309-032-0870 Standards for Approval of Regional Acute Care Psychiatric Service (1) The facility in which a regional acute care psychiatric service is provided shall maintain state certificates and licenses as required by Oregon law for the health, safety, and welfare of the individuals served. Non-hospital facilities shall be licensed by the Division as required by ORS 443.410. Non-hospital facilities shall be certified by the Division as required by OAR 309-008-0100 to 1600. The facility shall also be approved under OAR 309-033-0530 (Approval of Hospitals and Nonhospital Facilities that Provide Services to Committed Persons and to Persons in Custody or on Diversion) and OAR 309-033-0540 (Administrative Requirements for Hospitals and Nonhospital Facilities Approved to Provide Services to Persons in Custody, Psychiatric Hold or Certified for 14 Days of Intensive Treatment). (2) A regional acute care psychiatric service shall include 24-hours a day psychiatric, multi-disciplinary, inpatient or residential stabilization care and treatment for adults ages 18 and older with severe psychiatric disabilities in a designated region of the state. For the purpose of these rules, a state hospital is not a regional acute care psychiatric service. The goal of a regional acute care service is the stabilization, control, and amelioration of acute dysfunctional symptoms or behaviors that result in the earliest possible return of the individual to a less restrictive environment. (3) A regional acute care psychiatric service shall maintain clinical records as follows: (a) Except as otherwise applicable, clinical records are confidential as set forth in ORS 179.505 and 192.502 and any other applicable state or federal law. For the purposes of disclosure from non-medical individual records, both the general prohibition against disclosure of “information of a personal nature” and limitations to the prohibition in ORS 192.502 shall apply; (b) Clinical records shall be secured, safeguarded, stored, and retained in accordance with OAR 166-030-1015; (c) Clinical record entries required by these rules shall be signed by the staff providing the service and making the entry. Each signature shall include the individual’s academic degree or professional status and the date signed. (4) The clinical record shall contain: (a) Identifying demographic information including, if available, who to contact in an emergency and the names of individuals who encompass the support system of the patient; (b) Consent to release information and explanation of fee policies. At the time of admission, staff shall present the patient with forms for obtaining consent so that information may be shared with family and others. An explanation of fee policies shall also be provided in written form at the earliest time possible. The patient shall be asked to sign each. If the patient is unwilling or unable to sign, staff shall record that the patient is unable or unwilling to do so; (c) An admitting mental health assessment shall be completed by or under the supervision of an independent medical practitioner with supervised training or experience in a mental health related setting within 24 hours of admission. The admitting mental health assessment shall include a description of the presenting problem, a mental status examination, an initial DSM diagnosis, and an assessment of the resources currently available to the individual. The assessment shall result in a plan for the initial services to be provided. The admitting mental health assessment shall also include documentation that a medical history and physical examination of the individual has been performed within 24 hours after admission by a physician, physician assistant, or nurse practitioner. If the independent medical practitioner believes a new medical history and physical examination are not necessary and if within 30 days of admission a complete physical history has been recorded and a complete physical examination has been performed, the signed report of the history and examination may be placed in the clinical record and may be considered to constitute an appropriate physical health assessment; (d) A psycho-social assessment shall be completed for each patient within 72 hours of admission. If the patient stays less than 72 hours, a psycho-social assessment need not be written. The assessment must be completed by a qualified mental health professional or supervisor. The assessment does not need to be a single document but shall include the following elements: (A) A description of events precipitating admission and any goals of the patient in seeking or entering services; (B) When relevant to the patient’s service needs, historical information including: a current Declaration for Mental Health Treatment; mental health history; medical history; substance use history; developmental history; social history including family and interpersonal history; sexual and other abuse history; educational, vocational, and employment history; and legal history; (C) An identification of the patient’s need for assistance in maintaining financial support, employment, housing, and other support needs; (D) Recommendations for discharge planning and any additional services, interventions, additional examinations, tests, and evaluations that are needed; (E) A copy of the patient’s Declaration for Mental Health Treatment if the patient elected to complete or provided one. (e) A treatment plan individually developed with the patient from the findings of the admitting mental health assessment and psycho-social assessment must be completed by a QMHP or supervisor within 72 hours of the person’s admission. The plan must be written at a level of specificity that will permit its subsequent implementation to be efficiently monitored and reviewed. The recorded plan shall contain the following components: (A) The rehabilitation and other goals, including those articulated by the patient; (B) Specific objectives, including discharge objectives and the measurable or observable criteria for determining when each objective is attained; (C) Specific services to be used to achieve each objective; (D) The projected frequency and duration of services; (E) Identification of the QMHP or supervisor assigned to the patient who is responsible for coordinating services; (F) The signature of the patient indicating they have participated in the development of the plan to the degree possible. If the patient is unwilling or unable to sign the plan, staff shall record on the plan that the patient is unable or unwilling to do so; (G) The plan must be reviewed weekly and updated with the participation of the patient when needed to reflect significant changes in the patient’s status and when significant new goals are identified; (H) The patient’s anticipated continuing care needs, including need for housing, and for individuals with SPMI, the coordination needs for a warm handoff process. (f) Progress notes shall document observations, treatment rendered, response to treatment, changes in the patient’s condition, and other significant information relating to the patient. All entries involving subjective interpretation of the patient’s progress shall be supplemented by a description of the actual behavior observed; (g) Reports of medication administration, medical treatments, and diagnostic procedures; (h) Telephone communications about the patient, releases of information, and reports from other sources; (i) The record shall contain medical and mental health advance directives or note that the patient has been provided this information; (j) The record shall contain documentation that the patient has been provided information on patient rights, grievance procedure, and abuse reporting; (k) The record shall contain documentation including physician’s orders and reasons for all restraint and seclusion episodes; (L) The discharge planning process shall begin at the time of admission with the participation of the patient and, when indicated, the family, guardian, or family of choice, and shall include, but is not limited to: (A) An assessment of continuing care needs, including prescribed medications, behavioral and primary health care needs, and housing needs; (B) Consultation with the individual’s CCO to address continuing care needs upon discharge, when applicable, and; (C) Planning a follow-up visit with a community mental health provider within seven days of the anticipated discharge date. (m) A warm handoff shall be offered to individuals with SPMI as part of the discharge planning process that involves a face-to-face meeting, either in person or through the use of telehealth, and includes either: (A) A community provider, the patient, and if possible hospital staff, or; (B) A transitional team, the patient, and if possible hospital staff to support the patient, to serve as a bridge between hospital staff and a community provider, and to ensure the patient connects with a community provider. (n) The discharge plan shall be based on the patient’s treatment goals, clinical needs, and informed choice and shall include the results of the admitting mental health assessment, DSM diagnoses, summary of the course of treatment including prescribed medications, final assessment of the individual's condition, a summary of continuing care needs including prescribed medications, behavioral and primary health care needs, and housing needs. Documentation to support linkages to timely and appropriate community services upon discharge shall be detailed in the discharge plan including, but not limited to: (A) The plan to address the patient’s need for immediate housing upon discharge, when applicable, including notifying the patient’s community provider regarding the need for housing; and (B) The plan to address the patient’s need for a follow-up visit with a community mental health provider within seven days of the anticipated discharge date; (C) For individuals with SPMI, the discharge plan shall also include: (i) Whether a warm handoff occurred and the community provider or transitional team involved in the warm handoff process, when applicable; or (ii) Whether the patient declined a warm handoff. (5) The regional acute care psychiatric service shall supply the Division, using the Division’s on-line OPRCS via computer and modem, information about individuals admitted to and discharged from the service. The information shall include the patient’s name, DSM diagnosis, admission date, discharge date, legal status, Medicaid eligibility, Medicaid Prime Number, and various patient demographics. The information shall be entered on the day of admission and updated on the day of discharge. (6) The regional acute care psychiatric service shall: (a) Have sufficient appropriately qualified professional, administrative, and support staff to assess and address the identified clinical needs of individuals served, provide needed services, and coordinate the services provided; (b) Designate a program administrator to oversee the administration of the services and carry out these rules; (c) Designate a medical director to oversee the patient care program. The medical director shall have the final authority concerning inpatient medical care including admissions, continuing care, and discharges; (d) Designate an individual responsible for maintaining, controlling, and supervising medical records and be responsible for maintaining the quality of clinical records; (e) Designate an individual responsible for the development, implementation, and monitoring of a written safety management plan and program who shall keep records of identified concerns and problems and actions taken to resolve them; (f) Designate an individual responsible for the development, implementation, and monitoring of a written infection control plan and program who shall keep records of identified concerns and problems and action taken to resolve them; (g) Designate or contract with a licensed pharmacist to be responsible for the development of pharmacy policies and procedures and to assure that the service adheres to standards of practice and applicable state and federal laws and regulations; (h) Maintain a schedule of unit staffing that shall be readily available to the Division for a period of at least the three previous years; (i) Have on duty at least one registered nurse at all times; (j) Maintain a personnel file for each patient care staff that includes a written job description; the minimum level of education or training required for the position; copies of applicable licenses, certifications, or degrees granted; annual performance appraisals; a biennial, individualized staff development plan signed by the staff; documentation of CPR training; documentation of annual training and certification in managing aggressive behavior, including seclusion and restraint; and other staff development and skill training received; (k) A physician shall be available, at least on-call, at all times. (7) The regional acute care psychiatric service shall have a policy and procedure manual. The policy and procedure manual must be made available to any individual upon request. The manual shall describe: (a) The following policies and procedures: (A) Governance and management, including a table of organization describing the agency structure and lines of authority, a plan for professional services, and a plan for financial management and accountability; (B) Procedures for the management of disasters, fire, and other emergencies; (C) Policies and procedures required under OAR 309-033-0700 through 0740, Standards for the Approval of Community Hospitals and Nonhospital Facilities to Provide Seclusion and Restraint to Committed Persons and to Persons in Custody or on Diversion, addressing seclusion and restraint; (D) Patient rights, including informed consent, access to records, and grievance procedures. The manual shall assure rights guaranteed by ORS 426.380 to 426.395 for committed persons and ORS 430.205 to 430.210 for those not committed. The grievance procedure shall be in writing and include written responses, time limits for responses, use of a neutral party, and a method of appeal. Programs shall post copies of the rights and grievance procedures in places accessible to all individuals. Programs shall provide written copies of the rights and grievance procedures upon request; (E) Abuse reporting for mentally ill or developmentally disabled as required by ORS 430.731 through 430.768; (F) Clinical record content and management policies and procedures, including the requirements of these rules; (G) Psychiatric, medical, and dental emergency services policies and procedures; (H) Pharmacy services policies and procedures approved by a licensed pharmacist; (I) Quality assessment and improvement processes; (J) Procedures for documenting privileges granted by the service in personnel records or other records; (K) Policies and procedures for transfer of patients to other hospitals. (b) The following policies and procedures, developed and amended in consultation with the council: (A) Patient admission and discharge criteria. Unless the service has a policy and procedure recommended by the council and approved by the Division, the service shall only admit individuals age 18 and older; (B) Quality assessment and improvement processes relating to regional admissions and discharges; (C) Patient admission, discharge, and aftercare planning, including scheduling and planning for transportation of patients to the service by the referring county and from the service to the county of residence; (D) Procedures for admission and discharge of geropsychiatric patients and individuals with physical disabilities, including designation of a county or regional geropsychiatric liaison staff member; (E) Linkage agreements with entities involved in patient care; (F) Medical and emergency care procedures approved by the Division; (G) Criteria for accepting pre-admission medical screening; (H) Billing and collecting reimbursement from patients and third-party payers. (8) The service shall have an adequate number of hold rooms, but at least one holding room, and hold a current Certificate of Approval to hold and treat individuals alleged to be mentally ill under OAR 309-033-0500 through 0560, (Approval of Hospital and Nonhospital Facilities that Provide Services to Committed Persons or to Persons in Custody or on Diversion). (9) The facility in which a service is operated shall comply with all applicable federal rules and regulations. (10) If the facility in which the regional acute care psychiatric service is operated is not in a general hospital, it shall have a letter of agreement with a general hospital for both emergency and medical care that shall be renewed every two years. (11) The regional acute care psychiatric service shall have an ongoing quality assessment and improvement program to objectively and systematically monitor and evaluate the quality of care provided to patients served, pursue opportunities to improve care, and correct identified problems. The program shall include: (a) Policies and procedures that describe the quality assessment and improvement program’s objectives, organization, scope, and mechanisms for improving services; (b) A written annual plan to monitor and evaluate services. The written plan shall result in reports of findings, conclusions, and recommendations. Reports shall address: (A) The care of patients served, including admission and discharge planning; (B) Resource utilization, including the appropriateness and clinical necessity of admissions and continued stay, services provided, staffing levels, space, and support services; (C) Quality and content of clinical records; (D) Medication usage, including records, adverse reactions, and medication errors; (E) Accidents, injuries, safety of patients, and safety hazards; and (F) Uses of seclusion and restraint; (G) An annual needs assessment survey of individuals that have received services. (c) A report to the governing board and council, at least annually, addressing: (A) Findings and conclusions from studies; (B) Recommendations, action taken, and results of the action taken; and (C) An assessment of the effectiveness of the quality assessment and improvement program, including a review of the program’s objectives, scope, organization and effectiveness. (12) The regional acute care psychiatric service shall have a council to ensure appropriate and effective care and treatment. The council shall meet to assess and collaboratively plan for improving care and treatment to patients, including patient transitions into and out of the service. Statutory/Other Authority: ORS 413.042 & 430.640 Statutes/Other Implemented: ORS 430.630 & 430.640 History: MHS 8-2017, f. & cert. ef. 6-23-17 MHS 22-2016, f. & cert. ef. 12-1-16 MHD 8-1994, f. & cert. ef. 11-28-94