N.Y. Comp. Codes R. & Regs. tit. 14 § 580.6

Current through Register Vol. 46, No. 51, December 18, 2024

Section 580.6 - Program

(a) General.

(1) The program of services shall be provided through a person-centered process with shared decision making.

(2) The program of services shall be informed by the understanding that implicit bias may affect the assessment, diagnosis, treatment, and discharge planning of Black, Indigenous, People of Color (BIPOC) and other marginalized individuals.

(3) The program of services shall be provided in accordance with the principle of continuity of care, whereby a single member of the professional clinical staff shall exercise primary responsibility for each individual at all times.

(4) Direct service to individuals shall be provided in accordance with an individual written plan of care, treatment and rehabilitation, specifying the nature of the conditions and the disabilities found to be present and those which are to be affected, relating these to the methods of care, treatment and rehabilitation to be provided, identifying the intended benefits of care and treatment and providing for appropriate review and revision.

(5) A single case record which contains current information regarding diagnosis, treatment and evaluation of results of care or treatment for each individual shall be available to all professional staff involved in the care or treatment of that individual.

(6) The programs provided by the unit shall include diagnostic and active, person-centered treatment, including but not limited to individual and group psychotherapy, acceptable interventional therapies, pharmacological therapies, psychiatric nursing care and a therapeutic milieu. In addition, in order to provide alternatives to inpatient care and a continuum of support and care beyond inpatient stay, a general hospital shall, either within its facility or by affiliation with or referral to other public or nonprofit or other approved agencies, assure access for individuals, as clinically appropriate, to partial hospitalization services, outpatient and crisis and emergency services. The functions of the partial hospital services and outpatient programs shall closely relate to the inpatient unit, be established by written agreement if not provided by the psychiatric inpatient unit, and shall be available to all individuals who might benefit.

(7) Hospitals shall utilize best practices and person-centered approaches on the screening, assessment, treatment and disposition of individuals presenting to the hospital with acute psychiatric needs necessitating emergency and inpatient services, in accordance with office guidance.

(8) The treatment program in those hospitals which provide services to children shall include the means for providing instruction to children under the age of 18, consistent with their age, needs, and clinical condition, as well as, the needs and circumstances within the facility or program, in techniques and procedures which will enable such individuals to report abuse and maltreatment.

(9) A nurse practitioner or registered nurse shall be on duty on the unit at all times.

(10) A physician shall be on duty at all times at the hospital, and other medical staff shall be available on call as needed.

(11) The unit shall have continuously in force a written policy on prescription and dispensing of medications, including appropriate time limits for prescriptions or drug orders and requirements for review by the physician responsible.

(12) All facilities accepting admissions pursuant to section 9.39 of the Mental Hygiene Law shall demonstrate the capacity to, when appropriate, control the access to and exit from units or areas of units in which individuals admitted pursuant to section 9.39 reside.

(b) Admissions.

(1) All admissions shall be conducted in accordance with the provisions of article 31 of the Mental Hygiene Law in a form and format designated by the office.

(2) The certified bed capacity of the unit shall not be exceeded at any time. Provided, however, i n extraordinary circumstances, such capacity may be exceeded upon written approval of the office, on a situational and time-limited basis.

(3) A hospital shall accept for observation, diagnosis and treatment any suitable person presented for admission as provided in section 9.39 of the Mental Hygiene Law, regardless of the time of day or person referring such individual.

(4) If minors under the age of 18 are admitted to the hospital, they shall not be commingled with adults in areas of the unit where the adults reside, nor shall they receive services in groups which include adults. In extraordinary circumstances, such commingling may be permitted upon written approval of the Office, on a situational and time-limited basis.

(5) Admission requirements. When an individual is admitted to a unit, clinical staff shall:

(i) review documentation of assessments, treatment, and other services provided in referring outpatient, emergency, or hospital program;

(ii) review documentation of prior presentations to the hospital unit and attempt to obtain medical records from other hospitals where the individual received services;

(iii) in accordance with HIPAA and section 33.13 of the Mental Hygiene Law, attempt to obtain the authorization of the individual or someone authorized to make health care decisions on the individual's behalf to access, use and disclose personal health information from collaterals or other data sources as outlined in this subdivision. If the authorization of the individual cannot practicably be obtained due to incapacity or emergency circumstance, unit staff may, in the exercise of professional judgment, determine whether the access, use, or disclosure is necessary to prevent imminent, serious harm to the individual. If so, only that personal health information that is necessary to protect the individual from the anticipated harm or which is in the best interest of the individual may be accessed, used, or disclosed. The reasons for the access, use, or disclosure must be appropriately documented in the clinical record;

(iv) attempt to obtain collateral information on all admitted individuals;

(v) review information in PSYCKES regarding admitted individuals regarding prior psychiatric and medical history and contact information for outpatient treatment teams and care managers with consent as required. In the event of incapacity or emergency circumstance, staff may temporarily access a PSYCKES clinical profile for the limited purposes authorized by this section and in accordance with PSYCKES policy or as authorized by other policy, law or regulation;

(vi) review information in any other available information network databases regarding admitted individuals with consent as may be required by the database policy or as authorized by other policy, law or regulation; and

(vii) check to see if the individual has a PAD or other Wellness Plan and preferred contacts in PSYCKES. Staff shall obtain consent as required to access the full view of the PAD, Wellness Plan, or preferred contacts. In the event of incapacity or emergency circumstance, staff may temporarily access a PSYCKES clinical profile, for the limited purposes authorized by this section and in accordance with PSYCKES policy or as authorized by other policy, law or regulation. If the individual does not have PAD, clinical staff shall provide a copy and explanation of a PAD. If the individual chooses to complete a PAD, it shall be placed in their chart.

(6) Screening requirements on admission. The following screenings shall take place on admission and documented in the individual's chart:

(i) All individuals shall be screened for suicide risk using a validated instrument. Positive screens shall be followed by a suicide risk assessment by a licensed professional trained in assessing suicide risk.

(ii) Each hospital shall have policies regarding violence risk screening and assessment. All individuals shall be screened, and the hospital policy shall describe a process for subsequent assessment and intervention in the case of a positive screen. As part of the screening, all individuals shall be asked about access to firearms or other weapons.

(iii) All individuals above the age of 12 shall be screened for substance use using a validated instrument. Positive screens shall be followed by an assessment for high risk substance use and substance use disorder by a licensed professional or CASAC working within their scope of practice.

(iv) A determination shall be made as to whether an individual has complex needs.

(c) Discharge Requirements.

(1) All discharges shall be conducted in accordance with the provisions of section 29.15 of the Mental Hygiene Law, in a form and format designed by the office.

(2) The discharge plan shall be developed through shared decision making in a person-centered process. The discharge plan shall reflect individual strengths and level of social support and address psychiatric, substance use disorder, chronic medical, and social needs. The plan shall also address relevant concerning information obtained from collateral sources of information.

(3) For discharges of individuals with complex needs, the discharging unit shall provide a verbal clinical sign-out on the day of discharge, or as soon as possible thereafter, to the receiving outpatient behavioral health treatment program and if applicable, the residential program licensed or funded by the office or Office of Addiction Services and Supports, Office for Persons with Developmental Disabilities or the Department of Health, where the individual will reside. This must be done in accordance with section 33.13 of the Mental Hygiene Law.

(4) The unit shall send a discharge summary detailing the presenting history of present illness (HPI), hospital course, and other relevant information to the outpatient, residential, or long-term care treatment program(s) within seven days of discharge in accordance with section 33.13 of the Mental Hygiene Law.

(5) Prior to discharge, and in accordance with section 33.13 of the Mental Hygiene Law, the hospital shall schedule and confirm a follow up appointment with an identified provider to occur within seven calendar days following discharge. If, after making diligent efforts, a hospital cannot identify an aftercare provider with an available appointment within seven calendar days, the hospital shall document its efforts and schedule the appointment for as soon as possible thereafter. A referral to a walk-in intake clinic is insufficient to meet this requirement. Individuals who are leaving the hospital against medical advice, or who state they do not wish to receive aftercare services, shall be provided information about available treatment options and have an appointment scheduled whenever possible.

(6) For individuals with complex needs enrolled in outpatient or residential care management, the unit shall coordinate discharge plan details and timing with care managers, including supporting on unit predischarge visits.

(7) For eligible individuals with complex needs who are not enrolled in intensive care management or are enrolled in care management but need intensive care management, hospital staff shall make a referral to an intensive care management provider, in accordance with office guidance.

(8) All individuals shall be screened for suicidality prior to their discharge. Individuals with an elevated risk of self-harm or suicide shall have a community suicide safety plan completed before discharge. Lethal means shall be identified and a plan for restriction addressed in the safety plan. The unit shall document their work with collaterals to implement the plan to restrict lethal means and confirm completion prior to discharge.

(9) Discharge of individuals with an elevated risk of violence shall include, to every extent possible, close collaboration with the county DCS if applicable, current and new outpatient treatment providers, residential providers if applicable, and school if applicable, to incorporate strategies to address violence risk factors and access to weapons into the overall discharge plan in accordance with section 33.13 of the Mental Hygiene Law.

(10) When determining whether an individual is ready for discharge and the most appropriate discharge setting, the whole clinical presentation and history, as well as the availability of existing services in the individual's community, shall be considered.

(11) Individuals who meet criteria for any substance use disorder shall be offered pharmacological interventions, if appropriate, and referred to a new or existing provider who can continue treatment for their substance use disorder.

(12) Individuals who require treatment with an antipsychotic medication but have history of difficulty with consistently taking oral medications, shall be considered through shared decision making, for treatment with a long-acting injectable medication.

(13) A hospital shall be prohibited from discharging any person with serious mental illness to a transitional adult home, as defined in regulations of the Commissioner of Health, unless the person was a resident of the home immediately prior to their current period of hospitalization.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 580.6

Amended New York State Register December 18, 2024/Volume XLVI, Issue 51, eff. 12/18/2024