Code of Massachusetts Regulations
104 CMR - DEPARTMENT OF MENTAL HEALTH
Title 104 CMR 28.00 - Licensing and Operational Standards for Community Services
Subpart C - STANDARDS FOR COMMUNITY CRISIS STABILIZATION SERVICES
Section 28.18 - Additional Requirements for all CCS Services

Universal Citation: 104 CMR 28.00 MA Code of Regs 28.18

Current through Register 1531, September 27, 2024

Providers of Community Crisis Stabilization Services Licensed as Class I, II or III or any Combination thereof shall meet the following requirements:

(1) Hours of Operation. The service shall operate and accept admissions 24 hours per day, seven days per week, 365 days per year.

(2) Admission Procedures. Within 24 hours of admission, the provider shall conduct a screening for risk including but not limited to suicide risk and substance use/misuse using standardized screening tools. Admission procedures shall also include a comprehensive assessment that includes a history of trauma including, but not limited to, physical or sexual abuse or witnessing violence, to inform and develop an individualized treatment plan and an initial transition/discharge plan and make referrals for aftercare services where clinically indicated for each person admitted to the service. A clinical formulation, psychiatric assessment, and a medication evaluation shall be completed and documented and entered in the person's record. Risk screenings and assessments conducted by the referring entity may be incorporated into the provider's screening and assessments to the extent clinically appropriate.

(3) Staffing. In addition, to the requirements of 104 CMR 28.12(2) and 104 CMR 28.14(3), and any specific contractual requirements under which a provider may be operating, the service shall be staffed at a level sufficient to meet the clinical needs of persons admitted, as well as the administrative and ancillary services necessary for the operation of the service. Clinical staff must have sufficient education, training, and requisite professional licensure to provide the services including, but not limited to, crisis prevention and stabilization, initial and continuing biopsychosocial assessment, nursing assessments, psychiatric evaluations, care management, and medication management.

(a) The provider shall employ a physician to fulfill the role of medical director who is responsible for the administration of all medical or behavioral health services performed by the service. The medical director shall be fully licensed to practice medicine under Massachusetts law, and shall be board-eligible or board-certified in psychiatry.

(b) The provider must have staff who are qualified by education, training, and experience to provide peer support, psychoeducation and assist with mobilization of family/guardian/natural supports and linkages to community resources.

(c) The provider shall have adequate nursing leadership to meet the needs for training and supervision of nursing staff for the applicable service.

(d) Members of the multidisciplinary treatment team must have experience, skills, and training in the acute treatment of mental health and co-occurring mental health and substance use conditions of youth and adults, commensurate with the service's applicable class of license.

(e) Staffing must include peer roles. An ACS service must have adequate Adult Peer Specialists and for YCS service, adequate Young Adult Peer Mentors and Family Partners, as clinically appropriate

(4) Staffing Pattern . The provider shall maintain a sufficient staff to person served ratio to safely care for all persons served. For services serving youth younger than 18 years old the licensee shall maintain a staff to child ratio of 1:3 with two awake overnight staff and a clinician on call 24/7. Volunteers shall not be included in the staff to child ratio. Sufficient numbers and types of qualified staff shall be on duty and available at all times to provide necessary and adequate safety and care, to accept admissions during all shifts, plan transitions, and to conduct planned discharges. The CCS provider shall have a written plan that delineates, by shift, the number and qualifications of staff, including psychiatry, nursing, clinicians, social workers, and other staff in relation to its average daily census.

(a) The provider shall provide sufficient psychiatric coverage, including a board-eligible or board-certified attending psychiatrist who may be the medial director or another psychiatrist or a psychiatric APRN.

(b) Psychiatric coverage by a psychiatrist or psychiatric APRN must be available during all hours of operations, seven days per week to provide psychiatric assessment, medication evaluations, and medication management, and contribute to the comprehensive assessment and discharge planning decisions.

(c) The psychiatrist or psychiatric APRN must be available for phone consultation within 15 minutes of request and for a face-to-face evaluation within 60 minutes of request, when clinically indicated.

(d) Staffing must include sufficient nursing staff 24 hours per day, seven days a week, including a Licensed Practical Nurse available for the second and third shift on weekdays and all three shifts on weekends, and at least one master's level clinician on-site at least one shift per day

(e) At least one staff person certified in C.P.R. and First Aid must be available on-site on each shift.

(f) At least one staff person trained in the use of Naloxone shall be available on-site on each shift.

(g) Staffing must also include sufficient numbers of direct care staff on all shifts.

(h) The Department may issue guidance specifying minimum numbers of staff and may determine that a staffing pattern is insufficient to fulfill the service objectives. In issuing such guidance or making such determinations, the Department shall take into consideration the staffing requirements a provider may have with a payor for that service. If an order for increased staffing is issued as a result of a deficiency finding pursuant to 104 CMR 28.21(2) or other programmatic circumstances, such order shall be for a specific period of time and may be renewed or extended upon review by the Department.

(5) Service components shall include: screening for substance use disorder and suicide risk, completion of a comprehensive assessment, pharmacological evaluation and treatment, comprehensive treatment and transition/discharge planning, individual, group, and family therapies, peer/family support, care coordination, use of recreation, art, or pet therapies, and daily wellness activities such as yoga, meditation, mindfulness, and exercise and development of behavioral plans and safety plans.

(6) Medication. The CCS provider shall ensure that each person has access to medications prescribed for physical or behavioral health conditions. The CCS provider shall ensure that medication is only administered by staff who are properly licensed. The provider must have a medication reconciliation process to ensure against medication errors. All medication orders and reviews shall be properly documented in the medical record.

(7) Physical Site. The service site must provide a therapeutic and comfortable environment conducive to treatment, stabilization and recovery. In addition to the physical standards set forth in 104 CMR 28.13, the site shall provide sufficient and separate space for the provision of clinical services such as individual and group counseling sessions and sensory spaces intended for self-soothing and self-calming. The physical site must also accommodate the need for visitation, leisure and group and individual recreational activities.

(a) Restrooms shall be conveniently located and accessible and designed to permit opening a locked door from the outside in an emergency, ensure privacy through the use of partitions and doors, and provide adequate ventilation through windows or exhaust fans.

(b) The provider shall ensure that all indoor space is tobacco-free in accordance with M.G.L. c. 270, § 22. The prohibition extends to provider-owned or leased vehicles, and personal vehicles when used to transport persons.

(c) A provider that serves children younger than six years old shall ensure that the premises are free of lead paint.

(8) Room Assignments . The provider shall ensure that room assignments are appropriate, taking into consideration the age, gender and needs of the Person.

(9) Nutrition. The provider shall provide a nourishing and well-balanced diet to all persons, including three meals daily. The provider shall have a policy and procedure for nutritional services including the purchase, storage, preparation and serving food in a manner appropriate to the age and persons served, including special dietary requirements that address food allergies and intolerances, special dietary needs (e.g., vegan, vegetarian) and religious requests. A provider serving children and youth shall prepare menus that have been reviewed by a person who has had training in the nutritional needs of children and youth. The provider shall maintain copies of menus used.

(10) Restraint. Medication restraint, mechanical restraint or seclusion shall not be used. Emergency physical restraint shall only be used in accordance with the provisions of 104 CMR 28.05.

(11) Orientation and Training. The provider shall provide orientation and ongoing training for all employees regarding the service's philosophy, organization, policies and services. The licensee's policy and procedure for staff orientation and ongoing training shall include the characteristics of the persons served; symptoms and behavioral signs of emotional disturbance; symptoms of drug overdose, alcohol intoxication or possible medical emergency; the service's emergency and evacuation procedures, procedures for reporting suspected incidents of child abuse and neglect and other reportable incidents; orientation in first aid and C.P.R.; training in infection control procedures, including universal precautions; and the services policies including those on human rights, trauma informed and trauma responsive care, restraint prevention/use, de-escalation techniques, medication, and behavioral support.

(12) CORI Checks. The provider shall comply with requirements established by the Executive Office of Health and Human Services under 101 CMR 15.00: Criminal Offender Record Checks. A CCS provider serving youth shall require volunteers, students, employees and employment candidates being considered for hire to sign a consent form allowing the Department of Children and Families to release information including whether their name appears on the Registry of Alleged Perpetrators.

(13) Volunteers, Student Interns and Contract Agency Staff . Volunteers and student interns may be used only as an adjunct to regular paid staff and not as a substitute for a paid work force. If the provider uses staff employed by a contract or temporary agency, the provider shall ensure that it has a qualified service organization agreement with the contract or temporary agency which specifies that the contract or temporary agency has complied with requirements established by the Executive Office of Health and Hunan Services under 101 CMR 15.00: Criminal Offender Record Checks. The provider shall also have a written policy and procedure to ensure and document that such staff receive appropriate orientation and supervision.

(14) Policies and Procedures. The provider shall have written policies and procedures consistent with the requirements of 104 CMR 28.12 and accepted standards of care for Community Crisis Stabilization Services and applicable law.

(15) Self-preservation Standards. The CCS provider shall comply with the self-preservation standards set forth in 104 CMR 28.14.

(16) Child Safety. If children are permitted on the premises for any reason, the provider shall ensure that the children are supervised at all times by an adult, and that the area where child access is permitted is safe for children.

(17) Complaints and Investigations. A person admitted to a DMH licensed CSS service shall have the right to make a complaint regarding any incident or condition which is believed to be dangerous, illegal or inhumane as those terms are defined in 104 CMR 32.00: Investigation and Reporting Responsibilities. Such complaints shall be reported, reviewed, investigated and resolved in accordance with the requirements of 104 CMR 32.00.

(18) Internal Investigations and Reporting. The licensee shall develop and follow written procedures for conducting internal investigations and shall immediately inform the Department orally, and in writing the next business day, of any incident or allegation connected with the service that involves the health or safety of a person in the service.

(19) Records and Confidentiality. The records of a person receiving CCS services are confidential and shall be maintained and disclosed in conformity with applicable law, including the provisions of 104 CMR 28.09. Records of substance use treatment are subject to the requirements of 42 CFR Part 2.

(20) Transition and Discharge Planning and Linkages to Community Services. The CCS provider, and treatment team, must develop a written transition and discharge plan, that includes: a brief summary of the course of treatment including a description of treatment interventions and strategies that were effective in stabilizing the crisis, medications at discharge including an assessment of the person's ability to self-administer, and recommended aftercare services including substance use assessment and treatment emergency after hour contacts and services. The transition and discharge plan shall be developed to the greatest extent possible with the participation of the person served and, with appropriate authorization, the family/legally authorized representative of the person served. The CCS provider shall not initiate a discharge to a shelter or the street. Should the CCS provider receive a request for such discharge from a person served, the provider shall take steps to identify and offer alternative options. Efforts to counsel the person served on the risks of discharging to a shelter or the street must be completed and documented in the record. In addition, safety assessments and crisis planning, including provisions for notification of known collateral contacts must be updated and documented.

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