for a civil or criminal offense.
7.
Employee Misconduct. Work-related conduct or activity of an employee that
results in potential liability for the Department or the Agency for Health Care
Administration (Agency); death or harm to an individual receiving services;
abuse, neglect or exploitation of an individual receiving services; or which
results in a violation of statute, rule, regulation, or policy. This includes
falsification of records; failure to report suspected abuse or neglect;
contract mismanagement; or improper commitment or expenditure of state
funds.
8. Missing Child. When the
whereabouts of a child in the custody of the Department are unknown and
attempts to locate the child have been unsuccessful.
9. Security Incident - Unintentional. An
unintentional action or event that results in compromised data confidentiality,
a danger to the physical safety of personnel, property, or technology
resources; misuse of state property or technology resources; or, denial of use
of property or technology resources. This excludes instances of compromised
information of individuals in treatment.
10. Sexual Abuse/Sexual Battery. Any
unsolicited or non-consensual sexual activity by one individual receiving
services to another individual receiving services; or, sexual activity by a
service provider employee or other person to an individual receiving services,
or an individual receiving services to an employee regardless of the consent of
the individual receiving services. This may include sexual battery, as defined
in Chapter 794, F.S.
11.
Significant Injury to Individuals in Treatment. Any severe bodily trauma
received by an individual in a CSU or SRT that requires immediate medical or
surgical evaluation or treatment in a hospital emergency department to address
and prevent permanent damage or loss of life.
12. Significant Injury to Staff. Any serious
bodily trauma received by a staff member as result of a work-related activity
that requires immediate medical or surgical evaluation or treatment in a
hospital emergency department to prevent permanent damage or loss of
life.
13. Suicide Attempt. A
potentially lethal act which reflects an attempt by an individual to cause his
or her own death as determined by a licensed mental health professional or
other licensed healthcare professional.
14. Other. Any major event not previously
identified as a reportable critical incident but has, or is likely to have, a
significant impact on individuals receiving services, on the Department, or on
the Agency, such as:
a. Human acts that
jeopardize the health, safety, or welfare of individuals receiving services,
such as kidnapping, riot, or hostage situation;
b. Bomb or biological/chemical threat of harm
to personnel or property involving an explosive device or biological/chemical
agent received in person, by telephone, in writing, via mail, electronically,
or otherwise;
c. Theft, vandalism,
damage, fire, sabotage, or destruction of state or private property of
significant value or importance;
d.
Death of an employee or visitor while on the grounds of the CSU or
SRT;
e. Significant injury of a
visitor while on the grounds of the CSU or SRT that requires immediate medical
or surgical evaluation or treatment in a hospital emergency department to
prevent permanent damage or loss of life, or
f. Events regarding individuals receiving
services or providers that have led to or may lead to media
reports.
(c)
Seclusion and Restraint Event Reporting.
All public and private designated Baker Act receiving
facilities and all SRTs shall develop policies and procedures for reporting
seclusion and restraint events into the statewide designated electronic system
specific to seclusion and restraints.
(11) Data. Every CSU and SRT shall
participate in reporting data as mandated under Section
394.461, F.S.
(12) Health and Safety.
(a) Disaster Preparedness.
1. Each CSU and SRT shall have, or operate
under, a safety committee with a safety director or officer who is familiar
with the applicable local, state, federal and National Fire Protection
Association safety standards. The committee's functions may be performed by an
already existing committee with related interests and
responsibilities.
2. Each CSU and
SRT shall have, or be a part of, a written internal and external disaster plan,
developed with the assistance of qualified fire, safety and other experts.
a. The plan and fire safety manual shall
identify the availability of fire protection services and provide for the
following:
(I) Use of the fire
alarm;
(II) Transmission of the
alarm to the fire department;
(III)
Response to the alarm;
(IV)
Isolation of the fire;
(V)
Evacuation of the fire area or facility utilizing posted evacuation
routes;
(VI) Preparation of the
residents and building for evacuation;
(VII) Fire extinguishment;
(VIII) Descriptive procedures for the
operation and maintenance of fire equipment;
(IX) Procedures for staff training and the
provision of monthly fire drills rotated so that all shifts have at least one
fire drill quarterly;
(X)
Documentation of monthly and periodic professional inspections of equipment;
and,
(XI) Provision for annual
review and revision of the fire safety manual and plan.
b. The plan shall be made available to all
facility staff and posted in appropriate areas within the facility.
c. There shall be records indicating the
nature of disaster training and orientation programs offered to
staff.
(b) Fire
Safety. CSUs and SRTs must comply with all federal and local fire safety
standards. Local fire codes which are more stringent standards, or add
additional requirements, shall take precedent over the minimum requirements set
forth in this rule.
(c) Personal
Safety. The grounds and all buildings on the grounds shall be maintained in a
safe and sanitary condition.
(d)
Health and Sanitation.
1. Appropriate health
and sanitation inspections shall be obtained before occupying any new physical
facility or addition. A report of the most recent inspections must be on file
and accessible to authorized individuals.
2. Hot and cold running water under pressure
shall be readily available in all washing, bathing and food preparation areas.
Hot water in areas used by individuals being served shall be at least 100
degrees Fahrenheit but not exceed 120 degrees Fahrenheit.
3. Garbage, Trash and Rubbish Disposal.
a. All garbage, trash, and rubbish from
residential areas shall be collected daily and taken to storage facilities.
Garbage shall be removed from storage facilities frequently enough to prevent a
potential health hazard or at least twice per week. Wet garbage shall be
collected and stored in impervious, leak proof, fly tight containers pending
disposal. All containers, storage areas and surrounding premises shall be kept
clean and free of vermin.
b. If
public or contract garbage collection service is available, the facility shall
subscribe to these services unless the volume makes on-site disposal feasible.
If garbage and trash are disposed of on premises, the method of disposal shall
not create sanitary nuisance conditions. Facilities must comply with the
Florida Department of Health's garbage, trash, and rubbish disposal
requirements, as stated in Chapter 62-701,
F.A.C.
(13) Food Services.
(a) At least three nutritious meals per day
and nutritional snacks, shall be provided each individual receiving services.
No more than 14 hours may elapse between the end of an evening meal and the
beginning of a morning meal. Special diets shall be provided when an individual
requires it. Under no circumstance may food be withheld for disciplinary
reasons. Menus shall be reviewed and approved in advance at least quarterly by
a Florida registered dietitian.
(b)
For food service areas with a capacity of 13 or more individuals, facilities
must comply with the Florida Department of Health's food service requirements,
as stated in Chapter 64E-11, F.A.C.
(c) Third Party Food Service. When food
service is provided by a third party, the provider must comply with the Florida
Department of Health's food service requirements, as stated in Chapter 64E-11,
F.A.C. There shall be a formal contract between the facility and provider
containing assurances that the provider will meet all food service and dietary
standards imposed by this rule. Sanitation reports and food service
establishment inspection reports shall be on file in the
facility.
(14)
Housekeeping and Maintenance. Every CSU and SRT shall have housekeeping and
maintenance standards which meet the following criteria:
(a) Facilities shall be clean, in good
repair, and free of hazards such as cracks in floors, walls, or ceilings;
warped or loose boards, tile, linoleum, hand rails or railings; broken window
panes; and any similar type hazard.
(b) The interior and exterior of the building
shall be clean and in good repair. Loose, cracked or peeling wallpaper or paint
shall be promptly replaced or repaired to provide a satisfactory
finish.
(c) All furniture and
furnishings shall be clean and in good repair, and contribute to creating a
therapeutic environment.
(d) An
adequate supply of linen shall be maintained to provide clean and sanitary
conditions for each individual at all times.
(e) Mattresses and pillows shall have fire
retardant covers or similar protection for fire safety and sanitation
purposes.
(15) Compliance
with Statutes and Rules. The program director or administrator shall ensure
that the program complies with Chapter 394, F.S., and Chapters 65E-5, 65E-12,
and 65E-14, F.A.C.
(16) Register of
Individuals and Census. An admission and discharge logbook shall be maintained
which lists individuals admitted sequentially by name with identifying
information about each including age, race, sex, county of residence,
disposition, and the actual location to which the individual was discharged or
transferred. A daily census record shall be maintained which includes the name
of individuals on the unit and on authorized pass. This may be maintained
electronically, but shall be easily accessible to all relevant facility staff
and administrators.
(17)
Pharmaceutical Services.
(a) Every CSU and
SRT must handle, dispense or administer drugs in accordance with the Department
of Health's Rule Chapter 65E-16, F.A.C.
(b) The professional services of a consultant
pharmacist shall be used in the delivery of pharmaceutical services. Standards,
policies and procedures shall be established by the consultant pharmacist for
the control and accountability of all drugs kept at the program.
(c) Medication Orders. All orders for
medications shall be issued by a Florida licensed physician or psychiatric
nurse.
(18) Emergency
Medical Services. Every CSU or SRT shall have written policies and procedures
for handling medical emergency cases which may arise subsequent to an
individual's admission. All staff shall be familiar with the policies and
procedures.
(a) Emergency Treatment Orders.
Policies and procedures shall be written to address the use of emergency
treatment orders as specified in Section
394.459, F.S., and Chapter
65E-5, F.A.C. They shall address the following:
1. Emergency treatment orders shall be
initiated only upon direct order of a physician or psychiatrist;
2. The clinical justification shall be
documented in the clinical record; and,
3. The use of standing, pro re nata (PRN), or
routine orders for emergency treatment orders is
prohibited.
(b)
Cardiopulmonary Resuscitation and Choke Relief. All nurses and direct service
staff shall be trained to practice basic cardiopulmonary resuscitation (CPR)
and choke relief technique at employment or within 6 months of employment and
have a refresher course at least every 2 years. There shall be one person on
the premises at all times who is CPR certified and proficient in choke relief
techniques. Training shall be documented in the personnel record of the
employee. Consent for referral and the disclosure of vital information is not
required in life-threatening situations.
(c) Medical Kit and Emergency Information. A
physician, psychiatrist, consultant pharmacist, and registered nurse,
designated by the program director or administrator, shall select drugs and
ancillary equipment to be included in an emergency medical kit. The kit shall
be maintained at the program and safeguarded in accordance with laws and
regulations pertaining to the specific items included. A list of emergency
programs and poison centers shall be maintained near a telephone for easy
access by all staff.
(19)
Protection of Individuals Receiving Services.
(a) Unauthorized Entry or Exit. Each CSU and
SRT shall have policies and procedures regarding unauthorized entry to or exit
from the unit.
(b) Control of
potentially injurious items.
1. Policies and
procedures shall prohibit the transmittal onto or carrying onto the unit
sharps, flammables, toxins, weapons, caustic chemicals, rope, or other items
potentially injurious to individuals on the unit.
2. Therapeutic activity materials shall also
exclude similarly potentially hazardous items such as bats, paddles, mallets,
knives, ropes, cords, wire clothes hangers, wire, sharp pointed scissors,
luggage straps, and sticks.
3.
Housekeeping supplies and chemicals shall, whenever practical, be non-toxic or
non-caustic. The unit shall implement procedures to avoid access by individuals
receiving services during use or storage.
4. Nursing and medical supplies including
drugs, sharps, and breakables shall be safeguarded from access by individuals
receiving services through storage, use, and disposal
processes.
(c) Use of
Restraint or Seclusion. Each CSU and SRT shall develop and maintain detailed
policies and procedures for the use of seclusion and restraint. Such policies
and procedures shall be readily available to CSU and SRT staff, individuals
served, guardians, and others as specified by the individual.
(d) Suicide Precaution.
1. Suicide precaution is for the protection
of individuals who have been assessed to be potentially suicidal and require a
higher level of supervision.
2. The
modification or removal of suicide precautions shall require clinical
justification determined by an assessment and shall be specified by the
attending physician or psychiatric nurse and documented in the clinical record.
A registered nurse, clinical psychologist or other mental health professional
may initiate suicide precautions prior to obtaining a psychiatric nurse's,
physician's or psychiatrist's order, but in all instances must obtain an order
within 1 hour of initiating the precautions. Telephone orders shall be reviewed
and signed by a psychiatric nurse or physician within 24 hours of their
initiation.
3. Each CSU shall
develop policies and procedures for implementing suicide precautions
addressing: assessment, staffing, levels of observation and documentation.
Policies and procedures shall require constant visual observation of
individuals clinically determined to be actively suicidal.
(e) Other high risk behaviors, such as
elopement and assaultive behavior, shall be addressed in the CSU and SRT
policies and procedures.
(20) Nursing Services.
(a) Medical Prescription. Registered nurses
shall ensure that each psychiatric nurse's, physician's, or psychiatrist's
orders are followed. When a determination is made that the orders have not been
followed or were refused by the individual being served, the psychiatric nurse,
physician or psychiatrist shall be notified within 24 hours. The registered
nurse or nursing service shall substantiate this action through documentation
in the individual's clinical record.
(b) Nursing Standards. Each CSU and SRT shall
develop and maintain a standard manual of nursing services which shall address
medications, treatments, diet, personal hygiene care and grooming, clean bed
linens and environment, and protection from infection.
(21) Continuity of Care. Upon admission, all
individuals receiving services, in both a CSU and SRT shall be assessed for the
need of case management services. If determined to need case management
services, the individual shall be linked to a case manager in the
community.
(22) Children. Every CSU
and SRT which serves individuals under 18 years of age shall define, in
policies and procedures, the services and supervision to be provided to the
children. Minors under the age of 14 years shall not be admitted to a bed in a
room or ward with an adult. They may share common areas with an adult only when
under direct visual observation by unit staff. This shall be reviewed and
documented on a daily basis.
(23)
Collocation.
(a) Collocation means the
operation of CSU and SRT, or CSU and substance abuse detoxification services
from a common nurses' station without treatment system integration. It may
result in the administration of those services by the same organization and the
sharing of common services, such as housekeeping, maintenance and professional
services. A CSU shall be separated and secured by locked doors from the SRT and
detoxification units.
(b) Whenever
a CSU is collocated with an SRT or substance abuse detoxification unit there
shall be no compromise in CSU standards. In all instances, whenever there is a
conflict between CSU rules and SRT, substance abuse rules, the more restrictive
rules shall apply.
(c) Individuals
receiving CSU, SRT, and detoxification services shall not commingle or share a
common space unless individually authorized by a physician's, psychiatrist's,
or psychiatric nurse's written order to participate in specific treatment and
evaluation activities on other units as specified in the individual's service
plan. Service plan documentation shall include: type of activity, supervision,
frequency of activity, and duration of each activity session.
(d) Collocation Staffing Requirements. CSU
and SRT, or CSU and detoxification staff may be shared if the individual
served-staff ratio is not violated and the health, safety and welfare of the
individual is not jeopardized. When services are collocated and staff resources
are shared, the staffing pattern shall be the more restrictive as required by
this rule, based on the combined total number of beds. When the combined number
of beds exceeds 30, nursing and direct service staff shall not be
shared.
(24) Passes.
(a) A psychiatric nurse's or physician's
order shall be written in accordance with unit policies and procedures
specifying each occasion that an individual receiving services is permitted off
unit and consistent with the service plan.
(b) Each written order shall specify: the
clinical basis for the order; the necessity and purpose of the order; the level
of supervision while off the unit; the staff designated responsible for the
individual receiving services; and the authorized time of departure and return
deadline which cannot exceed 24 hours for CSUs and 48 hours for
SRTs.
(25) Smoking. Each
CSU and SRT shall designate smoking areas or declare the facility non-smoking
and shall post signs to so indicate. Areas frequented by smokers and
non-smokers shall not be designated a smoking area. The facility shall ensure
the operation of adequate smoke evacuation mechanisms to maintain a healthful
air quality throughout.
(26)
Personal Items. Individuals receiving services in CSUs and SRTs are entitled to
wear their own clothing except when this right is restricted for safety. This
restriction must be fully justified in the clinical record. Policies and
procedures shall be developed which describe the utilization of special
clothing, or describe unit restrictions concerning other potentially hazardous
personal articles, such as sharps and ingestibles.
(27) Universal Infection Control. Each CSU
and SRT shall develop and implement policies and procedures for universal
infection control and prevention to protect people from blood and body fluid
borne disease. Specific procedures shall include management of individuals who
potentially have infectious diseases, such as Hepatitis B, Human
Immunodeficiency Virus (HIV), Acquired Immune Deficiency Syndrome (AIDS), or
other infectious diseases. These procedures shall include: isolation, specific
infection control techniques, availability of proper equipment, proper disposal
of potentially infected waste, transfer, and the release of confidential
information to select unit medical and direct care staff on a need-to-know
basis. Any testing for HIV must be done in accordance with the Department of
Health's requirements as stated in Chapter 64D-2, F.A.C. Policies and
procedures shall be regularly updated to include information provided by the
department, the Department of Health, and the Center for Disease Control. All
biohazardous waste must be handled and disposed in accordance with the
Department of Health's requirements as stated in Chapter 64E-16,
F.A.C.
(28) HIV and AIDS Education
Requirements. Each CSU and SRT must meet the Department of Health's
requirements for HIV and AIDS education pursuant to Section
381.0035, F.S., for each
employee and individual receiving services and maintain records of such
training.
(29) Unit operating
policy and procedure manuals shall be organized and maintained for easy access
and reference and available to all facility staff at all times. The CSU and SRT
shall have a copy of Chapter 394, F.S., Chapters 65E-5 and 65E-12, F.A.C., on
the unit available to all staff and individuals receiving services at all
times.
(30) CSUs and SRTs shall
ensure that the unit's licensed professionals and other unit staff function
together under a set of written reciprocal unit protocols. These protocols
shall establish the sequence of activities to be performed, designate
authorized or responsible personnel, and establish standards for the accuracy,
completion, and comprehensiveness of activities.
Rulemaking Authority
394.457,
394.46715,
394.879(1),
394.907(8) FS.
Law Implemented 394.455,
394.457,
394.4572,
394.459,
394.4615,
394.463,
394.77,
394.875,
394.879,
394.907 FS.
New 2-27-86, Amended 7-14-92, Formerly 10E-12.106, Amended
9-1-98, 10-4-00, 4-8-18.
