North Dakota Administrative Code › Title 33 - State Department of Health › Article 33-07 - Licensing Medical Hospitals › Chapter 33-07-01.1 - Hospitals › Section 33-07-01.1-36 - Psychiatric services in hospitals

Current through Supplement No. 393, July, 2024
1.
				General acute hospitals providing psychiatric services are subject to the
				psychiatric services in hospitals requirements for specialized hospitals in
				this section. If, in the course of the inspection of a general acute hospital,
				the department finds from a review of the psychiatric treatment rendered and
				the adequacy of the consultation and referral resources that the hospital
				practice and staffing warrants the establishment of a psychiatric service, the
				department shall notify the hospital of the need to establish the service in a
				manner that complies with this section.
2. Primary care hospitals may not provide
				psychiatric services.
3. Any
				facility that provides or purports to provide psychiatric inpatient or
				inpatient and outpatient diagnosis or treatment on other than an emergency
				basis shall comply with this section. A hospital may not hold itself out to the
				public as providing psychiatric services unless such psychiatric service has
				been licensed by the department and meets the requirements for a psychiatric
				hospital in this section.
a. Hospitals
				accredited by a national accrediting entity in the category of psychiatric
				services shall submit, upon receipt, all accreditation survey results,
				recommendations, and plans of correction to the department.
b. In hospitals without an approved
				psychiatric service, psychiatric care to patients with a primary diagnosis of a
				psychiatric disorder may be rendered on an emergency basis by appropriate
				members of the medical staff as determined by the hospital. Psychiatric
				consultation must be available and utilized appropriately as determined by the
				hospital.
c. The organization and
				responsibilities of the medical staff for psychiatric services must be in
				accordance with licensure requirements, except as amended and modified:
(1) The physician in charge of the
				psychiatric services must be a psychiatrist who is licensed to practice
				medicine in North Dakota.
(2) The
				psychiatrists on the staff of the psychiatric hospital or psychiatric services
				of a general acute hospital must have as minimum qualifications at least three
				years' approved residency training in psychiatry or equivalent training and
				experience. If physicians other than psychiatrists are authorized to treat
				patients in a psychiatric hospital or in a psychiatric service there must be
				timely evidence of psychiatric consultation after the patient is admitted, and
				ongoing consultation with a psychiatrist who is a member of the psychiatric
				staff, as needed.
(3) There must be
				other medical staff in appropriate specialties, available at all times to the
				psychiatric staff.
d. The
				organization and staffing of the nursing service must be in accordance with the
				licensure requirements, except as amended and modified:
(1) The registered nurse supervising the
				nursing services of the psychiatric services must have experience and
				demonstrated competency in psychiatric nursing.
(2) The nursing personnel of the psychiatric
				services in a general acute hospital must be a separate staff who are assigned
				to the psychiatric services.
(3)
				There must be at least one registered nurse with experience in psychiatric
				nursing on duty at all times on each psychiatric nursing unit. The number of
				registered nurses and other nursing personnel must be adequate to provide the
				individual patient care required to carry out the patient care plan for each
				patient.
e. The following
				services or consultative resources are required: clinical psychological
				services, social work services, and occupation and recreational therapy
				services. These services must be under the direction of a psychiatrist in
				charge of the psychiatric services in a general acute hospital or the
				psychiatric diagnosis or treatment units in a psychiatric hospital. The staff
				used to support these services must be adequate in number and be qualified by
				professional education, experience, and demonstrated ability. If registration
				or licensing of personnel is required by statute or regulation, the
				registration number must be on file and available upon request.
f. Personnel development and training for
				psychiatric services staff must include the following:
(1) There must be written evidence of
				orientation training for all staff and ongoing, planned, and scheduled
				inservice training for all staff.
(2) Ongoing interdisciplinary staff
				conferences must be held to ensure communication, coordination, and
				participation of all professional staff and personnel involved in the care of
				patients.
g. Specialized
				procedures for psychiatric services must be provided for and implemented as
				follows:
(1) A patient may not be subject to
				the withholding of privileges or to any system of rewards, except as part of a
				treatment plan.
(2)
				Electroconvulsive therapy, experimental treatments involving any risk to the
				patient, or aversion therapy may not be prescribed, unless:
(a) The patient's treatment team has
				documented in the patient's record that all reasonable and less intensive
				treatment modalities have been considered, the treatment represents the most
				effective therapy for the patient at that time, the patient has been given a
				full explanation of the nature and duration of the proposed treatment and why
				the treatment team is recommending the treatment, and the patient has been
				informed of the right to accept or refuse the proposed treatment and, if the
				patient consents, has the right to revoke the consent for any reason at any
				time prior to or between treatments.
(b) The treatment was recommended by
				qualified staff members trained and experienced in the treatment procedure and
				has been approved by the psychiatrist.
(c) The patient has given written informed
				consent to the specific proposed treatment. In the alternative, oral informed
				consent is sufficient if that consent is witnessed by two individuals not part
				of the patient's treatment team. In either case, such consent must be limited
				to a specified number of maximum treatments over a period of time and must be
				revocable at any time before or between treatments. Such withdrawal of consent
				is immediately effective.
(d) If a
				patient's treatment team determines that the patient could benefit from one of
				those specified treatments but also believes that the patient does not have the
				capacity to give informed consent to the treatment, appropriate consent
				consistent with applicable state laws must be obtained before such treatment
				may be administered to the patient.
(3) A patient may not be subject to chemical,
				physical, or psychological restraints, including seclusion, other than in
				accordance with the policy and procedures for seclusion and restraint approved
				by the medical staff and governing body. A copy of the applicable regulations
				must be made available to patients upon request.
(4) A patient may not be the subject of any
				research, unless conducted in strict compliance with federal regulations on the
				protection of human subjects. Patients considered for research approved by the
				hospital must receive and understand a full explanation of the nature of the
				research, the expected benefit, and the potential risk involved. Copies of the
				federal regulations must be made available to patients or their advocates
				involved in, or considering becoming involved in, research.
h. If the treatment team
				determines that continued voluntary inpatient treatment is not indicated, the
				treatment team shall discharge the patient with an appropriate postdischarge
				plan. The postdischarge plan must address followup needs, future consultative
				needs, or in the event of patient regression or deterioration, treatment or
				admission needs.
i. Care of
				patients for psychiatric services must include the following:
(1) Each psychiatric unit shall have
				available recreational and occupational therapy and other appropriate
				facilities adequate in size in relation to patient population, number of beds,
				and program.
(2) Restraints and
				seclusion facilities must be available, and written policies must be
				established for their use. Mechanical restraints or seclusion may be used only
				on the written order of a physician. This written order must be valid for
				specific periods of time. In an emergency, the licensed professional in charge
				may order restraints. Confirmation of the order by a physician must be secured.
				Policies and procedures regarding use of restraints and seclusion must be
				reviewed annually. The patient medical record must indicate justification for
				the restraint, time applied and released, and other pertinent
				information.
(3) A current policy
				and procedure manual must be maintained for the psychiatric service. The manual
				must include procedures for the care and treatment of patients including the
				care of suicidal and assaultive patients, and the elopement of patients. The
				manual must identify the relationship with state agencies and community
				organizations providing psychiatric services. It must also describe plans for
				the evaluation and disposition of psychiatric emergencies.
(4) The design of facilities and the
				selection of equipment and furnishings must be conducive to the psychiatric
				program and must minimize hazards to psychiatric patients.
j. The psychiatric services shall develop an
				interdisciplinary team composed of mental health professionals, health
				professionals, and other individuals who may be relevant to the patient's
				treatment. At least one member of the team must be a psychiatrist. The team and
				patient or advocate shall formulate and evaluate an appropriate treatment plan
				for the patient.
(1) The director of the
				interdisciplinary team shall assure that staff trained and experienced in the
				use of modalities proposed in the treatment plan participate in its
				development, implementation, and review.
(2) The director of the interdisciplinary
				team is responsible for:
(a) Ensuring that the
				patient in treatment is encouraged to become increasingly involved in the
				treatment planning process.
(b)
				Implementing and reviewing the individualized treatment plan and participating
				in the coordination of service delivery with other service providers.
(c) Ensuring that the unique skills and
				knowledge of each team member are utilized and that specialty consultants are
				utilized when needed.
(3)
				Although an interdisciplinary team must be under the direction of a
				psychiatrist, specific treatment modalities may be under the direction of other
				mental health professionals when they are specifically trained to administer or
				direct such modalities.
k. A comprehensive individualized treatment
				plan must:
(1) Be formulated to the extent
				feasible with the consultation of the patient. When appropriate to the
				patient's age, or with the patient's consent, the patient's family, personal
				guardian, or appropriate other individuals should be consulted about the
				plan.
(2) Be based upon diagnostic
				evaluation that includes examination of medical, psychological, social,
				cultural, behavioral, familial, educational, vocational, and developmental
				aspects of the patient's situation.
(3) Set forth treatment objectives and
				prescribe an integrated program of therapies, activities, experiences, and
				appropriate education designed to meet these objectives.
(4) Result from the collaborative
				recommendation of the patient's interdisciplinary team.
(5) Be maintained and updated with progress
				notes, and be retained in the patient's medical record.
(6) State the basis for the restraints if the
				plan provides for restraints. The patient medical record must indicate what
				less restrictive alternatives were considered and why they were not
				utilized.
(7) Be written in terms
				easily explainable to the lay person. A copy of the current treatment plan must
				be available for review by the patient in treatment.
(8) Note when the most appropriate form of
				treatment for the individual is not available or is too expensive to be
				feasible.
l. At least
				once every seven days every patient in treatment must be plan reviewed. A
				report of the review and findings must be summarized in the patient's medical
				record and the treatment plan must be updated as necessary.
m. Subject to certain limitations authorized
				by a parent, legal guardian, legal custodian, or a court of law concerning a
				minor or guardian of an individual who is incapacitated or restrictions by the
				treating physician or psychiatrist, which in their professional judgment is in
				the best interest of the patient, each patient has the right to:
(1) Receive or refuse treatment for mental
				and physical ailments and for the prevention of illness or
				disability.
(2) The least
				restrictive conditions necessary to achieve the purposes of the treatment
				plan.
(3) Be treated with dignity
				and respect.
(4) Be free from
				unnecessary restraint and isolation.
(5) Visitation and telephone
				communications.
(6) Send and
				receive mail.
(7) Keep personal
				clothing and possessions.
(8)
				Regular opportunities for outdoor physical exercise.
(9) Participate in religious worship of
				choice. (10) Be free from unnecessary medication.
(11) Exercise all civil rights, including the
				right to habeas corpus.
(12) Not be
				subjected to experimental research without the express written consent of the
				patient or of the patient's guardian.
(13) Not be subjected to psychosurgery,
				electroconvulsive treatment, or aversive reinforcement conditioning, without
				the express and informed written consent of the patient or the patient's
				guardian.
n. Each
				hospital must have a clearly defined appeal system through which any patient
				who wishes to voice objections concerning the patient's treatment must be heard
				and have objections determined.
(1) Each
				hospital shall monitor the appeal system to see that it works properly and
				records must be maintained for review by the department in order to investigate
				any complaint.
(2) All patients
				must be advised of such system and be encouraged to use it when they believe
				their treatment plan is not necessary or appropriate to their needs.
o. Medical record requirements for
				psychiatric hospitals and psychiatric services of general acute hospitals must
				include the following:
(1) Medical records
				must stress the psychiatric components of the patient's condition and care
				including history of findings and treatment rendered for the psychiatric
				condition for which the patient is hospitalized.
(2) A provisional or admitting diagnosis must
				be made on every patient at the time of admission and include the diagnoses of
				current diseases as well as the psychiatric diagnoses.
(3) Data from all pertinent sources must be
				included, in addition to data obtained from the patient.
(4) A psychiatric evaluation must be
				performed within forty-eight hours of admission, include a medical history,
				contain a record of mental status, and note the onset of illness, the
				circumstances leading to admission, attitudes, behavior, estimate of
				intellectual functions, memory functioning, orientation, and an inventory of
				the patient's assets in descriptive, not interpretive, fashion.
(5) A complete neurological examination must
				be recorded at the time of the admission physical examination, when
				indicated.
(6) Social service
				records, including reports of interviews with patients, family members, and
				others must provide an assessment of home plans, family attitudes, and
				community resource contacts, with appropriate recommendations for family or
				community resource involvement, as well as a social history.
(7) Reports of consultations, reports of
				electroencephalograms, and other pertinent reports of special
				studies.
(8) The patient's
				comprehensive treatment plan must be recorded, must be based on an inventory of
				the patient's strengths as well as disabilities, and must include a
				substantiated diagnosis in the terminology of the most current edition of the
				American psychiatric association's diagnostic and statistical manual,
				short-term and long-range goals, and the specific treatment modalities utilized
				as well as the responsibilities of each member of the treatment team in such a
				manner that it provides adequate justification and documentation for the
				diagnoses and for the treatment and rehabilitation activities carried
				out.
(9) The treatment received by
				the patient must be documented to assure that all active therapeutic efforts
				such as individual and group psychotherapy, drug therapy, milieu therapy,
				occupational therapy, recreational therapy, industrial or work therapy, nursing
				care, and other therapeutic interventions are included.
(10) The discharge summary must include a
				recapitulation of the patient's hospitalization and recommendations from
				appropriate services concerning followup or aftercare as well as a brief
				summary of the patient's condition on discharge.
(11) Confidentiality of the psychiatric
				record must be recognized and safeguarded in medical records services of the
				hospital.