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CODE OF RHODE ISLAND RULES
AGENCY 18. DEPARTMENT OF BEHAVIORAL HEALTHCARE, DEVELOPMENTAL DISABILITIES AND HOSPITALS
SUB-AGENCY 040. DIVISION OF BEHAVIORAL HEALTHCARE SERVICES
CHAPTER 001. LICENSING OF BEHAVIORAL HEALTHCARE ORGANIZATIONS
Date:
08/31/2009
Document:
18 040 001. LICENSING OF BEHAVIORAL HEALTHCARE ORGANIZATIONS
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Section 10.0 Management of the Environment of Care.
10.1 The organization shall plan for and provide a safe, accessible, effective and efficient environment consistent with its mission, services, and applicable federal, state, and local laws, codes, rules, and regulations. The organization shall have processes for:
10.1.1 Conducting risk assessments that proactively evaluate the impact of buildings, grounds, equipment, occupants, and internal physical systems on individuals served, staff, and public safety;
10.1.2 Reporting and investigating all incidents to include property damage or injury that affects individuals served, staff, or visitors;
10.1.3 Ongoing hazard surveillance, including relevant product safety recalls;
10.1.4 The examining of safety issues by appropriate organizational representatives.
10.2 The organization shall plans for and implements a plan for the safety of staff and persons served.
10.2.1 Safety policies and procedures shall be distributed, practiced, and enforced.
A. Reviews shall be conducted annually.
10.2.2 At all sites owned, rented or leased by the organization First Aid equipment and supplies are in a designated location and readily available to personnel during all hours of operation.
10.2.3 The organization shall implements policies and procedures to prevent the misuse and abuse of drugs at all sites owned, rented or leased by the organization.
10.2.4 When services are provided off site, the organization shall:
A. Have a policy addressing the safety of personnel
B. Provide training related to potential risks.
10.2.5 The organization shall designate individuals to oversee development, implementation and monitoring of safety management.
10.3 The premises of all the facilities of the organization shall be sanitary, in good repair, free from accumulation of combustible debris and waste material and free from offensive odors.
10.4 Smoking shall be prohibited in all buildings owned by the organization, in all building space rented or leased by the organization, except residential apartments, and in all vehicles owned, rented, or leased by the organization.
10.5 The organization shall develop and implement a plan for managing hazardous materials and wastes that is consistent with applicable law and regulation.
10.6 The organization shall develop and implement an emergency management plan that addresses the four (4) phases of emergency management activities: mitigation, preparedness, emergency response, and restoration/recovery. The emergency management plan shall provide processes for:
10.6.1 Identifying specific procedures in response to a variety of disasters based on a hazard vulnerability analysis performed by the organization.
10.6.2 Notifying the Department and other relevant external authorities of emergencies. For purpose of this licensing section, emergencies are defined as any and all of the following:
A. Disruption of normal service delivery.
B. Any natural or man-made event that adversely impacts, or could potentially adversely impact, the operation of the organization's delivery of services, facility or community served.
C. Any event that necessitates mutual aid assistance from other behavioral health organizations to maintain operations.
10.6.3 Documenting mitigation actions to be taken by the organization to lessen the severity and impact of any potential disaster.
10.6.4 Documenting performance standards for disaster responses that identify staff skill levels and knowledge of their individual role in the organizations emergency preparedness management program.
10.6.5 Identifying the staff responsible for covering all necessary staff positions and for implementing emergency management activities at each facility.
10.6.6 Notifying internal staff of the procedures and modes of communication to be used.
10.6.7 Identifying back up internal and external means of communication.
10.6.8 Managing space, supplies, and security.
10.6.9 Evacuating all facilities in the event that the environment of care cannot support adequate care and treatment.
10.6.10 Conducting at least two (2) drills annually that test emergency management procedures in response to:
A. A natural disaster, e.g. hurricane, flood, blizzard
B. A man-made disaster, e.g. explosion, building fire, biochemical terrorist act, etc.
10.6.11 Conducting evacuation drills at each treatment facility on each shift at least annually.
10.6.12 Record all drills and document corrective action taken.
10.6.13 Accessing information on persons served that may be needed in a disaster.
10.6.14 Provide an orientation and education program for personnel who participate in implementing the emergency management plan.
10.6.15 Communicating emergency plans to all personnel and to persons served, as appropriate.
10.6.16 Defining and integrating the organization's role with community and state emergency response agencies.
10.6.17 Provide supportive measures and debriefing assistance for staff who participate in implementing the emergency plan.
10.6.18 Conducting an annual evaluation of the objectives, scope, performance, and effectiveness of the emergency management plan.
10.7 The organization shall develop and implement a fire prevention plan that is consistent with all laws and regulations.
10.8 The organization shall have equipment appropriate to the needs of the persons served and personnel for fire detection and suppression.
10.9 If fire safety approval for a building in which the organization provides services is withdrawn or restricted, the organization shall notify the Department orally within twenty four (24) hours and in writing within forty eight (48) hours of the withdrawal or restriction.
10.10 If a building is structurally renovated or altered after the initial fire safety approval is issued, the organization shall submit, from the appropriate fire safety authority, the new fire safety approval or written certification that a new fire safety approval is not required.
10.11 At all sites that are owned, rented leased or operated by the organization, fire exit drills shall be conducted and documented:
10.11.1 At least quarterly in non-residential facilities.
10.11.2 At least one (1) per shift per quarter in residential facilities.
10.12 Fire drill documentation shall be maintained and shall include:
10.12.1 Name of person conducting drill;
10.12.2 Date and time of drill;
10.12.3 Amount of time taken to evacuate the building
10.12.4 Type of drill (obstructed or unobstructed);
10.12.5 Record of problems and steps taken to correct them.
10.13 The organization shall develop and implement a plan to monitor, test and inspect all utilities and equipment, including medical equipment.
10.14 Safety self-inspections conducted by the organization shall:
10.14.1 Occur twice each year;
10.14.2 Occur at all sites owned, rented, or leased by the organization;
10.14.3 Be documented, to include:
A. Identification of areas inspected
B. Corrective actions taken in response to deficiencies cited.
10.15 The organization shall have a process for identifying and implementing violence prevention measures.
10.16 To the extent permitted by law, weapons shall be prohibited at the licensed site(s), except when carried by licensed security personnel.
10.17 The organization shall establish an environment that meets the needs of individuals served, promotes their rights, and respects their human dignity.
10.17.1 The organization shall display the Rights of Persons Served and the Concern and Complaint Resolution Procedure, specified in these Regulations, in conspicuous places, such as waiting rooms and common areas, in all buildings where services are provided by the organization.
A. Information about how to obtain copies shall be included in the posted material.
10.17.2 Waiting or reception areas shall be comfortable and adequately accommodate visitors and individuals served.
10.18 Restrooms shall be available and accessible for staff and individuals served.
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Section 40.0 Residential Services.
Residential programs operate twenty-four (24) hours a day, seven (7) days per week providing services and supervision to designated populations. Services promote recovery and empowerment and enable individuals to improve or restore overall functioning. These regulations apply to all behavioral health programs that provide twenty-four (24) hour supervised housing and treatment.
40.1 Each residential program shall have on-site policies and procedures that describe admission, continuing care, and discharge criteria specific to the type of residential setting.
40.2 An initial assessment, indicating the need for twenty-four (24) hour supervised care, shall be completed for each person admitted to the program.
40.3 A Psychiatric Rehabilitative Residence Personal Care Checklist (Appendix II) shall be completed within seven days of an individual's admission to a mental health residential program.
40.3.1 The assessment shall include all areas outlined in the Checklist and shall be conducted by staff with specific skills and knowledge in the area being assessed.
40.3.2 The Checklist shall be authorized and signed by the treating psychiatrist.
40.3.3 Areas on the Checklist that require assistance or monitoring shall be addressed on the individual's treatment plan.
40.4 A physical health assessment, including a medical history and physical examination, shall be completed by a qualified medical, licensed, independent practitioner, within one (1) week after admission to a residential program.
40.4.1 If a comprehensive medical history and physical examination have been completed within thirty (30) days before admission to the program, a durable, legible copy of this report may be used in the treatment record as the physical assessment, but any changes to the individual's condition must be recorded at the time of admission.
40.5 Within seven (7) days of admission, a comprehensive treatment plan shall be completed with each resident and, as appropriate, his or her family.
40.5.1 The treatment plans and treatment plan reviews of each resident of a mental health residential program must be signed by the psychiatrist who is treating the resident.
40.6 Each supervised apartment residential program shall serve no more than three (3) residents per apartment unit and each resident shall have his or her own, individual bedroom. The supervised apartments shall be comprised of no more than twelve (12) apartment units excluding any single apartment unit designated as a "staff apartment" and/or office space. The configuration of units, in total, shall serve no more than twelve (12) individuals.
40.6.1 All apartment units must be either in the same building and/or same apartment complex and/or same condominium association and/or same contiguous block.
40.6.2 A staff person must be able to be present in any individual apartment unit within five (5) minutes of receiving an alert or a request regarding a resident of an apartment. This includes third shift "sleep over" staff if they are utilized by the program.
40.6.3 All apartment units shall have an accessible working telephone.
40.6.4 Each supervised apartment program shall implement smoking regulations that include the following:
A. Smoking shall be strongly discouraged in any sleeping room.
B. Staff shall strongly encourage that smoking be limited to only one (1) area of each apartment unit.
C. Ashtrays of noncombustible material and safe design shall be provided where smoking occurs.
D. Metal containers with self-closing cover devices into which ashtrays may be emptied shall be provided and readily available where smoking occurs.
E. Each resident who smokes shall receive special smoking fire safety instruction and this instruction shall be documented in the resident's treatment record.
40.6.5 Reasonable accommodations and individually tailored support services shall be made available to all residents in supervised apartment programs including, but not limiting to the following:
1. The provision of specialized safety equipment such as irons, stoves, and other equipment that shut off when unattended.
2. The availability of one to one (1:1) staffing for periods of time when a resident is in crisis.
40.6.6 All buildings that house supervised and residential apartment programs shall meet the requirements of the applicable standards of the Rhode Island Fire Safety Code.
40.7 The service elements offered by a residential program shall include but not be limited to the provision of or linkage to the following based on each resident's individualized treatment plan:
40.7.1 Behavioral health therapeutic and rehabilitative services necessary for the resident to attain recovery
40.7.2 Individual, group, and family counseling
40.7.3 Medication prescription, administration, education, cueing and monitoring
40.7.4 Educational activities (appropriate to age and need)
40.7.5 Behavioral Management
40.7.6 Menu planning, meal preparation, and nutrition education
40.7.7 Skill training regarding health and hygiene
40.7.8 Budgeting skills training and/or assistance
40.7.9 Crisis intervention
40.7.10 Community and daily living skills training
40.7.11 Community resource information and access
40.7.12 Transportation
40.7.13 Social skills training and assistance in developing natural social support networks
40.7.14 Vocational/Employment services
40.7.15 Coordination with the resident's medical care providers
40.7.16 Cultural/Spiritual Activities
40.7.17 Aftercare/follow-up services
40.7.18 Limited temporary physical assistance, as appropriate
40.8 In addition to essential services each residential program must provide the following for its residents:
40.8.1 A homelike and comfortable setting, that provides the individual adequate space for personal belongings
40.8.2 Opportunities to participate in activities not provided within the residential setting
40.8.3 Regular meetings between the residents and program personnel
40.8.4 A daily schedule of activities
40.8.5 Provisions for review of the individual's treatment goals and progress of these goals
40.8.6 Sleeping arrangements based on individual need for group support, privacy, or independence, as well as, the individual's gender and age
40.8.7 Provisions for external smoking areas, quiet areas, and areas for personal visits
40.8.8 Required training for residents and staff in safety drills, infection control policies, and risk management procedures.
40.9 In accordance with the needs of the individual served, good standards of personal hygiene are taught and maintained, with due regard for privacy.
40.10 All residential programs shall be staffed on-site, twenty-four (24) hours per day, seven (7) days per week as long as there are residents physically present. Staff may be situated in a central location in an apartment program. In all cases, a staff person must be able to be present in any room or apartment unit within five (5) minutes in response to any alert or request regarding a resident.
40.11 During all hours of operation in all residential programs, there are provisions for the availability of at least one (1) individual trained in basic First Aid and in cardiopulmonary resuscitation (CPR).
40.12 Residential facilities shall have policies and procedures that insure compliance with all federal and state laws and regulations pertaining to accessibility, health, fire, and safety.
40.12.1 Residential programs shall maintain the appropriate documentation regarding the testing, maintenance, and monitoring of such laws and regulations.
40.13 Each residential program shall have written policies and procedures for the evacuation of all residents in the event of a fire or other emergency that includes, but is not limited to, the following:
40.13.1 Each residential program shall conduct a test to determine each resident's ability to evacuate the premises within two (2) minutes.
A. Each potential resident shall be tested before he or she is admitted to the program, or within the first 48-hours in the case where an individual is referred from a detoxification or prison setting.
B. Each resident shall be tested at least quarterly. The test may be conducted as part of a fire drill.
C. The tests shall be documented in the resident's record, or in an on-site program record for all residents. The documentation shall include:
1. Name of resident;
2. Type of assistance, if any required;
3. Time required to evacuate from the resident's sleeping quarters;
4. Date and time of the test;
5. Name and title of the person who conducted the test.
D. In the following manner, each resident shall be classified according to his or her ability to evacuate the premises within two (2) minutes in the event of a fire or other emergency:
1. Does not require physical assistance, supervision, or instruction.
2. Does not require physical assistance but does require supervision or instruction.
3. Requires physical assistance.
40.13.2 At least one (1) fire exit drill per shift per quarter shall be conducted in each residential program. At least fifty percent (50%) of such drills shall be obstructed drills, as defined by the state fire/safety regulations.
40.13.3 All program staff shall have fire safety training annually that includes training in the program's emergency evacuation plan.
A. This training shall be documented in each staff person's personnel record.
40.13.4 Each resident shall be trained in, and shall practice, the proper actions to take in the event of a fire. This training shall include actions to take in the event the primary escape route is blocked.
A. This training shall be documented in each resident's treatment record or in a program report for all residents that is kept on site at the residential program.
40.13.5 All smoke detectors shall be checked at least four (4) times per year to ensure their proper operation.
40.14 Substance abuse residential programs shall:
40.14.1 Provide the level and type of service needed by each resident following ASAM-PPC guidelines.
40.14.2 Provide at least five (5) hours per week of individualized, professionally directed treatment for each resident.
40.14.3 Offer family counseling and education services on an as-needed basis.
40.15 Clinical Supervisors of residential staff shall have at a minimum, the qualifications listed in 33.8
40.16 Direct service staff in residential programs shall have, at a minimum, the following qualifications relevant to the service they are providing: at least, a license as a Registered Nurse or an Associate's Degree in Human Service field or a combination of education and prior work or life experience that the organization determines is comparable.
40.16.1 Residential programs promoting their services as a specialty program with co-occurring disorders must have an appropriate ratio or qualified mental health and substance abuse personnel.
40.17 Residential programs that provide substance abuse services shall maintain a written cooperative agreement with a detoxification facility.
40.18 A minimum of two (2) follow-up contact attempts shall be made within six (6) months of each person's discharge from a residential program. (RIGL Section 40.1-24-19).
40.19 Documentation of both successful and unsuccessful follow-up contacts shall be recorded in the treatment record. This documentation shall include at least the following:
40.19.1 Date and time of contact or attempted contact;
40.19.2 Summary of contact (summary of the client's progress or regression);
40.19.3 Reason for unsuccessful contact (if applicable);
40.19.4 Plan for future follow-up contacts (if applicable);
40.19.5 Signature of staff person making the contact. Regulations 40.20 through 40.25 apply only to Substance Abuse Residential Programs that Serve Minors.
40.20 Substance Abuse residential programs that serve minors shall provide staffing that allows for constant adult supervision at all times and includes the following:
40.20.1 Awake staff coverage twenty-four (24) hours per day
40.20.2 Direct care staff to resident ratio is at least one to ten ( 1:10 ) when residents are awake and one to twenty ( 1:20 ) when residents are asleep.
40.21 Residential programs that serve minors for more than thirty (30) days, shall provide, or arrange through school districts, an academic and physical education program for each minor within fourteen (14) days of his or her admission.
40.22 Residential facilities and treatment services for minors shall be separate from those provided for the adult population, except for the following minors:
40.22.1 Pregnant minors;
40.22.2 Children of adults undergoing residential treatment.
40.23 Parental consent shall be required for all minors treated in substance abuse residential programs, except as otherwise provided by Rhode Island General Laws section 14-5-4.
40.24 Programs providing services to minors shall comply with Rhode Island General Laws section 11-9-13 pertaining to the purchase, sale, or delivery of tobacco products to persons under the age of eighteen (18).
40.25 Residential programs shall have a written policy regarding staff responsibilities when a minor is absent without permission. The policy shall include:
40.25.1 Immediate notification of the parent(s) or legal guardian(s)
40.25.2 Notification of the proper legal authorities after the minor is absent for twenty-four (24) hours
40.25.3 Documentation in the minor's treatment record of the elopement and of the appropriate notifications as they were completed. Regulations 40.26 through 40.35 apply only to the Behavioral Health Acute Stabilization Unit.
40.26 Purpose: The Behavioral Health Acute Stabilization Unit (BHASU) is a hospital diversion and step down unit for Rhode Island residents eighteen (18) years of age or older who are experiencing a psychiatric and/or substance abuse related crisis. This unit will provide assessment and observation, crisis intervention and treatment for psychiatric, substance abuse and co-occurring treatment.
40.27 Capacity: The unit must have access to a minimum of ten (10) beds located in one facility. The maximum capacity that can be located in one facility is sixteen (16) beds.
40.27.1 Ideally, there should be no more than two (2) clients in one (1) room. Exceptions to this policy require prior approval by BHDDH and are limited to allowing one (1) room to have three (3) clients.
40.27.2 A program must have the capacity to supervise clients individually in a room if clinically necessary.
40.28 Admission Criteria:
A. Individuals must be eighteen (18) years of age or older and a resident of Rhode Island.
B. Individuals must have the capacity to safely stay in an unlocked facility.
C. Individuals must voluntarily agree to be admitted into the unit.
D. Individuals must be medically stable and receive medical clearance for the transfer by both the referring facility and the BHASU when referred by an emergency room or if being stepped down from an inpatient facility. Disputes regarding medical clearance must be resolved at the physician level.
E. Referrals will only be accepted through an emergency room, or an inpatient facility or a Rhode Island Licensed Behavioral Healthcare provider.
40.29 Exclusion Criteria: Clients exhibiting one (1) or more of the following may be excluded from the program at the discretion of the BHASU Program Director.
A. Acute substance intoxication
B. Acute psychosis with evidence of impaired judgment or lack of impulse control as evidenced by psychiatric symptoms of command hallucinations or delusional thinking;
C. Acute mania impairing judgment and impulse control;
D. Gross functional impairment due to vegetative signs of depression such as remaining in bed all day, deterioration of cognitive ability and inability to perform self care;
E. Assaultive ideation, evidenced by threats and likelihood to harm, kill or injure others;
F. Assaultive behaviors evidenced by threats and/or restraining orders combined with the likelihood to act on those behaviors;
G. Active self-injurious behaviors such as head banging, lacerating wrists, and threatening to elope from the unit;
H. Recent suicide attempt with a continued threat or plan to act on suicidal ideation
I. A determination that the client's physical condition is too compromised for the unit to handle despite medical clearance at the point of the original evaluation. This determination must be made at the physician level and documented at the Unit. All refusals based on this item must be reported to BHDDH within forty-eight (48) hours with full documentation being forwarded to the Department upon request.
40.30 Proposed Length of Stay: Length of stay will be individualized based on each individual's service needs. A typical stay for diversion programs of this nature is 3-7 days and exceeds fourteen (14) days only on rare occasions.
40.31 Discharge Criteria: Clients may be discharged if one (1) or more of the following criteria are met:
A. Treatment issues identified in the treatment plan are resolved;
B. The individual is unable to be safely managed at the unit due to increased severity and intensity of symptoms;
C. The individual is in need of acute medical treatment requiring a hospital setting;
D. The individual is in need of hospital level of care to safely manage the symptoms of detoxification and/or withdrawal;
E. Physical aggression towards staff or other residents;
F. Self abusive behavior, unable to be managed in the unit;
G. Involvement in criminal/antisocial activity while in the program, i.e. stealing, drug use, possession or distribution, threats or intimidating behavior towards others;
H. Crisis is stabilized and client can be referred to less intensive treatment.
40.32 Admission Procedures: The Unit will have the capacity to accept admissions 24-hours a day, seven (7) days a week (24/7). The initial referral will come by phone directly to a person who is either located on site at the unit or is available by phone with direct access to the unit. Delays in dealing with a referral are not expected unless multiple referrals are made simultaneously.
A. The initial phone screening must be supervised by a Licensed Independent Clinician or Practitioner who shall have overall clinical responsibility for the screening process.
B. Upon completion of the phone screening, the unit must have the capacity to finalize the disposition with the referral source within sixty minutes.
C. Once admission is accepted, transportation issues are the responsibility of the inpatient facility/ER and may be billed under Medicaid fee-for-service using standard allowable codes. Unaccompanied transportation by a taxi cab may not be utilized.
D. The Unit RN will contact the referring emergency room to receive the nurse-to-nurse report prior to receiving the admission. The Unit RN will request copies of all pertinent medical information regarding the client including lab work, toxicology results, etc.
E. Individuals will receive a medical pre-screening or physical examination by the unit RN immediately upon arrival at the unit,
F. Once cleared by the unit RN, individuals will undergo a safety check including a trauma-informed search of the client and any belongings that the client brings with them at the time of admission unless clinically contraindicated. The search must be conducted by two (2) unit staff, be culturally sensitive, and include efforts to maximize the information given to the patient; maximize client choice wherever possible; assume a collaborative and respectful stance; and minimize coercion. A decision to bypass the safety search based on clinical grounds must be authorized by Licensed Independent Clinician or Practitioner supervising the admission.
G. A Licensed Independent Clinician or Practitioner will conduct an initial assessment within 24-hours of admission and collaborate with the individual and treatment team to develop a treatment plan. This assessment should take into consideration any findings of the triage assessment and, if conducted upon the client's arrival to the unit, may replace same.
H. Clients must also receive an orientation to the program, a copy of the Client Rights form, and be informed of all program policies and procedures on admission.
40.33 Staffing: The program must be staffed 24/7. This includes on-site coverage at all times by nurses, counselors, and care managers, as well as access to a psychiatrist available to respond within thirty (30) minutes.
40.33.1 The program must have on-site scheduled psychiatry time as required by the client mix at any given time.
40.33.2 Clinical supervisors of residential staff shall have, at a minimum, the qualifications listed in 33.8
40.33.3 All staff providing direct services who are not Licensed Independent Clinicians or Practitioners shall receive clinical supervision on an ongoing basis, as specified under BH Regulation 9.9
40.33.4 During all hours of operation in all residential programs, there are provisions for the availability of at least one (1) individual trained in basic First Aid and in cardiopulmonary resuscitation (CPR).
40.33.5 Required training for staff includes: safety drills, infection control policies, and risk management procedures.
40.34 Program Description of Services:
40.34.1 24 Hour Crisis Services: All staff will be trained in risk assessment and crisis intervention services. Upon arrival to the program, individuals are to receive a face-to-face initial triage review by a Licensed Independent Clinician or Practitioner to assess acuity, risk status, and client level of need for the interim period prior to a full assessment and development of an initial treatment plan.
40.34.2 Hospital Step Down Services: The unit must offer step-down services for clients who do not require inpatient hospitalization or detox but who require further stabilization before returning to the community.
40.34.3 Care Management Services: Every client on the unit will have an identified care manager. The care manager is responsible for the coordination of care while the client is on the unit and also for insuring that the client has appropriate follow-up appointments upon discharge.
40.34.4 Psychiatry Services: The unit must have a psychiatrist available 24/7 to respond to medication orders and any medical concerns. The psychiatrist must also be scheduled to be on-site at the program for psychiatric assessments and medication reviews as required by the specific client mix at any given time.
40.34.5 Medication Services: An RN is to be on-site 24/7 for the administration and monitoring or medication.
40.34.6 Inpatient Psychiatric and Medical Admissions:
A. The unit will have a staff member meeting the requirements of the Mental Health Law on site 24/7 to facilitate inpatient psychiatric admission from the unit site to an inpatient facility if required.
B. The unit will also have an RN on-site 24/7 to facilitate transfers for medical admissions.
40.34.7 Evidence Based Co-occurring Treatment Services: Services will be offered that are evidenced based for individuals with co-occurring treatment needs. Interventions to treat both disorders are to be listed in the treatment plan and implemented by staff with knowledge, skills and qualifications to provide both mental health and substance abuse services.
40.34.8 Group and Individual Counseling: All individuals have access to participate in group and or individual counseling as indicated by their treatment needs and treatment plan.
40.34.9 Discharge Planning: All individuals will have a discharge plan, which shall be started within 24-hours after admission.
A. Follow up appointments are not to exceed 48 hours for the first
B. Appointment and 14 days for a follow up medication appointment.
C. Individuals are not to simply be given phone numbers to contact as follow-up.
D. Individuals referred to homeless shelters will have scheduled follow up appointments with providers and will also make attempts to have releases signed so that coordination of care between the unit and the homeless shelter can occur.
E. Transportation issues are to be resolved and documented in the individual's record describing how the individual will attend the first appointment. (i.e. family member, self, public transit, staff to transport etc).
F. All discharge plans will be documented and approved by a licensed practitioner of the healing arts.
40.34.10 Family Psychoeducation and Supportive Services: Services are available to family members to be involved in treatment planning and discharge meetings. Education, information, and support is to be provided to family members.
40.35 Residential Regulations not applicable for BHASU
A. 40.3 - 40.11
B. 40.14 - 40.19
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**Note: Only the section analyzed by the PHASYS team is included here as the entire regulation exceeded ~100 pages.
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