6 Colo. Code Regs. § 1011-1 Chapter 04, pt. 29

Current through Register Vol. 47, No. 17, September 10, 2024

Part 29 - PSYCHIATRIC SERVICES

29.1 Hospitals may provide psychiatric services. If provided, the following standards shall apply.

(A) Hospitals that do not provide psychiatric or substance-use disorder services shall develop and implement a written plan for the referral of patients to treatment options.

(B) For purposes of this Part 29, psychiatric care includes, but is not limited to, the provision of the following as appropriate to the patient: psychiatric physician and nursing services, psychological services, social services, occupational therapy, and recreational therapy.

29.2 The director of psychiatric services shall be a physician who is board certified or has met the training and experience requirements for examination by the American Board of Psychiatry and Neurology or the American Osteopathy Board of Neurology and Psychiatry.

29.3 Nursing Services

(A) Psychiatric Nursing Director

(1) Psychiatric nursing care shall be directed by a registered nurse qualified by education, training, competencies, and experience to effectively direct psychiatric nursing, provide skilled nursing care and therapy, and evaluate the nursing care furnished.

(2) Education and Experience Requirements:

(a) The psychiatric nursing director shall have either a bachelor's degree in nursing and two (2) years of clinical experience in a psychiatric setting; or

(b) An associate's degree in nursing and five (5) years of experience in a psychiatric setting.

(3) Regardless of education and experience level, the psychiatric nursing director shall have at least one (1) year of nurse supervision experience as a registered nurse.

(B) Additional Nursing Personnel

(1) A registered nurse qualified by education, training, competencies, and experience to provide psychiatric care shall be available in the psychiatric unit twenty-four (24) hours per day, seven (7) days per week.

(2) All nursing personnel assigned to care for specific populations, such as pediatric or geriatric patients, shall be qualified by education, training, competencies, and experience to provide care to that population.

29.4 Psychology services, if provided, shall be directed by a licensed psychologist, licensed psychiatrist, or licensed clinical social worker. There shall be sufficient psychology services to meet the needs of the patients in accordance with care plans.

29.5 Social services shall be directed by an individual with a master's degree in social work or an individual with a related master's degree and documented training, competencies, and experience to oversee the social services provided by the hospital.

(A) The hospital shall ensure there is social work staff available to provide psychological data for diagnosis and treatment, participate in discharge planning, and arrange for follow-up care, in order to meet the needs of the patients in accordance with care plans.

29.6 The hospital shall ensure there are qualified personnel available to provide therapeutic and recreational therapy programming designed to improve the patient's ability to adjust to social stress, physical demands, and daily living skills, in order to meet the needs of the patients in accordance with care plans.

29.7 The hospital shall ensure there are qualified clinical and supportive staff available to assess the needs of psychiatric patients, implement individualized active treatment care plans, and ensure a safe, therapeutic environment for patients and staff, in order to meet the needs of the patients in accordance with care plans.

29.8 The hospital shall provide annual training to direct care personnel on the following topics, at a minimum:

(A) Use of least-restrictive alternatives;

(B) Management of assaultive and self-destructive behaviors, including effective methods to de-escalate various states of agitation;

(1) This training shall also be provided to security personnel assigned to the service.

(C) Patient rights, in compliance with 6 CCR 1011-1, Chapter 2, Part 7; and

(D) Special needs of the patient population.

29.9 Patient Assessments

(A) Within four (4) hours of admission, an initial assessment for immediate safety needs shall be conducted by qualified personnel.

(B) Within eight (8) hours of admission, a nursing assessment shall be conducted. Care shall be provided, as determined by the nursing assessment, to maintain the individual's safety and physical well-being.

(C) Within twenty-four (24) hours of admission for inpatients, or within three (3) days of initiating services for outpatients, a comprehensive psychiatric assessment shall be conducted by medical staff. The assessment shall include, but not be limited to:

(1) Medical history and physical evaluation;

(2) Psychiatric history;

(3) A complete mental status exam, including but not limited a determination of the onset of the illness and circumstances leading to admission; and

(4) Current attitudes, behavior, memory, and orientation.

29.10 Care Plan

(A) The patient shall receive services in accordance with an individualized care plan that meets the needs of the patient.

(B) The plan shall:

(1) Be initiated within twenty-four (24) hours after admission and updated as needed for inpatients, or within seven (7) days after initiating treatment for outpatients.

(2) Be developed by an interdisciplinary team and based on the psychiatric, medical, social behavior, and developmental aspects of the patient as identified through assessments.

(a) The interdisciplinary team shall complete the care plan within seventy-two (72) hours of admission and review the plan at least every seven (7) days for appropriateness for the first thirty (30) days, or more often if indicated by changes in the patient's condition.

(b) For inpatient stays longer than thirty (30) days, and up to twelve (12) months, subsequent care plan reviews shall be conducted at intervals specified by the patient's psychiatrist. Such intervals shall not exceed thirty (30) days.

(c) For inpatient stays longer than twelve (12) months, subsequent care plan reviews shall be conducted at intervals specified by the patient's psychiatrist. Such intervals shall not exceed three (3) months.

(3) Include short- and long-term goals with measurable outcomes, active treatment modalities to be used, and the responsibility of each member of the treatment team.

(4) Reflect patient and family participation to the extent possible.

(5) Incorporate environmental modifications necessary to keep the patient from harming self or others, as applicable.

29.11 The hospital shall develop and implement policies and procedures, based on nationally-recognized guidelines and standards of practice that address, at a minimum, the following:

(A) Restraint and seclusion consistent with state and federal law and regulation, including 6 CCR 1011-1, Chapter 2, Part 8, Protection of Persons from Involuntary Restraint or Seclusion. Medications shall only be used for treatment and stabilization, not for staff convenience.

(B) Admissions and discharge compliant with involuntary commitment law and regulation.

(C) Safety and security precautions for the prevention of suicide, assault, elopement, and patient injury at all hours. This policy shall include, at a minimum, protocols for:

(1) Systematic assessments and elimination of environmental risks, to include periodic checking of breakaway hardware;

(2) Summoning immediate assistance for staff and patients;

(3) Opening locked or barricaded doors in the event of an emergency, using methods that do not cause harm to patients; and

(4) Immediately addressing and treating any incidents of overdose or accidental poisoning.

(D) Behavior management techniques ranging from the least to most restrictive and when techniques that can result in harm to the patient are authorized.

(E) The use of electroconvulsive therapy, consistent with Section 13-20-401, C.R.S., et seq., if applicable. This policy shall address the following:

(1) indications for use,

(2) informed consent,

(3) medical clearance,

(4) response to life- or limb-threatening emergencies, and

(5) the services and facilities necessary to provide treatment adequately and safely.

(F) Medical detoxification and any other types of substance-use disorder treatment, if applicable.

(G) Medication monitoring.

(H) Visitors.

(I) Confidentiality.

(1) This policy shall ensure that all information about psychiatric patients, whether oral or written, shall be kept confidential by all personnel, staff (including volunteers), and physicians or licensed independent practitioners at the hospital, and shall only be disclosed in accordance with state and federal law.

29.12 Discharge Planning

(A) The service shall comply with the discharge planning requirements in Part 13, General Patient Care Services.

(B) The patient's discharge plan shall include notations from each member of the patient's interdisciplinary team regarding continuity of care, as appropriate.

(C) In evaluating the post hospital care needs, the hospital shall consider the patient's ability to comply with the medication regimen and to live independently.

29.13 Pediatric Psychiatric Services

(A) Children, adolescent, and adult populations are shall not be commingled on inpatient care units.

(1) Children shall be classified as ages five (5) through twelve (12).

(2) Adolescents shall be classified as ages thirteen (13) through eighteen (18).

(3) The hospital shall develop and implement policies and procedures governing the decision-making process to place a patient of one age category (children/adolescent/adult) on a unit designed and operated for a different age category.

(B) The hospital shall make appropriate education programs available to all school-age patients who will be hospitalized for over fourteen (14) days.

(1) These educational programs may be provided by either the local school district or by the hospital.

(2) If provided by the hospital, the educational program shall be approved by the Colorado Department of Education.

(C) Hospitals shall develop and implement policies and procedures regarding the treatment of pediatric patients. These policies shall be based on nationally-recognized guidelines and standards of practice and shall address, at a minimum, the following:

(1) Training requirements for all personnel regarding the special needs of pediatric patients.

(2) Strategies regarding family involvement in the care of the patient.

(3) Provision of psychiatric, social, and recreation services in a manner that is appropriate for pediatric patients.

(4) Modifications to the policies developed and implemented pursuant to Part 29.11, as appropriate, to meet the needs of pediatric patients.

(D) In addition to the assessment requirements in Part 29.9(C), an assessment of a pediatric patient shall also address the following:

(1) The impact of the patient's condition on the family and the family's impact on the patient;

(2) The patient's legal custody status;

(3) The patient's growth and development, including physical, emotional, cognitive, educational, nutritional, and social development; and

(4) The patient's play and daily activity needs.

6 CCR 1011-1 Chapter 04, pt. 29