Code of Massachusetts Regulations › 104 CMR - DEPARTMENT OF MENTAL HEALTH › Title 104 CMR 27.00 - LICENSING AND OPERATIONAL STANDARDS FOR MENTAL HEALTH FACILITIES › Subpart C - OPERATIONAL STANDARDS FOR MENTAL HEALTH FACILITIES › Section 27.11 - Periodic Review

Current through Register 1525, July 5, 2024
(1)
Schedule of Periodic Reviews
. Every facility shall
				conduct a periodic review of each patient upon admission, and for patients
				whose hospitalizations are expected to be at least 90 days, during the first
				three months, during the second three months, and annually thereafter until
				discharge, except that for facilities licensed as Class VI, Limited Class VI
				and VII and for units of Department facilities that admit patients younger than
				19 years old, such periodic reviews shall be conducted as clinically indicated
				but no less frequently than quarterly.
(2)
Notice to Patient and
				Family
. Prior to the periodic review, the facility director or
				designee shall give reasonable advance written notice to each patient and his
				or her legally authorized representative. If there is no legally authorized
				representative, the director shall inform the patient that, unless the patient
				knowingly objects, notice of the periodic review shall also be given to his or
				her nearest relative giving the date of such review.
(3)
Thorough Clinical
				Examination
. Each periodic review shall include a thorough
				clinical examination, which shall consist of: a mental status examination; a
				review of the patient's clinical history, including a review of the treatment
				plan, of response to treatment, and of medications administered; and an
				evaluation of general behavior and social interaction by clinical personnel
				from the various disciplines providing treatment. At least once in every
				12-month period, a thorough clinical examination shall also include a physical
				examination.
(4)
Evaluation of Capacity
. For each periodic review, the
				legal capacity of a patient shall be evaluated to determine whether he or she
				has capacity to remain on, or to apply for, voluntary or conditional voluntary
				status, to render informed consent to customary and usual medical care or
				extraordinary treatment, including administration of antipsychotic medications,
				or to manage his or her own funds in accordance with the requirements of
				104 CMR
				30.01(4):
Evaluation
				of Ability to Manage Funds
.
(a) If a
				patient on voluntary or conditional voluntary status is believed no longer to
				have capacity to remain on that status, and the patient remains in need of
				continued hospitalization, then the facility director shall take reasonable
				steps to obtain alternate authority for continued hospitalization by seeking an
				order of commitment pursuant to M.G.L. c. 123, §§ 7 and 8, or obtain
				consent of a legally authorized representative.
(b) If the question of a patient's capacity
				is raised by a periodic review or if the facility director has reason to
				believe that a patient who has been under the care of the facility, who is not
				under guardianship or conservatorship, is unable to care for his or her person
				or property, the facility director shall promptly take reasonable steps to
				initiate the process to obtain a legally authorized representative.