Current through Register Vol. 63, No. 9, September 1, 2024
(1) The facility in
which a regional acute care psychiatric service is provided shall maintain
state certificates and licenses as required by Oregon law for the health,
safety, and welfare of the individuals served. Non-hospital facilities shall be
licensed by the Division as required by ORS
443.410. Non-hospital facilities
shall be certified by the Division as required by OAR
309-008-0100 to 1600. The
facility shall also be approved under OAR
309-033-0530 (Approval of
Hospitals and Nonhospital Facilities that Provide Services to Committed Persons
and to Persons in Custody or on Diversion) and OAR
309-033-0540 (Administrative
Requirements for Hospitals and Nonhospital Facilities Approved to Provide
Services to Persons in Custody, Psychiatric Hold or Certified for 14 Days of
Intensive Treatment).
(2) A
regional acute care psychiatric service shall include 24-hours a day
psychiatric, multi-disciplinary, inpatient or residential stabilization care
and treatment for adults ages 18 and older with severe psychiatric disabilities
in a designated region of the state. For the purpose of these rules, a state
hospital is not a regional acute care psychiatric service. The goal of a
regional acute care service is the stabilization, control, and amelioration of
acute dysfunctional symptoms or behaviors that result in the earliest possible
return of the individual to a less restrictive environment.
(3) A regional acute care psychiatric service
shall maintain clinical records as follows:
(a) Except as otherwise applicable, clinical
records are confidential as set forth in ORS
179.505 and
192.502 and any other applicable
state or federal law. For the purposes of disclosure from non-medical
individual records, both the general prohibition against disclosure of
"information of a personal nature" and limitations to the prohibition in ORS
192.502 shall apply;
(b) Clinical records shall be secured,
safeguarded, stored, and retained in accordance with OAR
166-030-1015;
(c) Clinical record
entries required by these rules shall be signed by the staff providing the
service and making the entry. Each signature shall include the individual's
academic degree or professional status and the date signed.
(4) The clinical record shall
contain:
(a) Identifying demographic
information including, if available, who to contact in an emergency and the
names of individuals who encompass the support system of the patient;
(b) Consent to release information
and explanation of fee policies. At the time of admission, staff shall present
the patient with forms for obtaining consent so that information may be shared
with family and others. An explanation of fee policies shall also be provided
in written form at the earliest time possible. The patient shall be asked to
sign each. If the patient is unwilling or unable to sign, staff shall record
that the patient is unable or unwilling to do so;
(c) An admitting mental health assessment
shall be completed by or under the supervision of an independent medical
practitioner with supervised training or experience in a mental health related
setting within 24 hours of admission. The admitting mental health assessment
shall include a description of the presenting problem, a mental status
examination, an initial DSM diagnosis, and an assessment of the resources
currently available to the individual. The assessment shall result in a plan
for the initial services to be provided. The admitting mental health assessment
shall also include documentation that a medical history and physical
examination of the individual has been performed within 24 hours after
admission by a physician, physician assistant, or nurse practitioner. If the
independent medical practitioner believes a new medical history and physical
examination are not necessary and if within 30 days of admission a complete
physical history has been recorded and a complete physical examination has been
performed, the signed report of the history and examination may be placed in
the clinical record and may be considered to constitute an appropriate physical
health assessment;
(d) A
psycho-social assessment shall be completed for each patient within 72 hours of
admission. If the patient stays less than 72 hours, a psycho-social assessment
need not be written. The assessment must be completed by a qualified mental
health professional or supervisor. The assessment does not need to be a single
document but shall include the following elements:
(A) A description of events precipitating
admission and any goals of the patient in seeking or entering services;
(B) When relevant to the patient's
service needs, historical information including: a current Declaration for
Mental Health Treatment; mental health history; medical history; substance use
history; developmental history; social history including family and
interpersonal history; sexual and other abuse history; educational, vocational,
and employment history; and legal history;
(C) An identification of the patient's need
for assistance in maintaining financial support, employment, housing, and other
support needs;
(D) Recommendations
for discharge planning and any additional services, interventions, additional
examinations, tests, and evaluations that are needed;
(E) A copy of the patient's Declaration for
Mental Health Treatment if the patient elected to complete or provided one.
(e) A treatment plan
individually developed with the patient from the findings of the admitting
mental health assessment and psycho-social assessment must be completed by a
QMHP or supervisor within 72 hours of the person's admission. The plan must be
written at a level of specificity that will permit its subsequent
implementation to be efficiently monitored and reviewed. The recorded plan
shall contain the following components:
(A)
The rehabilitation and other goals, including those articulated by the patient;
(B) Specific objectives, including
discharge objectives and the measurable or observable criteria for determining
when each objective is attained;
(C) Specific services to be used to achieve
each objective;
(D) The projected
frequency and duration of services;
(E) Identification of the QMHP or supervisor
assigned to the patient who is responsible for coordinating services;
(F) The signature of the patient
indicating they have participated in the development of the plan to the degree
possible. If the patient is unwilling or unable to sign the plan, staff shall
record on the plan that the patient is unable or unwilling to do so;
(G) The plan must be reviewed weekly and
updated with the participation of the patient when needed to reflect
significant changes in the patient's status and when significant new goals are
identified;
(H) The patient's
anticipated continuing care needs, including need for housing, and for
individuals with SPMI, the coordination needs for a warm handoff process.
(f) Progress notes shall
document observations, treatment rendered, response to treatment, changes in
the patient's condition, and other significant information relating to the
patient. All entries involving subjective interpretation of the patient's
progress shall be supplemented by a description of the actual behavior
observed;
(g) Reports of medication
administration, medical treatments, and diagnostic procedures;
(h) Telephone communications about the
patient, releases of information, and reports from other sources;
(i) The record shall contain medical and
mental health advance directives or note that the patient has been provided
this information;
(j) The record
shall contain documentation that the patient has been provided information on
patient rights, grievance procedure, and abuse reporting;
(k) The record shall contain documentation
including physician's orders and reasons for all restraint and seclusion
episodes;
(L) The discharge
planning process shall begin at the time of admission with the participation of
the patient and, when indicated, the family, guardian, or family of choice, and
shall include, but is not limited to:
(A) An
assessment of continuing care needs, including prescribed medications,
behavioral and primary health care needs, and housing needs;
(B) Consultation with the individual's CCO to
address continuing care needs upon discharge, when applicable, and;
(C) Planning a follow-up visit with a
community mental health provider within seven days of the anticipated discharge
date.
(m) A warm handoff
shall be offered to individuals with SPMI as part of the discharge planning
process that involves a face-to-face meeting, either in person or through the
use of telehealth, and includes either:
(A) A
community provider, the patient, and if possible hospital staff, or;
(B) A transitional team, the patient, and if
possible hospital staff to support the patient, to serve as a bridge between
hospital staff and a community provider, and to ensure the patient connects
with a community provider.
(n) The discharge plan shall be based on the
patient's treatment goals, clinical needs, and informed choice and shall
include the results of the admitting mental health assessment, DSM diagnoses,
summary of the course of treatment including prescribed medications, final
assessment of the individual's condition, a summary of continuing care needs
including prescribed medications, behavioral and primary health care needs, and
housing needs. Documentation to support linkages to timely and appropriate
community services upon discharge shall be detailed in the discharge plan
including, but not limited to:
(A) The plan
to address the patient's need for immediate housing upon discharge, when
applicable, including notifying the patient's community provider regarding the
need for housing; and
(B) The plan
to address the patient's need for a follow-up visit with a community mental
health provider within seven days of the anticipated discharge date;
(C) For individuals with SPMI, the discharge
plan shall also include:
(i) Whether a warm
handoff occurred and the community provider or transitional team involved in
the warm handoff process, when applicable; or
(ii) Whether the patient declined a warm
handoff.
(5) The regional acute care psychiatric
service shall supply the Division, using the Division's on-line OPRCS via
computer and modem, information about individuals admitted to and discharged
from the service. The information shall include the patient's name, DSM
diagnosis, admission date, discharge date, legal status, Medicaid eligibility,
Medicaid Prime Number, and various patient demographics. The information shall
be entered on the day of admission and updated on the day of discharge.
(6) The regional acute care
psychiatric service shall:
(a) Have
sufficient appropriately qualified professional, administrative, and support
staff to assess and address the identified clinical needs of individuals
served, provide needed services, and coordinate the services provided;
(b) Designate a program
administrator to oversee the administration of the services and carry out these
rules;
(c) Designate a medical
director to oversee the patient care program. The medical director shall have
the final authority concerning inpatient medical care including admissions,
continuing care, and discharges;
(d) Designate an individual responsible for
maintaining, controlling, and supervising medical records and be responsible
for maintaining the quality of clinical records;
(e) Designate an individual responsible for
the development, implementation, and monitoring of a written safety management
plan and program who shall keep records of identified concerns and problems and
actions taken to resolve them;
(f)
Designate an individual responsible for the development, implementation, and
monitoring of a written infection control plan and program who shall keep
records of identified concerns and problems and action taken to resolve them;
(g) Designate or contract with a
licensed pharmacist to be responsible for the development of pharmacy policies
and procedures and to assure that the service adheres to standards of practice
and applicable state and federal laws and regulations;
(h) Maintain a schedule of unit staffing that
shall be readily available to the Division for a period of at least the three
previous years;
(i) Have on duty at
least one registered nurse at all times;
(j) Maintain a personnel file for each
patient care staff that includes a written job description; the minimum level
of education or training required for the position; copies of applicable
licenses, certifications, or degrees granted; annual performance appraisals; a
biennial, individualized staff development plan signed by the staff;
documentation of CPR training; documentation of annual training and
certification in managing aggressive behavior, including seclusion and
restraint; and other staff development and skill training received;
(k) A physician shall be available, at least
on-call, at all times.
(7) The regional acute care psychiatric
service shall have a policy and procedure manual. The policy and procedure
manual must be made available to any individual upon request. The manual shall
describe:
(a) The following policies and
procedures:
(A) Governance and management,
including a table of organization describing the agency structure and lines of
authority, a plan for professional services, and a plan for financial
management and accountability;
(B)
Procedures for the management of disasters, fire, and other emergencies;
(C) Policies and procedures
required under OAR 309-033-0700 through 0740,
Standards for the Approval of Community Hospitals and Nonhospital Facilities to
Provide Seclusion and Restraint to Committed Persons and to Persons in Custody
or on Diversion, addressing seclusion and restraint;
(D) Patient rights, including informed
consent, access to records, and grievance procedures. The manual shall assure
rights guaranteed by ORS
426.380 to
426.395 for committed persons
and ORS 430.205 to
430.210 for those not committed.
The grievance procedure shall be in writing and include written responses, time
limits for responses, use of a neutral party, and a method of appeal. Programs
shall post copies of the rights and grievance procedures in places accessible
to all individuals. Programs shall provide written copies of the rights and
grievance procedures upon request;
(E) Abuse reporting for mentally ill or
developmentally disabled as required by ORS
430.731 through
430.768;
(F) Clinical record content and management
policies and procedures, including the requirements of these rules;
(G) Psychiatric, medical, and dental
emergency services policies and procedures;
(H) Pharmacy services policies and procedures
approved by a licensed pharmacist;
(I) Quality assessment and improvement
processes;
(J) Procedures for
documenting privileges granted by the service in personnel records or other
records;
(K) Policies and
procedures for transfer of patients to other hospitals.
(b) The following policies and procedures,
developed and amended in consultation with the council:
(A) Patient admission and discharge criteria.
Unless the service has a policy and procedure recommended by the council and
approved by the Division, the service shall only admit individuals age 18 and
older;
(B) Quality assessment and
improvement processes relating to regional admissions and discharges;
(C) Patient admission, discharge,
and aftercare planning, including scheduling and planning for transportation of
patients to the service by the referring county and from the service to the
county of residence;
(D) Procedures
for admission and discharge of geropsychiatric patients and individuals with
physical disabilities, including designation of a county or regional
geropsychiatric liaison staff member;
(E) Linkage agreements with entities involved
in patient care;
(F) Medical and
emergency care procedures approved by the Division;
(G) Criteria for accepting pre-admission
medical screening;
(H) Billing and
collecting reimbursement from patients and third-party
payers.
(8) The
service shall have an adequate number of hold rooms, but at least one holding
room, and hold a current Certificate of Approval to hold and treat individuals
alleged to be mentally ill under OAR
309-033-0500 through 0560,
(Approval of Hospital and Nonhospital Facilities that Provide Services to
Committed Persons or to Persons in Custody or on Diversion).
(9) The facility in which a service is
operated shall comply with all applicable federal rules and
regulations.
(10) If the facility
in which the regional acute care psychiatric service is operated is not in a
general hospital, it shall have a letter of agreement with a general hospital
for both emergency and medical care that shall be renewed every two years.
(11) The regional acute care
psychiatric service shall have an ongoing quality assessment and improvement
program to objectively and systematically monitor and evaluate the quality of
care provided to patients served, pursue opportunities to improve care, and
correct identified problems. The program shall include:
(a) Policies and procedures that describe the
quality assessment and improvement program's objectives, organization, scope,
and mechanisms for improving services;
(b) A written annual plan to monitor and
evaluate services. The written plan shall result in reports of findings,
conclusions, and recommendations. Reports shall address:
(A) The care of patients served, including
admission and discharge planning;
(B) Resource utilization, including the
appropriateness and clinical necessity of admissions and continued stay,
services provided, staffing levels, space, and support services;
(C) Quality and content of clinical records;
(D) Medication usage, including
records, adverse reactions, and medication errors;
(E) Accidents, injuries, safety of patients,
and safety hazards; and
(F) Uses of
seclusion and restraint;
(G) An
annual needs assessment survey of individuals that have received services.
(c) A report to the
governing board and council, at least annually, addressing:
(A) Findings and conclusions from studies;
(B) Recommendations, action taken,
and results of the action taken; and
(C) An assessment of the effectiveness of the
quality assessment and improvement program, including a review of the program's
objectives, scope, organization and effectiveness.
(12) The regional acute care
psychiatric service shall have a council to ensure appropriate and effective
care and treatment. The council shall meet to assess and collaboratively plan
for improving care and treatment to patients, including patient transitions
into and out of the service.
Stat. Auth.: ORS
413.042 &
430.640
Stats. Implemented: ORS
430.630 &
430.640
