27-10 PowerPoint Presentation - Oct. '04


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27-10 PowerPoint Presentation - Oct. '04

  1. 1. Overview of the Minimum Standards for the Care and Treatment of Persons with Mental Illness (2 CCR 502-1) With excerpts from the Care and Treatment of the Mentally Ill Act (CRS 27-10-101 et seq. ) October 2004
  2. 2. Caution! This presentation is not a complete overview of the Care and Treatment of the Mentally Ill Act (CRS 27-10-101 et seq. )
  3. 3. Major Changes to Standards in April 2004 Revision (Last revision was in 1993) <ul><li>Added secure treatment facilities </li></ul><ul><li>Updated practices to follow Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or Centers for Medicare and Medicare Services (CMS) </li></ul><ul><li>Added data requirements </li></ul><ul><li>Increased requirements for staff training </li></ul><ul><li>Updated confidentiality to reflect HIPAA </li></ul>
  4. 4. <ul><li>Updated seclusion/restraint to follow </li></ul><ul><li>JCAHO or CMS </li></ul><ul><li>Clarified use of emergency medications </li></ul><ul><li>Added use of chemical sprays as a restraint is not permitted </li></ul><ul><li>Updated Electroconvulsive Therapy (ECT) rule to follow Statute </li></ul><ul><li>Added recommendation for soft restraints when transporting patients </li></ul>
  5. 5. <ul><li>Added section on electronic records </li></ul><ul><li>Increased assessment date to include cultural issues </li></ul><ul><li>Added documentation required for ongoing assessments </li></ul><ul><li>Increased documentation requirements under discharge planning </li></ul><ul><li>Use of jails deleted from the regulations; remains in Statute </li></ul>
  6. 6. Types of Designated Facilities <ul><li>Licensed general or psychiatric hospitals </li></ul><ul><li>Community Mental Health Centers (CMHCs) or Clinics </li></ul><ul><li>Residential Child Care Facilities (RCCFs) </li></ul><ul><li>By special designation </li></ul><ul><li>No nursing facilities or assisted living facilities unless operated by one of the above </li></ul><ul><li>No jails or other types of facilities unless by special designation </li></ul>
  7. 7. Types of Designations <ul><li>72-Hour Treatment and Evaluation Facilities </li></ul><ul><li>Short-Term Treatment Facilities </li></ul><ul><li>Long-Term Treatment Facilities </li></ul><ul><li>CMHCs must be designated as Long-Term Treatment Facilities </li></ul><ul><li>72-Hour facilities cannot keep an involuntary patient longer than 72 hours, excluding week-ends and holidays </li></ul><ul><li>Short-term facilities cannot keep an involuntary patient for longer than 180 days (extended short-term certification) </li></ul>
  8. 8. Application of Revised Rules <ul><li>Hospitals must follow all the rules of </li></ul><ul><li>2 CCR 502-1 </li></ul><ul><li>RTCs must follow all provisions of related rules </li></ul><ul><li>CMHCs must follow general and organization provisions and, for those individuals they are treating involuntarily, they must follow treatment provisions </li></ul>
  9. 9. Statutory Changes <ul><li>One change in 27-10 Statute in 2004 – Addition of Licensed Addiction Counselors to Persons who may place a person under an emergency 72-hour hold (CRS 27-10-105) </li></ul><ul><li>Must have additional knowledge, judgment and skill in psychiatric or clinical mental health therapy, forensic psychotherapy, or evaluation of mental disorders </li></ul>
  10. 10. Reminder <ul><li>No designated facility has to accept a 72-hour hold </li></ul><ul><li>Emergency Department physicians may complete an evaluation and release the person </li></ul><ul><li>Only 72-hour holds ordered by a court cannot be refused </li></ul>
  11. 11. Persons Who May Complete a 72-Hour Mental Health Evaluation & Certify for Treatment <ul><li>Licensed physician </li></ul><ul><li>Licensed psychologist </li></ul>
  12. 12. Actions Following 72-Hour Evaluation <ul><li>Person is certified for treatment </li></ul><ul><li>OR </li></ul><ul><li>Person signs in for voluntary treatment OR </li></ul><ul><li>Person is released </li></ul>
  13. 13. Placement Facilities <ul><li>Designated facilities may enter into a written contract with another facility to provide mental health services on their behalf </li></ul><ul><li>A placement facility may be a general or psychiatric hospital, community clinic and emergency clinic, convalescent center, nursing care facility, intermediate health care facility or residential facility, licensed residential child care facility or community mental health center or clinic </li></ul><ul><li>Direct care supervision must be provided by a professional person </li></ul>
  14. 14. Enforcement <ul><li>Designated facilities shall be monitored for compliance annually </li></ul><ul><li>Placement facilities may be monitored at the discretion of the Department of Human Services (CDHS) / Division of Mental Health (DMH) </li></ul><ul><li>CDHS/DMH will investigate all complaints related to the 27-10 Statute and Rules </li></ul>
  15. 15. Waivers <ul><li>Specific requirements of the rules may be waived if the waiver would not adversely affect the health, safety and welfare of the patient, and </li></ul><ul><li>Either it would improve patient care or application of the particular rule would create a demonstrated financial hardship on the facility </li></ul>
  16. 16. Rights and Advocacy <ul><li>The facility must post the list of Patient Rights found in the Rules </li></ul><ul><li>The facility must give all 27-10 patients a written copy of the rights listed in the Rules </li></ul><ul><li>If the patient is unable to read the rights, they shall be read the rights in a language they understand </li></ul><ul><li>Children who are voluntarily receiving services under CRS 27-10-103 have additional rights they must be advised of – the right to object to hospitalization </li></ul>
  17. 17. Rights Restrictions <ul><li>Some Patient Rights may be limited or denied for good cause by the professional person providing treatment </li></ul><ul><li>Only the following rights may be restricted: </li></ul><ul><ul><li>To receive and send sealed correspondence </li></ul></ul><ul><ul><li>To have access to letter writing materials </li></ul></ul><ul><ul><li>To use the telephone </li></ul></ul><ul><ul><li>To have visitors (except the client’s attorney, religious representative or physician) </li></ul></ul><ul><ul><li>To wear his/her own clothing </li></ul></ul>
  18. 18. Rights Restrictions (continued) <ul><li>The reason for denying the right must be documented in the clinical record and evaluated on an ongoing basis </li></ul><ul><li>Restrictions must be ordered and documented every 7 calendar days by a professional person </li></ul>
  19. 19. Secure Treatment Facilities Rights Restrictions <ul><li>Secure Treatment Facility = Colorado Mental Health Institute at Pueblo (CMHIP) Institute for Forensic Psychiatry </li></ul><ul><li>A professional person may limit or deny rights for good cause based upon safety and security needs </li></ul><ul><li>Must have safety and security policies for each ward approved by CDHS </li></ul>
  20. 20. Secure Treatment Facilities Rights Restrictions (continued) <ul><li>Must have policy and criteria for placement of persons into secure treatment facilities </li></ul><ul><li>Policies must be posted on each unit </li></ul><ul><li>Restrictions must be noted in clinical record and reviewed every 30 days </li></ul>
  21. 21. Secure Treatment Facilities Rights Restrictions (continued) <ul><li>Cannot limit sending or receiving sealed mail, but may require patient open in presence of staff </li></ul><ul><li>Cannot limit right to see attorney, clergy or physician, but may require advance notice to unit </li></ul><ul><li>Department of Corrections (DOC) patients may have locked doors during sleeping hours </li></ul>
  22. 22. Secure Treatment Facilities Rights Restrictions (continued) <ul><li>All other newly admitted patients may be on units with locked bedroom doors during sleeping hours for 60 days </li></ul><ul><li>After 60 days this security level has to be documented in individualized assessment and address imminent danger to self and/or others </li></ul><ul><li>Sleeping hours cannot start before 9 PM, must end no later than 8 AM and not exceed 8 ½ hours </li></ul>
  23. 23. Secure Treatment Facilities Rights Restrictions (continued) <ul><li>Patients have to have an effective means of calling for assistance and staff must react promptly </li></ul><ul><li>Staff must monitor through visual checks every 15 minutes during the time patients are locked in their rooms </li></ul>
  24. 24. Secure Treatment Facilities Rights Restrictions (continued) <ul><li>Any person who meets the criteria for an imposition of legal disability or deprivation of a right (CRS 27-10-125) may have any right limited by a court </li></ul><ul><li>Information pertaining to denial of any right shall be made available to the patient and/or his/her attorney upon request </li></ul>
  25. 25. Advocacy <ul><li>Facilities must have a designated patient representative who is available </li></ul><ul><li>Patients must be given the name and telephone number of the patient rep – process must be in a written policy or documented in the clinical record </li></ul>
  26. 26. Advocacy (continued) <ul><li>The facility must post the name, location, phone number and responsibilities of the patient rep and include where to get a copy of the complaint process </li></ul><ul><li>Facility must have policies for handling complaints that include forwarding unresolved complaints to DMH </li></ul>
  27. 27. Employment of Patients <ul><li>Major changes in rules are: </li></ul><ul><ul><li>Vocational programs do not have to pay minimum wage unless they are of economic benefit to the facility </li></ul></ul><ul><ul><li>Work assignments, consent form and hourly wages must be documented in clinical record </li></ul></ul>
  28. 28. Quality Improvement <ul><li>JCAHO or CMS accredited facilities may follow those guidelines </li></ul><ul><li>Otherwise QI Program must include: </li></ul><ul><ul><li>Clinical peer review process </li></ul></ul><ul><ul><li>Physician review of medical status every 6 months </li></ul></ul><ul><ul><li>Policies regarding minor and critical incidents </li></ul></ul>
  29. 29. Quality Improvement (continued) <ul><ul><li>Written policy re how to identify trends and patterns in care, including involuntary medications and use of restraints/seclusion </li></ul></ul><ul><ul><li>Using findings in planning and decision making and staff and patient educational programs </li></ul></ul><ul><ul><li>Criteria and process for clinical competence and credentials </li></ul></ul><ul><ul><li>Review of complaints and incorporation of data into decision making </li></ul></ul>
  30. 30. Data Requirements <ul><li>New requirements include: </li></ul><ul><ul><li>Number of holds and demographics </li></ul></ul><ul><ul><li>Number of short and long-term certifications and demographics </li></ul></ul><ul><ul><li>Number of voluntary patients by age groups </li></ul></ul>
  31. 31. Data Requirements (continued) <ul><ul><li>Number of patients receiving involuntary meds </li></ul></ul><ul><ul><li>Number of patients receiving restraints/seclusion </li></ul></ul><ul><ul><li>Number of patients receiving ECT </li></ul></ul><ul><ul><li>Number of patients on ILD’S </li></ul></ul>
  32. 32. Staff Training Requirements <ul><li>New requirements </li></ul><ul><li>Facilities must develop a curriculum and schedule for training/competency </li></ul><ul><li>Facilities must develop policies and testing to assure competency </li></ul><ul><li>All staff must be trained and competent on the provisions of these rules and the statute </li></ul><ul><li>Staff who administer involuntary meds must be trained and competent on those rules </li></ul>
  33. 33. Staff Training Requirements (continued) <ul><li>All direct care staff must be trained in recognition and response to common side effects of psychiatric meds and trained to respond to emergency medication reactions </li></ul><ul><li>Staff in non-JCAHO or CMS facilities who administer restraint/seclusion techniques must have annual training in lower level behavioral interventions and the seclusion/restraint rules </li></ul><ul><li>Staff must be trained on needs identified via QI Program </li></ul>
  34. 34. Staff Training Requirements (continued) <ul><li>Administrative staff shall be trained and competent on alternative or representative medical decision making, i.e., advance directives, medical durable powers of attorney, proxy decision making and guardianships </li></ul><ul><li>Appropriate placement facilities staff must be trained and competent on the provisions in these rules and the statute </li></ul>
  35. 35. Confidentiality <ul><li>HIPAA guidelines must be followed </li></ul><ul><li>Limits information to family members previously authorized in statute (27-10-120.5) </li></ul><ul><li>Access remains for authorized representatives of CDHS </li></ul>
  36. 36. Confidentiality (continued) <ul><li>Observed criminal behavior committed on the premises of a designated or placement facility or any criminal offense committed against any person while performing or receiving services is not considered privileged or confidential </li></ul><ul><li>Information that concerns child abuse/neglect or therapist abuse shall be reported to appropriate authorities </li></ul>
  37. 37. Treatment Provisions <ul><li>CMHCs – Only follow for certified individuals </li></ul><ul><li>Hospitals and RTCs – Follow for all individuals </li></ul>
  38. 38. Medical/Dental Care <ul><li>Each patient must have access to emergency medical care and written plan for providing emergency care that includes physical exams within 24 hours of admission and availability of a physician or emergency medical facility at all times </li></ul><ul><li>Must be able to access emergency treatment within 1 hour </li></ul>
  39. 39. Medical/Dental Care (continued) <ul><li>Patients to be referred to appropriate specialists for further treatment/evaluation and the information will be documented in the record </li></ul><ul><li>Must be ongoing appraisals of the general health of each patient and documentation in clinical </li></ul><ul><li>No facility obligation to pay for such services – only to secure the services for each patient </li></ul>
  40. 40. Psychiatric Medications <ul><li>Informed consent required </li></ul><ul><li>Facility policy required regarding informed consent and documentation of such in record </li></ul><ul><li>Must follow advance directives to extent possible </li></ul><ul><li>Psychiatric meds may be administered by any professional authorized by law – not just MD </li></ul>
  41. 41. Psychiatric Medications (continued) <ul><li>Facility must have policies on: </li></ul><ul><ul><li>Administration of meds, errors and adverse reactions </li></ul></ul><ul><ul><li>Discontinuance of meds </li></ul></ul><ul><ul><li>Disposal of meds </li></ul></ul><ul><ul><li>Acceptance of verbal, fax or electronically transmitted med orders </li></ul></ul>
  42. 42. Psychiatric Medications (continued) <ul><li>Individual clinical records must contain following information: </li></ul><ul><ul><li>Name and dosage of med </li></ul></ul><ul><ul><li>Reason for medication </li></ul></ul><ul><ul><li>Time, date and dosage when administered </li></ul></ul><ul><ul><li>Name and credentials of person administering med </li></ul></ul><ul><ul><li>Name of prescribing professional </li></ul></ul><ul><ul><li>Notation if emergency or court-ordered </li></ul></ul>
  43. 43. Involuntary Psychiatric Medications <ul><li>Rules DO NOT APPLY to refusal of non-psychiatric medications or medical emergencies </li></ul><ul><li>Persons must be on a hold or certification to be given emergency psychiatric meds </li></ul>
  44. 44. Involuntary Psychiatric Medications (continued) <ul><li>Emergency is defined as: </li></ul><ul><ul><li>Imminent danger of hurting self or others (can rely on symptoms if predicted dangerousness in past) </li></ul></ul><ul><ul><li>A recent overt act such as credible threat of bodily harm, assault or self-destructive behavior </li></ul></ul>
  45. 45. Involuntary Psychiatric Medications (continued) <ul><li>Under the Colorado Department of Public Health and Environment statute (CRS 26-20-104), only physicians can administer emergency medications </li></ul>
  46. 46. Involuntary Psychiatric Medications (continued) <ul><li>If the emergency has abated because of meds but the MD deems it necessary to continue the meds to keep the emergency in abeyance, within 72 hours: </li></ul><ul><ul><li>A written request must be submitted for a court hearing </li></ul></ul><ul><ul><li>Must be documentation concurring consultation with another MD with their opinion regarding the emergency – if not obtained within 72 hours the medication must be stopped unless the medication must be titrated </li></ul></ul>
  47. 47. Involuntary Psychiatric Medications (continued) <ul><ul><li>Cannot give emergency meds beyond 10 days without a continuation order from the court </li></ul></ul><ul><ul><li>Patient must be notified of right to contact attorney and this must be noted in record </li></ul></ul>
  48. 48. Involuntary Psychiatric Medications (continued) <ul><li>Specific facts outlining behaviors supporting the use of emergency meds must be detailed in clinical record </li></ul><ul><li>Must be documented every 24 hours until a court order is obtained or the emergency is resolved or the patient accepts medications voluntarily </li></ul>
  49. 49. Involuntary Psychiatric Medications (continued) <ul><li>Patient must be offered emergency meds on a voluntary basis each time they are given – if patient consents and the MD determines they will likely continue to accept the meds, this must be documented in the record and emergency meds </li></ul><ul><li>If the patient refuses again and an emergency situation arises, emergency med procedures may be re-instituted (no time frame) </li></ul>
  50. 50. Non-Emergency Involuntary Medications <ul><li>If a person is certified and would benefit but will not consent to psychiatric meds, the facility may petition the court for involuntary meds if the following conditions are met: </li></ul><ul><ul><li>Patient is incompetent to participate in the decision </li></ul></ul><ul><ul><li>Medication is necessary to prevent significant deterioration in mental condition or to prevent patient from causing harm to self or others </li></ul></ul>
  51. 51. Non-Emergency Involuntary Medications (continued) <ul><ul><li>Less intrusive appropriate treatment is not available </li></ul></ul><ul><ul><li>Patient’s need for medication is sufficiently compelling to override interest of patient in refusing treatment </li></ul></ul><ul><ul><li>Petition must specify recommended medications </li></ul></ul><ul><ul><li>Cannot administer until court order is received </li></ul></ul>
  52. 52. Seclusion/ Restraint <ul><li>JCAHO and CMS approved facilities to follow those standards </li></ul><ul><li>Staff shall ensure no person will harm or harass a person who is secluded or restrained </li></ul><ul><li>Only certified persons can be restrained against their objection unless there is a signed informed consent form for using special procedures </li></ul>
  53. 53. Seclusion <ul><li>Use only for preventing imminent injury to self/others or eliminate prolonged, serious disruption to treatment environment </li></ul><ul><li>Any time a person is alone in a room and not allowed to leave, that is seclusion </li></ul><ul><li>An unlocked designated facility may place a person in seclusion to prevent departure if person is dangerous to self/others </li></ul>
  54. 54. Seclusion (continued) <ul><li>Must be based on current clinical assessment </li></ul><ul><li>Use only when other less restrictive methods fail </li></ul><ul><li>Can only be ordered by a professional person </li></ul>
  55. 55. Restraint <ul><li>Cannot restrain single limb unless court ordered </li></ul><ul><li>Chemical spray is not permissible </li></ul><ul><li>Type of restraint must be appropriate to type of behavior, physical condition of person, age and effect restraint may have on the person </li></ul>
  56. 56. Restraint (continued) <ul><li>Only if alternative interventions have failed unless they would be unsafe or ineffective </li></ul><ul><li>Only ordered by professional person </li></ul><ul><li>Does not apply to transportation of certain patients under criminal status </li></ul>
  57. 57. Informed Consent for Therapy or Treatments Using Special Procedures <ul><li>Written consent must be obtained for ECT and/or behavior modifications using physically painful, aversive or noxious stimuli </li></ul><ul><li>Guardians cannot consent to ECT </li></ul><ul><li>ECT cannot be administered to anyone under age 16 </li></ul><ul><li>ECT requires use of the DMH consent form </li></ul>
  58. 58. Informed Consent for Therapy or Treatments Using Special Procedures (continued) <ul><li>ECT requires use of the DMH consent form </li></ul><ul><li>Can be administered under a court order if consent is not obtained </li></ul><ul><li>Can be administered under emergency conditions if the life of the person is in imminent danger because of the person’s condition </li></ul>
  59. 59. Continuity of Care and Transfer of Care <ul><li>Facilities must have written policy including: </li></ul><ul><ul><li>Access to all necessary care and services within the facility </li></ul></ul><ul><ul><li>Coordination with previous care providers </li></ul></ul><ul><ul><li>Coordination with family members, guardians and other appropriate persons reflecting patient’s culture and ethnicity </li></ul></ul>
  60. 60. Continuity of Care and Transfer of Care (continued) <ul><ul><li>Facilitation of access to proper medical care </li></ul></ul><ul><ul><li>Transfer to another facility when adequate arrangements are made </li></ul></ul><ul><ul><li>24 hour notice of transfer to persons under certification unless it is an emergency </li></ul></ul><ul><ul><li>Notification of transfer to 2 persons as indicated by patient </li></ul></ul>
  61. 61. Transportation <ul><li>Assessment for dangerousness and potential for escape is required </li></ul><ul><li>Can be transported (no restraints) by ambulance, care van, private vehicle if clinically appropriate and safe </li></ul>
  62. 62. Transportation (continued) <ul><li>If dangerous to self/others or escape risk, may request transportation by Sheriff: </li></ul><ul><ul><li>Must include recommendation for use of restraint </li></ul></ul><ul><ul><li>Recommendations include consideration of age, physical abilities, culture and medical status </li></ul></ul><ul><ul><li>Sheriff is not required to follow these rules </li></ul></ul>
  63. 63. Outpatient Certification <ul><li>Must be certified inpatient first </li></ul><ul><li>Must continue to meet requirements for certification </li></ul><ul><li>Must have recent physical exam </li></ul>
  64. 64. Outpatient Certification (continued) <ul><li>Arrangements must be made for access to: </li></ul><ul><ul><li>Case management </li></ul></ul><ul><ul><li>Medical management </li></ul></ul><ul><ul><li>Essential food, clothing, shelter </li></ul></ul><ul><ul><li>Medical care and emergency dental care </li></ul></ul>
  65. 65. Outpatient Certification (continued) <ul><li>Service plan must reflect those arrangements and reflect outpatient certification status </li></ul><ul><li>If patient fails to comply with service plan, patient may be taken into custody and assessed for current clinical needs </li></ul>
  66. 66. Outpatient Certification (continued) <ul><li>Cannot force medication on person unless it is an emergency or it is court-ordered </li></ul><ul><li>If patient is not detained, facility must assist patient in returning to a reasonable location </li></ul>
  67. 67. Treatment Records <ul><li>Electronic records are permitted, need to capture signatures as required </li></ul><ul><li>Entries must be signed, dated with degree and title </li></ul><ul><li>Must be kept in secure location </li></ul>
  68. 68. Treatment Records (continued) <ul><li>Facilities must have policy that keeps records for: </li></ul><ul><ul><li>Outpatient – 7 years after discharge or 7 years beyond reaching age 18 after discharge </li></ul></ul><ul><ul><li>Inpatient – 10 years after discharge or 10 years beyond reaching age 18 after discharge </li></ul></ul>
  69. 69. Treatment Records (continued) <ul><li>Records must include: </li></ul><ul><ul><li>Written assessment information </li></ul></ul><ul><ul><li>Individualized, integrated comprehensive service plan (except for persons being evaluated under CRS 16-8-103.7) </li></ul></ul><ul><ul><li>Treatment progress documentation </li></ul></ul><ul><ul><li>Discharge planning information </li></ul></ul><ul><ul><li>Discharge summary </li></ul></ul>
  70. 70. New Assessment Data Requirements <ul><li>Cultural factors relating to age, ethnicity, linguistic/communication needs, gender, sexual orientation, relational roles and spiritual beliefs </li></ul><ul><li>Issues specific to older adults such as hearing loss, strength, mobility and other aging issues </li></ul><ul><li>Issues specific to children/adolescents such as growth and development, daily activities, educational activities and legal guardians </li></ul>
  71. 71. New Assessment Data Requirements (continued) <ul><li>History of use of restraint, emergency meds, ECT and their impact on patient and patient’s preference if emergency procedures are necessary </li></ul><ul><li>Information on advance directives, medical proxies, etc. </li></ul>
  72. 72. New Service Planning Requirements <ul><li>Written to promote patient’s highest possible level of independent functioning </li></ul><ul><li>Written in a manner that is understandable to the patient </li></ul>
  73. 73. New Service Planning Requirements (continued) <ul><li>Planning done in a manner appropriate to the cultural factors of the patient </li></ul><ul><li>When under age 18 patient will participate in planning and sign and be offered a copy </li></ul>
  74. 74. New Requirements for Treatment Progress Documentation <ul><li>Ongoing assessment information </li></ul><ul><li>Any serious injury of or by the patient and the circumstances and outcome </li></ul><ul><li>Use or non-use of advance directives </li></ul>
  75. 75. New Requirements for Discharge Summary <ul><li>Advance Directives </li></ul><ul><li>Patient’s attitude toward discharge </li></ul>
  76. 76. Contact Information <ul><li>For information on statute, rules, DMH monitoring, additional copies of this training or a copy of the training CD, etc., please contact </li></ul><ul><ul><li>Lori Banks, 303-866-7424, or [email_address] </li></ul></ul><ul><ul><li>Or your facility’s DMH liaison </li></ul></ul>