Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This rule sets forth regulations for
behavioral health crisis centers.
PUBLISHER'S NOTE: The secretary of state has
determined that publication of the entire text of the material that is
incorporated by reference as a portion of this rule would be unduly cumbersome
or expensive. This material as incorporated by reference in this rule shall be
maintained by the agency at its headquarters and shall be made available to the
public for inspection and copying at no more than the actual cost of
reproduction. This note applies only to the reference material. The entire text
of the rule is printed here.
(1) Definitions. Unless the context clearly
requires otherwise, the following terms as used in this rule mean-
(A) Behavioral Health Crisis Center (BHCC),
unit which operates twenty-four (24) hours per day, seven (7) days per week and
provides crisis services for individuals in severe distress with up to
twenty-three (23) consecutive hours of supervised care to assist with
deescalating the severity of their crisis;
(B) Crisis intervention, designed to
interrupt and/or ameliorate a behavioral health crisis experience. The goal of
crisis intervention is symptom reduction, observation, stabilization, and
restoration to a previous level of functioning for the individual being served.
Primary components include, but are not limited to-
1. Preliminary assessment of risk, mental
status, substance use status, and medical stability;
2. Stabilization of immediate
crisis;
3. Determination of the
need for further evaluation and/or behavioral health services; and
4. Linkage to needed additional treatment
services;
(C) Crisis
stabilization, a direct service that assists with deescalating the severity of
an individual's level of distress and/ or need for urgent care associated with
a behavioral health disorder; and
(D) Urgent Care Behavioral Health Crisis
Center (U-BHCC), unit which operates less than twenty-four (24) hours per day,
seven (7) days per week, and provides crisis services for individuals in severe
distress with supervised care to assist with deescalating the severity of their
crisis.
(2) Program
Description. BHCCs and U-BHCCs are provided or arranged by an administrative
agent or an affiliate. Services shall be provided in accordance with the 2020
edition of the National Guidelines for Behavioral Health Crisis Care, hereby
incorporated by reference and made a part of this rule, and can be obtained
from the Substance Abuse and Mental Health Services Administration (SAMHSA),
5600 Fishers Lane, Rockville, MD 20857, (877) 726-4727. This rule does not
incorporate any subsequent amendments or additions to this publication.
(A) Services shall be designed to serve as a
community-based alternative to emergency department services, unnecessary
hospitalization, and/or jail confinement by offering assessment, treatment, and
short term stabilization for individuals with a mental health and/or substance
use disorder.
(B) As specified in
best practice one (1) of the National Guidelines for Behavioral Health Crisis
Care, as referenced in section (2) of this rule, centers shall function as a
twenty-four (24) hour or less crisis receiving and stabilization
facility.
(3)
Certification/National Accreditation. At a minimum, organizations shall comply
with 9 CSR
10-7.130 Procedures to Obtain Certification, to apply
for certification/deemed status as a BHCC or U-BHCC and-
(A) Be certified by the department as a
Certified Community Behavioral Health Organization (CCBHO);
(B) Obtain appropriate accreditation for
crisis services within three (3) years of obtaining certification/deemed status
(if not accredited for such at the time of initial application to the
department) from the Commission on Accreditation of Rehabilitation Facilities
(CARF) International, The Joint Commission (TJC), or Council on Accreditation
(COA); and
(C) The CCBHO may arrange
for BHCC or U-BHCC services to be provided through a designated collaborating
organization (DCO).
(4)
Program Requirements. BHCCs and U-BHCCs shall provide prompt assessment,
stabilization (with or without medication), and determination of an appropriate
level of care for the individual's continued behavioral health treatment in
order to prevent unnecessary hospitalization, emergency department services,
and/or jail confinement.
(A) In accordance
with minimum expectation three (3) of the National Guidelines for Behavioral
Health Crisis Care, as referenced in section (2) of this rule, services shall
be designed to address-
1. Behavioral/mental
health crisis situations, including substance use; and
2. Varying clinical conditions to include
individuals with co-occurring behavioral health and intellectual/developmen-tal
disabilities.
(5) Target Populations. The target population
includes individuals with a confirmed or suspected mental health and/or
substance use disorder diagnosis who are experiencing a behavioral crisis or
are presenting for urgent behavioral health needs who are-
(A) Children and youth, individuals age five
(5) to seventeen (17) years; and/or
(B) Individuals age eighteen (18) years and
older.
(6) Physical
Environment and Safety. All BHCCs and U-BHCCs shall be in compliance with
9 CSR
10-7.120 Physical Environment and Safety, and
applicable state and local building codes, fire codes, and ordinances to ensure
the health, safety, and security of all individuals.
(A) The physical environment shall-
1. Promote a sense of safety, calm, and
deescalation for individuals and staff;
2. Have adequate space to ensure the comfort
of individuals served;
3. Have
adequate space to ensure privacy and confidentiality for individuals
served;
4. Have furnishing and
fixtures that are constructed of durable materials not capable of breakage into
pieces that could be used as a weapon, ligature risk, or for self-harm;
and
5. Have interior finishes,
lighting, and furnishings that suggest a non-institutional setting that
conforms to applicable fire and safety codes.
(B) In accordance with best practice two (2)
of the National Guidelines for Behavioral Health Crisis Care, as referenced in
section (2) of this rule, policies and procedures shall ensure there are
designated areas for individuals being transported to the center by law
enforcement/first responders and those seeking services on a walk-in basis.
1. Hours of operation shall be clearly
communicated to law enforcement and other referral sources.
(C) If the BHCC/U-BHCC has an open
floor model, space for screening, evaluation, and treatment services must be
separate for children/youth and adults, if both are served.
(7) Care Criteria. Each BHCC and
U-BHCC shall implement written screening and intake criteria for individuals
who present for an evaluation.
(A) A "no wrong
door" access model shall be utilized. In accordance with minimum expectations
one (1), six (6), and seven (7) of the National Guidelines for Behavioral
Health Crisis Care, as referenced in section (2) of this rule, all individuals
who present for an evaluation and/or stabilization shall be screened as
specified in subsection (7)(C) of this rule, including walk-ins and those who
are referred/transported by law enforcement.
(B) If screening results in an individual not
being offered services, documentation of the rationale for the denial of
services and facilitated referral of the individual to other appropriate
services must be maintained.
(C)
Service criteria shall include but is not limited to-
1. Presence of a suspected and/or known
mental illness diagnosis and/or substance-related disorder and the individual
is expressing a need for behavioral health services; and
2. Presence of a severe situational crisis;
and/or
3. Presence of risk of harm
to self, others, and/or property (risk may range from mild to
imminent).
(D) In
accordance with minimum expectation two (2) of the National Guidelines for
Behavioral Health Crisis Care, as referenced in section (2) of this rule,
medical clearance is not required prior to provision of services, however, each
individual served must be assessed for medical stability and receive necessary
medical support while in the program.
1. In
accordance with minimum expectation four (4) of the National Guidelines for
Behavioral Health Crisis Care, as referenced in section (2) of this rule,
physical health issues that can be appropriately managed by crisis center staff
shall be addressed by qualified staff in accordance with policies and
procedures.
2. If a physical health
issue occurs requiring medical care that cannot be addressed while an
individual is receiving services in the BHCC/U-BHCC, the treating center shall
arrange for the individual to be appropriately transported to a medical
facility to address the physical health issue.
(E) As appropriate, medications (including
medication assisted treatment for a substance use disorder) shall be prescribed
while connecting the individual with ongoing services.
(8) Staff Qualifications. In accordance with
minimum expectation five (5) of the National Guidelines for Behavioral
Health Crisis Care, as referenced in section (2) of this rule, the
BHCC/U-BHCC shall be adequately staffed to meet the treatment needs of
individuals served and to ensure their safety and the safety of staff.
(A) Each center shall have the staffing
capacity to assess individuals' physical health needs and deliver care for most
minor physical health challenges, with established written protocols to
transfer an individual to more medically staffed services, if needed.
(B) The center shall be staffed by a
multidisciplinary team who is able to respond to the needs of individuals
experiencing all levels of crisis. Staff shall include but is not limited to-
1. Medical director-a licensed psychiatrist
(available via telemedicine or audio-only). The medical director for the
BHCC/U-BHCC can be the same individual who serves in this capacity for the
CCBHO.
A. Direct services shall be provided by
a licensed physician (includes psychiatrist) or licensed psychiatric mental
health nurse practitioner (PMHNP), advanced practice registered nurse (APRN),
physician assistant, resident physician (includes psychiatrist), and/or
assistant physician in a written collaborative practice arrangement with a
physician and with experience treating the target population. Services may be
provided via telemedicine.
B. BHCCs
and U-BHCCs shall have access to a practitioner to prescribe medications
approved by the Food and Drug Administration to treat opioid use disorders
(methadone must be provided by a certified opioid treatment program);
2. Clinical program director-must
be a qualified mental health professional (QMHP) to oversee program operations
and clinical practice, with experience treating the target
population;
3. Nurse-registered
nurse (RN) or licensed practical nurse (LPN); and
4. Certified peer specialist.
(9) Staff Coverage.
Staff coverage shall ensure the continuous supervision and safety of
individuals served. Staff coverage shall be determined by the agency.
(A) Coverage at a minimum, shall include-
1. Two (2) behavioral health staff must be
on-site during receiving hours;
2.
One (1) QMHP must be available during receiving hours (may be via
telemedicine);
3. One (1) RN or one
(1) LPN must be available during receiving hours (may be via telemedicine);
and
4. A physician (includes
psychiatrist), PMHNP, APRN, assistant physician, resident physician (includes
psychiatrist), and/or physician assistant must be available during receiving
hours and must immediately respond to calls from staff, delay not to exceed one
(1) hour.
(B) Qualified
staff must be available to administer, screen, inventory, and store prescribed
medications within their scope of duties, practice, training, and as authorized
by statute.
(C) Qualified staff,
within their scope of duties, practice, and/ or training, shall be available to
conduct an initial health assessment and utilize evidence-based tools to
determine the individual's medical stability, intoxication, substance use, and/
or level withdrawal/impairment.
(10) Policies and Procedures. The BHCC/U-BHCC
shall maintain and implement written policies and procedures including but not
limited to-
(A) Intake screening, service, and
clinical assessment protocols;
(B)
Community outreach and education strategies for crisis stabilization services,
including access to and location of service site(s), hours, and days of
operation for each site through written material and other means of
communication, and how these components will be accomplished on an ongoing
basis;
(C)
Detoxification/withdrawal management services as defined in
9 CSR
30-3.120. If the BHCC/U-BHCC does not provide this
service, facilitated referrals to a local hospital or another qualified service
provider shall be made for withdrawal management or other medical services, if
determined necessary during an individual's evaluation process;
(D) Safety and emergency protocols as
specified in 9 CSR 107.120 Physical Environment and Safety, as well as specific
protocols for the population served;
(E) Prescription medication protocols,
including storage of medications in accordance with
9 CSR
10-7.070;
(F) Screening for and accessing services for
emergency medical conditions, including transport by emergency medical
service;
(G) Monitoring the
physical and psychological well-being of individuals including but not limited
to respiratory and circulatory status, skin integrity, vital signs, and any
special requirements specified in the organization's policies and procedures
associated with evaluations;
(H)
Linking individuals to housing services upon discharge, as needed;
(I) Linking individuals to transportation
services upon discharge, as needed;
(J) Linking individuals to social services or
community resources, as needed;
(K)
Assessment and referral process for individuals with a suspected substance use
disorder and/or mental health disorder;
(L) Care coordination and continuity of care
for individuals served including but not limited to referral process,
follow-up, and transfer of records within five (5) days, in accordance with
best practice five (5) of the National Guidelines for Behavioral Health Crisis
Care, as referenced in section (2) of this rule;
(M) Infection prevention and control;
and
(N) Use of physical and
chemical restraints as specified in
9 CSR
10-7.060 Emergency Safety Interventions.
(11) Community Partnerships. BHCCs
and U-BHCCs shall have a referral relationship, collaborative agreement, and/or
memorandum of understanding (MOU) with the following community providers:
(A) Crisis response with law enforcement,
dispatch, emergency medical services, and first responders;
(B) Local hospitals, primary care clinics,
and Federally Qualified Health Centers (FQHC);
(C) Qualified providers of
detoxification/withdrawal management services;
(D) Schools;
(E) Housing supports;
(F) Local Continuum(s) of Care; and
(G) Recovery support and recovery housing
providers.
(12)
Coordination and Continuity of Care. Service coordination and continuity of
care efforts shall include but are not limited to-
(A) Identifying and linking individuals with
available community resources necessary to stabilize the crisis and ensure
transition to routine care;
(B)
Referring individuals to behavioral health services if not currently receiving
such services;
(C) Connecting
and/or referring individuals to appropriate local resources including emergency
room enhancement (ERE) staff, community behavioral health liaisons (CBHLs),
and/ or certified peer specialists, who shall conduct and document timely
follow-up to determine the individual's current status and need for any
additional assistance or services;
(D) Contacting and coordinating care with
current service providers, when feasible and in accordance with state and
federal confidentiality regulations;
(E) Connecting individuals to housing, food,
or other resources;
(F) Connecting
individuals with recovery support and/or recovery housing providers;
(G) Connecting individuals with
community-based behavioral health providers in other geographic regions;
and
(H) Incorporating some form of
intensive support beds into a partner program (within the organization or with
another local agency), if available, for individuals who need additional
support beyond that of the BHCC/U-BHCC in accordance with best practice three
(3) of the National Guidelines for Behavioral Health Crisis Care, as referenced
in section (2) of this rule.
(13) Documentation Requirements. Based on the
individual's ability to cooperate and communicate with staff due to their
crisis situation, the following intake documentation shall be obtained:
(A) Presenting problem and referral source,
if applicable;
(B) Rationale for
denial of services and referral of the individual to other appropriate
services, if necessary;
(C)
Personal and identifying information;
(D) Status as a current or former member of
the U.S. Armed Forces;
(E) Current
mental health and substance use symptoms;
(F) Current medications and any medications
administered;
(G) Screening for
suicide risk and completion of a comprehensive, standardized suicide risk
assessment and planning, when clinically indicated, in accordance with minimum
expectation eight (8) of the National Guidelines for Behavioral Health Crisis
Care, as referenced in section (2) of this rule;
(H) Screening for risk of violence and
completion of a comprehensive, standardized violence risk assessment and
planning, when clinically indicated, in accordance with minimum expectation
nine (9) of the National Guidelines for Behavioral Health Crisis Care, as
referenced in section (2) of this rule;
(I) Current trauma-related symptoms and/or
concerns for personal safety;
(J)
Crisis intervention and prevention plan, when clinically indicated (a copy
shall be provided to the individual served); and
(K) Discharge information including outcome
of the crisis, services provided, treatment/recovery plan, care coordination
efforts, follow-up, and referrals.
(14) Measuring Program Effectiveness. In
accordance with best practice four (4) of the National Guidelines for
Behavioral Health Crisis Care, as referenced in section (2) of this rule, BHCCs
and U-BHCCs shall collect, enter, and submit data utilizing all reporting tools
as directed by the department.
(15)
Staff Training and Education. Staff are expected to comply with the training
requirements specified in
9 CSR
10-7.110(2)(F) Personnel. All staff
of the BHCC/U-BHCC shall complete minimum training requirements as follows:
(A) Screening, assessment, and planning for
risk of suicide;
(B) Screening,
assessment, and planning for risk of violence;
(C) Evidence-based and best practice
interventions to prevent and address disruptive behaviors and behavioral
crises;
(D) Basic First
Aid;
(E) Cardiopulmonary
Resuscitation (CPR); and
(F)
Administration of naloxone, as appropriate with staff qualifications.
(16) Trauma-Informed Care.
Services shall be provided in accordance with
9 CSR
10-7.010(11), Essential Principle,
Trauma-Informed Care.
