Code of Maine Rules › 14 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 193 - OFFICE OF ADULT MENTAL HEALTH › Chapter 6 - MENTAL HEALTH LICENSING REGULATIONS › INPATIENT SERVICE STANDARDS

Current through 2024-29, July 17, 2024
These standards, in addition to the core standards, are
				  applied to agencies providing inpatient services.
Access
IN.1 The agency has policies and procedures governing the
				  establishment of a waiting list for non-emergency admissions, that minimally
				  includes the following: prioritizing clients, selecting clients from the
				  waiting list, and referring clients to other providers.
Assessment
IN.2 A comprehensive assessment is conducted by an individual
				  chosen or agreed to by client, with the client's participation, within 10
				  working days of the client's admission.
IN. 2. A The comprehensive assessment minimally addresses the
				  following:
IN. 2. A.1 the client's strengths and weaknesses;
IN. 2. A.2 the client's perception of his or her needs,
				  including housing and financial assistance;
IN. 2. A.3 the family/guardian's input and perception of the
				  client's needs when appropriate, and with the client's consent;
IN. 2. A.4 a personal, family, and social history;
IN. 2. A.5 emotional and psychological strengths and
				  needs;
IN. 2. A.6 a psychiatric status and history, including,
				  subject to the client's consent, records of previous psychiatric
				  hospitalizations and services received by the client in the community,
				  including crisis services;
IN. 2. A.7 a physical health status and history, including
				  current prescription and over-the-counter medication use;
IN. 2. A.8 past and current drug/alcohol use;
IN. 2. A.9 a developmental history;
IN. 2. A.10 possible sources of assistance and support in
				  meeting the needs expressed by the client or legally responsible party,
				  including state and federal entitlement programs;
IN. 2. A.11 physical and environmental barriers that may
				  impede the client and family's ability to obtain services;
IN. 2. A.12 history of physical and/or sexual abuse;
IN. 2. A.13 the vocational, educational, social, living,
				  leisure/recreation and medical domains;
IN. 2. A.14 the signature of the person who performed the
				  assessment.
Interpretive Guideline for IN.2.A.1 thru IN.2.A.14
The Division of Licensing recognizes that in some cases no
				  all of the information requested in these standards will be able to be
				  obtained. The Division also recognizes that the level of detail required will
				  vary given a variety of factors (the client's level of cooperation, the
				  integrity of information sources, the length of services or treatment, the
				  condition being addressed. the practitioner's training, etc.). Although the
				  Division will attempt to be sensitive to these factors and flexible in
				  surveying this area, the agency should assure that assessments that do not
				  address all these standards have accompanying documentation that justifies
				  abbreviated or absent information.
IN. 2. B. The agency will establish policies and procedures
				  establishing criteria for the performance of the following assessments:
IN. 2. B.1 a nutritional assessment;
IN. 2. B.2 a cognitive functioning assessment:
Interpretive Guideline for IN.2.B.2
The client's cognitive functioning assessment should include
				  assessment of the following functions: problem solving, decision making,
				  organization, self-direction, system negotiation skills, concentration, and
				  abstract reasoning. For individuals over 60 years of age, this assessment
				  should also include memory, language, orientation, and visuo-spatial
				  abilities.
IN. 2. B.3 an assessment of the client's capacity to make
				  reasoned decisions;
IN. 2. B.4 a neurological assessment.
Interpretive Guideline for IN.2.B thru IN.2.B.4
These assessments do not necessarily have to be performed in
				  the agency or by agency staff. the intent of these standards are assure that
				  the agency has mechanisms by which to evaluate the need for these assessments
				  and to perform or refer for assessment those clients whose symptomatology
				  suggests the need for these assessments.
IN. 2. C The assessment(s) shall be obtained from the client,
				  legally responsible party, community service agencies, and to the extent
				  possible, from other individuals in the community as authorized by the client
				  or legally responsible party.
IN. 2. C.1. In instances in which the client receives
				  community support services and/or has an Individualized Support Plan, the
				  agency will, subject to the client's consent, attempt to coordinate the
				  assessment and subsequent treatment planning with the community support
				  provider.
IN. 2. C.1.a. Services provided to these clients will be
				  consistent with the targets and objectives of the Individualized Support
				  Plan.
IN. 2. D The client record contains a summary evaluation of
				  the data collected in the comprehensive assessment.
IN.3 The agency has a documented policy and procedure on
				  updating assessments that assures that assessments are current and in no case
				  exceed annual updates.
Treatment Planning
IN.4 There is documented evidence that the treatment planning
				  and revision process involves the client, legally responsible party, and other
				  representatives and professionals whom the client designates.
IN.5 A treatment plan is developed for each client, with the
				  client's consent, and within 3 working days of admission.
IN. 5. A. The treatment plan minimally contains the
				  following:
Interpretive Guideline for IN.4
The client and legally designated guardian shall be fully and
				  actively involved in the development or revision or the service plan, if
				  possible. If the client consents, the client's representative, family members
				  or significant others shall be included in the development and revision of the
				  service plan, unless contraindicated. When these individuals do not attend,
				  their absence is noted. Each agency shall document good faith efforts,
				  including 24 hour notice of any service planning meeting, to involve guardians,
				  representatives or legally responsible parents.
IN. 5. A.1 problem statements;
IN. 5. A.2 short- and long-range goals based upon client
				  needs with a projection of when such goals will be attained;
IN. 5. A.3 objectives stated in terms which allow objective
				  measurement of progress;
IN. 5. A.4 multidisciplinary input and specification of
				  treatment responsibilities;
IN. 5. A.5 client input and signature;
IN. 5. A.6 signatures of all people participating;
IN. 5. A.7 the methods and frequency of treatment,
				  rehabilitation, support;
IN. 5. A.8 a description of any physical handicap and any
				  accommodations necessary to provide the same or equal services and benefits as
				  those afforded non-disabled individuals; and
IN. 5. A.9 criteria for discharge or release to a less
				  restrictive setting.
IN. 5. B. Justification for not addressing problems
				  identified in the assessments is documented in the client record.
IN.6 The treatment plan is designed so that the client's
				  progress towards treatment plan goals can be monitored and evaluated.
IN.7 The treatment plan is reviewed at major decision points
				  in each client's treatment course, upon client request, & no less
				  frequently than every 30 days.
Standards
Interpretive Guideline for IN.5.B
The intent of this standard is to assure that the clinical
				  staff considers all of the client's identified problems in formulating the
				  service plan. Problems that are not reflected on the service plan should have
				  accompanying documentation identifying the rationale for not addressing the
				  problems at this time. This documentation can take many forms including
				  progress notes, service plan narratives, etc.
Interpretive Guideline for IN.6
Service plans should have measurable goals and some means for
				  reflecting, when, or to what degree, a goal has been attained. The organization
				  should also have mechanisms that document monitoring and evaluation or client
				  goals, e.g., quality assessment, treatment plan review documents.
Interpretive Guideline for IN.7
Major decision points may include, but are not necessarily
				  limited to the following: when there is a change in the client's condition,
				  when a service appears not to benefit the client, when the client is under- or
				  over-utilizing services.
IN.8 Unmet service needs are documented in the treatment
				  plan.
Interpretive Guideline for IN.8
If at the time of the service planning meeting, team members
				  know on the basis of reliable information that the needed services are
				  unavailable, they shall note them as "unmet service needs" on the service plan
				  and develop an interim plan based upon available services that meet, as nearly
				  as possible, the actual needs of the client. The organization should also
				  document notification of the organization's leadership and the Commissioner
				  regarding the unavailability of service that is causing the unmet service
				  need.
IN.9 The agency has a policy and procedure for providing
				  clients with a copy of their treatment plan within one week following its
				  formulation, review or revision and notification of client recourse should they
				  disagree with any aspect of the plan.
IN. 9. A. The agency will not fail to provide a copy of the
				  client's treatment plan and/or notify them of recourse should they
				  disagree.
IN.10 The hospital has a policy and procedure for developing
				  hospital treatment and discharge plans in coordination with Individualized
				  Support Plans for clients whose admissions are funded by the Department of
				  Mental Health and Mental Retardation.
Discharge Planning
IN.11 Each client record contains documentation of current
				  discharge or termination planning as required by IN.5.
IN. 11. A. Each discharge summary minimally addresses, but
				  need not be limited to the following:
IN. 11. A.1 the reasons for termination of service;
IN. 11. A.2 the final assessment, including the general
				  observations and significant findings of the client's condition initially,
				  while services were being provided and at discharge;
IN. 11. A.3 the course and progress of the client with regard
				  to each identified problem;
IN. 11. A.4 the recommendations and arrangements for further
				  continued service needs.
IN.12 A discharge summary is entered in the client record
				  within 15 days of discharge and includes the client's course of treatment and
				  ongoing needs at discharge.
IN.13 The agency documents the client's stated preference for
				  living situation in the discharge plan.
Interpretive Guideline for IN.13
When the client's preference for living situation cannot be
				  accommodated, the reasons are documented.
IN.14 Applicants who are not eligible for services will be
				  referred to appropriate services, if required, available and desired.
IN. 14. A The agency has a policy and procedure on referral
				  and/or transfers of individuals deemed inappropriate for services offered by
				  the agency that minimally includes communicating the rationale for the
				  referral/transfer to the applicant and providing them with a list of
				  alternative service providers and advocacy services.
IN. 14. B. The agency provides and documents other assistance
				  as required to assist the individual to obtain/access the services to which
				  they are referring him/her.
Health
IN.15 If food services are provided, the facilities for the
				  preparation and serving of food shall be inspected and approved by the
				  Department of Human Services.
IN. 15. A. If food is either prepared or served at the
				  facility, then the agency shall either a DHS Eating Establishment license or
				  show written evidence from DHS indicating that they need no such
				  license.
IN. 15. B. When the agency requires a DHS license, the
				  agency's Eating Establishment license is current.
IN.16 The agency shall have methods for obtaining on- or
				  off-site medical services for all clients.
IN. 16. A. The agency defines in policy and procedure those
				  medical services delivered on-site. For those medical services not provided
				  on-site, letters of agreement and/or procedures for accessing medical service
				  provider(s) are in effect.
Physical Plant
IN.17 A secure and readily accessible storage area of
				  adequate size is available to accommodate client belongings.
IN. 17. A. The agency has a policy and procedure related to
				  what personal belongings may be brought to the agency.
Inpatient Services
IN.18 Inpatient agencies meet all other mandatory regulatory
				  standards applicable to their organization, e.g., Medicare, Medicaid, DHS
				  Hospital Licensure.
IN.19 Clients who request community support services while in
				  an inpatient psychiatric facility are assigned a community support worker
				  within two working days.
IN. 19. A. The clients request for community support services
				  is documented in the client record and minimally includes the date and time of
				  the request
IN. 19. B. The agency documents contacting a community
				  support agency within one working day to allow the community support agency
				  adequate time to assign a community support worker.
IN. 19. C. The requesting client's record reflects the date
				  and time when a community support worker was assigned and the community support
				  worker's name.
IN. 19. D. There is evidence that the community support
				  worker has participated in treatment and discharge planning meetings to
				  coordinate service planning.
IN.20 For clients with prior inpatient hospitalizations, the
				  admitting hospital requests the client's consent to release previous records,
				  obtains them in a timely fashion, and considers them in treatment and discharge
				  planning.
IN. 20. A. Upon learning that a client has had a prior
				  psychiatric hospitalization, the individual coordinating the client's treatment
				  shall request the client's consent to the release of records.
IN. 20. B. Within two days of consent to release, the
				  individual coordinating the client's treatment, sends for copies of the
				  records.
IN. 20. C. Where prior records are obtained, there is
				  evidence in the treatment and discharge planning that the team considered
				  additional information from records of previous hospitalizations.
IN.21 Each inpatient service minimally provides the following
				  treatment services: individual, group, and family therapy, medication
				  evaluation and administration.
IN. 21. A. The agency can document that each client is
				  offered individual counseling with a psychiatrist, psychologist, clinical
				  social worker, psychiatric nurse, or a psychiatric physician extender for
				  sessions totaling no less than 3 hours per week.
IN. 21. B. Each client is evaluated for the need for
				  medication.