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Document Citation: 65E-12.106, F.A.C.
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FLORIDA ADMINISTRATIVE CODE
TITLE 65 DEPARTMENT OF CHILDREN AND FAMILY SERVICES
65E MENTAL HEALTH PROGRAM
CHAPTER 65E-12 PUBLIC MENTAL HEALTH CRISIS STABILIZATION UNITS AND SHORT-TERM RESIDENTIAL TREATMENT PROGRAMS
Date:
08/31/2009
Document:
65E-12.106 Common Minimum Program Standards.
(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 the agency 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 agency 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 persons 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 or volunteer acknowledging receipt of the evaluation.
(b) Personnel Records. Records on all employees and volunteers shall be maintained by the agency. Each employee record, available for employee review shall contain:
1. The individual'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 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 persons receiving services;
5. 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 Registry; and
6. Documentation that the individual has been fingerprinted and screened, if appropriate, in accordance with Section 394.4572, F.S.
7. Documentation of training as required by Section 381.0035, F.S., for all non-licensed staff.
(c) Fingerprint Screening. All mental health personnel, as defined in Section 394.4572, F.S., who have direct contact with unmarried persons under the age of 18 years shall be screened in accordance with Section 394.4572, 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 and indication if the position requires fingerprint screening. If fingerprint screening is required the record shall indicate the date of employment or transfer to the position, date of fingerprint card and information submission to the department, and receipt date of the individual's written assurance of compliance from the department.
(3) Staff Development and Training. Each CSU and SRT shall provide staff development and training for facility staff, part-time and temporary personnel, 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 or a mental health counselor 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, position and 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.
(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 person 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 Sections 394.459(3) and 394.4615, F.S. All staff shall receive training as part of staff orientation, with periodic update on file, regarding the effective maintenance of confidentiality of clinical records. It shall be emphasized that confidentiality includes oral discussions regarding persons 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 Sections 394.459(3), and 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 legal signature, title and discipline. 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. A person's complete clinical record shall be retained for a minimum period of 7 years following discharge, as provided by Section 95.11(4)(b), F.S.
(c) Content of Clinical Records. 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 individual's name and address;
2. Name, address, and telephone number of guardian, or representatives in accordance with Chapter 65E-5, F.A.C.;
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 other mental health assessments as appropriate, such as psychosocial, psychological, nursing, rehabilitation and nutritional;
9. The original service implementation plan, dated and signed, by the person receiving services and treatment staff, which contains short-term treatment objectives that relate to the long-term view in the comprehensive service plan, if the person has one, and description and frequency of services to be provided;
10. The signed and dated service implementation plan reassessments and reviews;
11. Examination, diagnosis and progress notes by physician, nurses, mental health treatment staff and other mental health professionals that relate to the service implementation 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 medication and treatment orders;
17. Signed consent for the release of information, if information is released;
18. An individualized discharge plan;
19. All appropriate forms mandated under Chapter 65E-5, F.A.C.;
20. A current, originally authorized HRS-MH Form 3084, October 1984, "Public Baker Act Service Eligibility, " which is herein incorporated by reference for all persons receiving services; and
21. Documentation of case manager contacts if the person receiving services has a case manager.
(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 HRS-MH Form 3042, to be rendered by the program, and as mandated by Rule 65E-5.050, F.A.C., or an emergency treatment order initiated pursuant to Section 394.459(3), F.S.
(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 guardians or representatives of individuals 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, he shall be notified and shall provide appropriate information and participate in the development of the discharge plan. Persons receiving services, or significant others, shall be informed of their eligibility or ineligibility status for publicly paid CSU or SRT services, either at admission or shortly thereafter, pursuant to Chapters 65E-5 and 65E-14, F.A.C.
(a) Mental Illness Criteria. All individuals admitted shall meet the criteria defined under Section 394.455(18), 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 person receiving services and significant others, if applicable, regarding admission and discharge standards, rules, procedures, activities and concepts of the program. A written copy of the above shall be provided to persons receiving services and their guardians. Persons receiving services shall be informed in writing of 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 central abuse registry as required by Section 415.1034, F.S.Programs shall not discourage or prevent anyone from contacting the central abuse registry.
(8) Protection of Persons 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 under evaluation and treatment. In addition to all rights granted under Chapter 394, Part I, F.S., individuals 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 and only to insure 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 person, 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 Client. Whenever feasible, the individual shall be present during a search.
3. Absence of Client. When it is impossible to obtain the individual's physical presence, the individual shall be given prompt written notice of the search and of any article taken.
4. Documentation. Written reports of all searches shall be placed in the individual's clinical record. A written inventory of items confiscated shall be forwarded to the program director or designee.
(c) Assured that facility policy prohibits any retaliation or reprisal against either the individual or against staff for reporting suspected abuse, neglect or exploitation, or violations of the individuals patient's rights. A copy of this facility policy shall be posted in a common patient area and provided to the patient 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 persons served.
(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. Individual 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 person receiving services.
5. The service implementation plan is comprehensive, relative to the full range of the needs of the person receiving services at the CSU or SRT.
6. Minimal standards for clinical records are being met as required by subsections 65E-12.106(5), (6), of this Rule.
7. Medication is prescribed and administered appropriately. All medication errors shall be reported under the agency's incident reporting system and subject to internal review by the agency's 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 suicides, death, serious injury, violence, and abuse of any person.
11. All incident reports are reviewed by the facility director within 2 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 for priority clients through case management.
15. Delay in receiving services is minimal.
(c) The quality assurance committee shall submit a quarterly report to the agency director and board of directors for their review and appropriate action.
(10) Event Reporting. Every CSU and SRT shall report events according to HRS Regulation No. 215-6, "Comprehensive Client Risk Management, " June 1, 1990, which is incorporated herein by reference.
(a) Every CSU and SRT shall develop policies and procedures for reporting to the department major events within 1 hour of their discovery or in accordance with the reporting provisions of an applicable district operating procedure.
(b) Only major types of events shall be reported. Every CSU and SRT shall develop a list, subject to district alcohol, drug abuse and mental health program office approval, that shall include the following: any death, serious injury or illness, any event involving recent non-admission or discharge, a felony crime, fire, natural or other disaster, epidemic, escape, riot, elopement, sexual harassment, sexual battery, or any situation which may evoke public reaction or media coverage.
(11) Data. Every CSU and SRT shall participate in reporting data as mandated under Sections 394.77 and 20.19(13), F.S.
(12) Facility Standards for Facilities Licensed Prior to or on July 14, 1993.
(a) Building Construction Requirements.
1. Construction, additions, refurbishing, renovations, and alterations to existing facilities shall comply with the following codes and standards:
a. The building codes described in Rule 9B-3.047, F.A.C.;
b. The fire codes contained in Chapter 4A-3, F.A.C., as described in the National Fire Protection Association (N.F.P.A.) 101, Chapters 12 and 13, Special Definitions, as applicable to limited health care facilities, which is included by reference in Chapter 59A-3, F.A.C.;
c. The accessibility by handicapped persons standards in Chapter 553, Part V, F.S.; and
d. The federal Americans with Disabilities Act as referenced in Chapter 59A-3, F.A.C.
2. Modernization or Renovation. Any alteration, or any installations of new equipment, shall be accomplished as nearly as practical in conformance with the requirements for new construction and accessibility. Alterations shall not diminish the level of safety or usable client space below that which exists prior to the alteration. Life safety features which do not meet the requirements for new buildings but exceed the requirements for existing buildings shall not be further diminished. Life safety features in excess of those required for new construction are not required to be maintained. In no case shall the resulting life safety be less than that required for existing buildings.
3. Sewage, including liquid wastes from cleaning operations, shall be disposed of in a public sewage system or other approved sewage system in accordance with Chapters 381, F.S., and 64E-6, F.A.C., Standards for Individual Sewage Disposal Facilities or Chapter 62-600, F.A.C., Domestic Wastewater Facilities.
4. All sanitary facilities shall comply with the requirements of Chapter 64E-10, F.A.C.
5. All plumbing shall comply with the requirements of Chapter 9B-51, F.A.C., Plumbing, or with the plumbing code legally applicable to the area where the facility is located.
6. The water supply must be adequate, of safe and sanitary quality and from an approved source in accordance with Chapters 381, F.S., and 64E-8, F.A.C., Drinking Water Systems.
7. Heat shall be supplied from a central heating plant or by an approved heating system in accordance with Chapter 59A-3, F.A.C.
(b) Minimum Physical Plant Requirements for Existing CSU and SRT Facilities That Were Licensed Prior To February 1986.
1. Each CSU and SRT shall conform to the following requirements no later than March 1987.
a. In multiple occupancy bedrooms or sleeping areas there shall be a minimum of 60 square feet per bed and no less than a 30 inch separation between beds. Bedrooms shall be limited to a maximum of four occupants.
b. The minimum size of a single occupant bedroom shall be 55 square feet.
c. Each CSU shall have at least one seclusion room and another room which may be used as a seclusion room as provided for in subparagraph 65E-12.106(19)(c)2. of this Rule. Seclusion rooms shall be a minimum of 55 square feet. If a restraint bed is utilized it shall have access around it and be bolted to the floor. Seclusion rooms shall minimally include a mattress. Ceilings shall be solid and all lighting fixtures shall be tamper-proof and power receptacles are not permitted in the room.
d. The facility shall have at least one water fountain readily accessible for the use of persons receiving services.
e. The facility shall have a minimum ratio of one shower for each eight individuals and one toilet and lavatory for each six individuals. Individual shower stalls and dressing areas shall be provided. The use of gang showers is prohibited. Access to a bathroom shall not be through another person's room.
f. The facility shall have a locked area for personal possessions being held for safekeeping. Individual shelves or other similar dividers shall be provided in the locked area for the storage of personal possessions. The facility shall have written policies and procedures to ensure reasonable access to personal possessions.
g. Each facility shall have a fenced outside recreation area with a minimum fence height of no less than six feet suitable for impeding elopements.
h. External windows shall have security screens or equivalent protection.
i. The facility shall provide an appropriate separate non-treatment area to serve as a general reception area with accommodations for such activities as receiving visitors. This reception area shall be separated from the treatment area by a locked doorway.
j. When a CSU is collocated with another program, as provided for in subsection 65E-12.106(23) of this Rule, these specified minimum facility requirements shall be met.
k. All CSUs shall be locked facilities and, to the maximum extent practical, provide a locked perimeter around a living unit and fenced exercise area within which individuals can reside 24-hours-a-day in an environment designed to minimize potential for injury. Where this is not possible, operational compensation shall be made as specified in subsection 65E-12.107(7) of this Rule.
l. Food preparation areas for 13 or more persons shall comply with the provisions of Chapter 64E-11, F.A.C., Food Hygiene.
(c) Health and Safety.
1. Disaster Preparedness.
a. 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.
b. 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.
(I) The plan and fire safety manual shall identify the availability of fire protection services and provide for the following:
(A) Use of the fire alarm;
(B) Transmission of the alarm to the fire department;
(C) Response to the alarm;
(D) Isolation of the fire;
(E) Evacuation of the fire area or facility utilizing posted evacuation routes;
(F) Preparation of the residents and building for evacuation;
(G) Fire extinguishment;
(H) Descriptive procedures for the operation and maintenance of fire equipment;
(I) Procedures for staff training and the provision of monthly fire drills rotated so that all shifts have at least one fire drill quarterly;
(J) Documentation of monthly and periodic professional inspections of equipment; and
(K) Provision for annual review and revision of the fire safety manual and plan.
(II) The plan shall be made available to all facility staff and posted in appropriate areas within the facility.
(III) There shall be records indicating the nature of disaster training and orientation programs offered to staff.
2. Fire Safety. CSUs and SRTs shall comply with Chapter 4A-3, F.A.C., 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.
3. Personal Safety. The grounds and all buildings on the grounds shall be maintained in a safe and sanitary condition, as required in Section 386.041, F.S., Nuisances Injurious to Health.
4. Health and Sanitation.
a. 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.
b. 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 persons being served shall be at least 100 degrees Fahrenheit but not exceed 120 degrees Fahrenheit.
c. Garbage, Trash and Rubbish Disposal.
(I) 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 and shall comply with the provisions of Section 386.041, F.S.
(II) 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 and shall comply with provisions of 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. 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 persons, all matters pertaining to food service shall comply with the provisions of Chapter 64E-11, F.A.C.
(c) Third Party Food Service. When food service is provided by a third party, the provider shall meet all conditions stated in this section, and shall comply with 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. Assurance of the following must be provided:
(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 painted, stained, or maintained so as to keep it reasonably attractive. 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 attractive, 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 person 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 and 65E-14, F.A.C., and these Rules.
(16) Client Register and Census. An admission and discharge logbook shall be maintained which lists persons 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.
(17) Pharmaceutical Services.
(a) Every CSU and SRT shall handle, dispense or administer drugs in accordance with Chapters 465, 499, and 893, F.S.
(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.
(18) Emergency Medical Services. Every CSU or SRT shall have written policies and procedures for handling medical emergency cases which may arise subsequent to a person'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 Chapter 394, Part I, F.S. 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 or routine orders for emergency treatment orders is prohibited.
(b) Cardiopulmonary Resuscitation and Choke Relief. All nurses and mental health treatment 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) Client Protection.
(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 persons on the unit.
2. Therapeutic activities 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 persons receiving services during use or storage.
4. Nursing and medical supplies including drugs, sharps and breakables shall be safeguarded from access by persons receiving services through storage, use and disposal processes.
(c) Use of Restraint or Seclusion.
1. The use of restraint or seclusion shall require documented clinical justification, including the failure of less restrictive means, and shall be employed only after less restrictive means have been attempted without success and to prevent a person from injuring himself or others, or to prevent serious disruption of the therapeutic environment. Restraint or seclusion shall not be employed as punishment or for the convenience of staff. Persons placed in seclusion or restraints shall be informed of the specific reason for seclusion or restraints and precondition for release.
2. Seclusion Room. Each CSU shall have at least one seclusion room located in the CSU facility. Additional space shall be available that can be used either as a seclusion room or bedroom, as need dictates. Policies and procedures shall be developed on handling emergency situations that require seclusion. Each SRT shall have a seclusion room.
3. Transfer. A person who is in restraint or seclusion may be considered for transfer to an inpatient unit.
4. Training. Staff who implement written orders for seclusion or restraints shall have documented performance based training, at least annually, in the proper use of the procedures, including verbal and physical aggression control techniques.
5. Policies and Procedures. The CSU and SRT shall develop and maintain detailed, written policies and procedures for the use of restraints or seclusion which shall include the following provisions:
a. Policies and Procedures Availability. Such policies and procedures shall be made available to the appropriate staff and to the persons served and their significant others.
b. Restraint. Protective restraint shall consist of any apparatus or condition which interferes with free movement.
c. Physical Holding. Only in an emergency shall physical holding be employed unless there is a physician's or psychiatrist's order for a restraint.
d. Client Protection. Physical holding or restraints, such as canvas jackets or cuffs, shall be used only when necessary to protect individuals from injury to themselves or others. All persons placed in protective restraints shall be physically isolated from other persons receiving services.
e. Restraint Order. Use of restraints reflect a psychiatric emergency and shall be ordered by a physician, or psychiatrist, be administered by trained staff and be documented in the clinical records. An order for a restraint shall designate the type of restraint to be used, the circumstance under which it is to be used and the duration of its use. Each written order shall be time-limited according to the clinical need. The order shall not exceed 24 hours and shall be reordered if further restraint is required. Orders by a physician or psychiatrist over the telephone must be given to a registered nurse. Telephone orders shall be reviewed and signed within 24 hours by a physician or psychiatrist. When a person is in imminent danger, a registered nurse may initiate use of restraint prior to obtaining a physician's or psychiatrist's order. In all instances an order must be obtained within 1 hour of initiating the restraints. The issuance of a standing or PRN order for the use of restraints is prohibited.
f. Documentation. Justification of need for the type of restraint ordered and used, the length of time employed, conditions for release, and condition of the individual restrained shall be recorded in the clinical record. Fifteen minute observations must be face-to-face and must be recorded at the time they are made. Documentation must include name of observer and time of the observation. Documentation must reflect unit policies and procedures for circulation and respiration checks, opportunity for fluids, meals, bathing, toileting, comfort and safety, and motion or exercise. The observation flow sheet must have a key to correctly identify symbols used for the person's behavior and activities, and a key to identify staff initials.
g. Seclusion Order. Each written order for seclusion shall be limited to 24 hours and must be rewritten if further seclusion is required. Orders given by a physician or psychiatrist over the telephone must be given directly to a registered nurse. Telephone orders shall be reviewed and signed within 24 hours by a physician or psychiatrist. When a person is deemed in imminent danger, a registered nurse may initiate seclusion prior to obtaining a physician's or psychiatrist's order. In all instances an order must be obtained within 1 hour of initiating the seclusion. The issuance of a standing or PRN order for seclusion is prohibited.
h. Documentation. Justification of need, the length of time in seclusion, conditions for release, and the condition of the person secluded shall be recorded in the clinical record. Fifteen minute observations must be face-to-face and must be recorded at the time they are made. Documentation must include name of observer and time of the observation. Documentation must reflect unit procedures for opportunity for fluids, comfort and safety, meals, bathing and toileting. The observation flow sheet must have a key to correctly identify symbols used for the persons behavior and activities, and a key to identify staff initials.
i. Observation. A person in restraint or seclusion shall be visually observed by a staff member every 15 minutes, and provisions made for regular meals, bathing, and use of the toilet and continuously monitored in these situations. When restraints are used, the observer must check for comfort and safety, making sure there is no impairment of circulation or respiration. As long as it does not endanger anyone, an opportunity for motion and exercise must be provided for a period of no less than 10 minutes during each waking hour in which the restraint is employed. The observation shall be documented on the observation flow sheet, including the time of the observation, and shall describe the person's condition. The documentation shall be included in the clinical record.
j. Logbook of Restraints and Seclusion. A logbook shall be maintained by each CSU and SRT that will sequentially indicate, the individuals placed in seclusion, or restraint by name, date, time, specified reason for seclusion or restraint, time removed, and length of time in seclusion or restraint and condition upon release.
(d) Suicide Precaution.
1. Suicide precaution is for the protection of persons 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 and documented in the clinical record. A registered nurse, clinical psychologist or other mental health professional may initiate suicide precautions prior to obtaining a 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 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 persons 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 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 person being served pursuant to Section 394.459(3), F.S., the 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 Services. Upon admission, all priority clients as defined in Chapter 65E-15, F.A.C., in both a CSU and SRT shall be assigned a case manager who will function pursuant to Chapter 65E-15, F.A.C.
(22) Children. Every program which serves persons under 18 years of age shall define, in local program standards, 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. Minors who are 14 years of age and older may be admitted to a bed in a room or ward in the mental health unit with an adult, if the clinical record contains documentation by a physician that such placement is medically indicated or for reasons of safety. 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, used by persons receiving services, 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, alcohol or drug abuse rules, the more restrictive rules shall apply.
(c) Persons receiving services on the CSU, SRT, and detoxification units shall not commingle or share a common space at the time unless individually authorized by a physician's or psychiatrist's written order to participate in specific treatment and evaluation activities on other units as specified in the individual's service implementation plan. Service implementation 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 client-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 mental health treatment staff shall not be shared.
(24) Passes.
(a) A physician's written order shall be written in accordance with unit policies and procedures specifying each occasion that a person receiving services is permitted off unit and consistent with the service implementation 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 individual designated responsible for the person 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 non-smokers, such as the only room with a television set, or activity or dining room, shall not be designated a smoking area. If the facility is non-smoking, a sheltered outside area shall be designated as a smoking area. The facility shall ensure the operation of adequate smoke evacuation mechanisms to maintain a healthful air quality throughout.
(26) Personal Items. Persons residing 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 persons 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 AIDS shall be done in accordance with Chapters 381, F.S., and 64D-2, F.A.C. Policies and procedures shall be regularly updated to include information provided by the department and the Center for Disease Control. All biohazardous waste shall be handled and disposed in accordance with Chapters 381, F.S., and 64E-16, F.A.C.
(28) Human Immunodeficiency Virus (HIV) and AIDS Education Requirements for Employees and Persons Receiving Services. Each CSU and SRT shall meet the educational requirements for HIV and AIDS pursuant to Section 381.0035, F.S.
(a) For persons receiving services the following criteria must be considered in determining course content, frequency and length of course:
1. The emotional, cognitive and functioning level of the person;
2. The time spent in the CSU or SRT;
3. The physical health of the person;
4. The educational level of the person;
5. The socioeconomic, cultural and ethnic background of the person; and
6. The high risk and drug use behaviors of the person.
(b) Employees shall receive 4 contact hours of education within 30 days of any face-to-face contact with persons receiving services and 2 hours biennially thereafter. Each professional who completes his respective board education requirement shall be considered as having met this requirement.
(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, 65E-12 and Chapter 65E-15, F.A.C., on the unit available to all staff and persons receiving services at all times.
(30) CSUs and SRTs shall ensure that the unit's licensed professionals, as defined in Sections 394.455(2), (21), (23), and (24), F.S., 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.
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