Overview of the Minimum Overview of the Minimum Standards for the Care and Standards for the Care and Treatment of Persons with Treatment of Persons with

Mental Illness (2 CCR 502-1)Mental Illness (2 CCR 502-1)

With excerpts from the Care and Treatment of the Mentally Ill Act

(CRS 27-10-101 et seq.)

October 2004

Caution!

This presentation is not a complete overview of the

Care and Treatment of the Mentally Ill Act

(CRS 27-10-101 et seq.)

Major Changes to Standards in Major Changes to Standards in April 2004 RevisionApril 2004 Revision(Last revision was in 1993)

Added secure treatment facilitiesUpdated practices to follow Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or Centers for Medicare and Medicare Services (CMS)Added data requirementsIncreased requirements for staff trainingUpdated confidentiality to reflect HIPAA

Updated seclusion/restraint to follow JCAHO or CMS

Clarified use of emergency medicationsAdded use of chemical sprays as a restraint is not permittedUpdated Electroconvulsive Therapy (ECT) rule to follow StatuteAdded recommendation for soft restraints when transporting patients

Added section on electronic recordsIncreased assessment date to include cultural issuesAdded documentation required for ongoing assessmentsIncreased documentation requirements under discharge planningUse of jails deleted from the regulations; remains in Statute

Types of Designated FacilitiesTypes of Designated Facilities

Licensed general or psychiatric hospitalsCommunity Mental Health Centers (CMHCs) or ClinicsResidential Child Care Facilities (RCCFs)By special designationNo nursing facilities or assisted living facilities unless operated by one of the aboveNo jails or other types of facilities unless by special designation

Types of DesignationsTypes of Designations

72-Hour Treatment and Evaluation FacilitiesShort-Term Treatment FacilitiesLong-Term Treatment FacilitiesCMHCs must be designated as Long-Term Treatment Facilities72-Hour facilities cannot keep an involuntary patient longer than 72 hours, excluding week-ends and holidaysShort-term facilities cannot keep an involuntary patient for longer than 180 days (extended short-term certification)

Application of Revised RulesApplication of Revised Rules

Hospitals must follow all the rules of 2 CCR 502-1

RTCs must follow all provisions of related rules

CMHCs must follow general and organization provisions and, for those individuals they are treating involuntarily, they must follow treatment provisions

Statutory ChangesStatutory Changes

One change in 27-10 Statute in 2004 – Addition of Licensed Addiction Counselors to Persons who may place a person under an emergency 72-hour hold (CRS 27-10-105)

Must have additional knowledge, judgment and skill in psychiatric or clinical mental health therapy, forensic psychotherapy, or evaluation of mental disorders

ReminderReminder

No designated facility has to accept a 72-hour hold

Emergency Department physicians may complete an evaluation and release the person

Only 72-hour holds ordered by a court cannot be refused

Persons Who May Persons Who May CompleteComplete a 72- a 72-Hour Mental Health Evaluation & Hour Mental Health Evaluation &

Certify for TreatmentCertify for Treatment

Licensed physician

Licensed psychologist

Actions Following 72-Hour Actions Following 72-Hour EvaluationEvaluation

Person is certified for treatment OR

Person signs in for voluntary treatment OR

Person is released

Placement FacilitiesPlacement Facilities

Designated facilities may enter into a written contract with another facility to provide mental health services on their behalfA placement facility may be a general or psychiatric hospital, community clinic and emergency clinic, convalescent center, nursing care facility, intermediate health care facility or residential facility, licensed residential child care facility or community mental health center or clinicDirect care supervision must be provided by a professional person

EnforcementEnforcement

Designated facilities shall be monitored for compliance annuallyPlacement facilities may be monitored at the discretion of the Department of Human Services (CDHS) / Division of Mental Health (DMH)CDHS/DMH will investigate all complaints related to the 27-10 Statute and Rules

WaiversWaivers

Specific requirements of the rules may be waived if the waiver would not adversely affect the health, safety and welfare of the patient, and

Either it would improve patient care or application of the particular rule would create a demonstrated financial hardship on the facility

Rights and AdvocacyRights and Advocacy

The facility must post the list of Patient Rights found in the RulesThe facility must give all 27-10 patients a written copy of the rights listed in the RulesIf the patient is unable to read the rights, they shall be read the rights in a language they understandChildren who are voluntarily receiving services under CRS 27-10-103 have additional rights they must be advised of – the right to object to hospitalization

Rights RestrictionsRights Restrictions

Some Patient Rights may be limited or denied for good cause by the professional person providing treatment

Only the following rights may be restricted:To receive and send sealed correspondenceTo have access to letter writing materialsTo use the telephoneTo have visitors (except the client’s attorney, religious representative or physician)To wear his/her own clothing

Rights RestrictionsRights Restrictions(continued)

The reason for denying the right must be documented in the clinical record and evaluated on an ongoing basis

Restrictions must be ordered and documented every 7 calendar days by a professional person

Secure Treatment FacilitiesSecure Treatment FacilitiesRights RestrictionsRights Restrictions

Secure Treatment Facility = Colorado Mental Health Institute at Pueblo (CMHIP) Institute for Forensic Psychiatry

A professional person may limit or deny rights for good cause based upon safety and security needs

Must have safety and security policies for each ward approved by CDHS

Secure Treatment FacilitiesSecure Treatment FacilitiesRights Restrictions Rights Restrictions (continued)

Must have policy and criteria for placement of persons into secure treatment facilities

Policies must be posted on each unit

Restrictions must be noted in clinical record and reviewed every 30 days

Secure Treatment FacilitiesSecure Treatment FacilitiesRights Restrictions Rights Restrictions (continued)

Cannot limit sending or receiving sealed mail, but may require patient open in presence of staff

Cannot limit right to see attorney, clergy or physician, but may require advance notice to unit

Department of Corrections (DOC) patients may have locked doors during sleeping hours

Secure Treatment FacilitiesSecure Treatment FacilitiesRights RestrictionsRights Restrictions (continued)

All other newly admitted patients may be on units with locked bedroom doors during sleeping hours for 60 daysAfter 60 days this security level has to be documented in individualized assessment and address imminent danger to self and/or othersSleeping hours cannot start before 9 PM, must end no later than 8 AM and not exceed 8 ½ hours

Secure Treatment FacilitiesSecure Treatment FacilitiesRights RestrictionsRights Restrictions (continued)

Patients have to have an effective means of calling for assistance and staff must react promptly

Staff must monitor through visual checks every 15 minutes during the time patients are locked in their rooms

Secure Treatment FacilitiesSecure Treatment FacilitiesRights RestrictionsRights Restrictions (continued)

Any person who meets the criteria for an imposition of legal disability or deprivation of a right (CRS 27-10-125) may have any right limited by a court

Information pertaining to denial of any right shall be made available to the patient and/or his/her attorney upon request

AdvocacyAdvocacy

Facilities must have a designated patient representative who is available

Patients must be given the name and telephone number of the patient rep – process must be in a written policy or documented in the clinical record

AdvocacyAdvocacy (continued)

The facility must post the name, location, phone number and responsibilities of the patient rep and include where to get a copy of the complaint process

Facility must have policies for handling complaints that include forwarding unresolved complaints to DMH

Employment of PatientsEmployment of Patients

Major changes in rules are:

Vocational programs do not have to pay minimum wage unless they are of economic benefit to the facility

Work assignments, consent form and hourly wages must be documented in clinical record

Quality ImprovementQuality Improvement

JCAHO or CMS accredited facilities may follow those guidelines

Otherwise QI Program must include:Clinical peer review processPhysician review of medical status every 6 monthsPolicies regarding minor and critical incidents

Quality ImprovementQuality Improvement (continued)

Written policy re how to identify trends and patterns in care, including involuntary medications and use of restraints/seclusionUsing findings in planning and decision making and staff and patient educational programsCriteria and process for clinical competence and credentialsReview of complaints and incorporation of data into decision making

Data RequirementsData Requirements

New requirements include:

Number of holds and demographicsNumber of short and long-term certifications and demographicsNumber of voluntary patients by age groups

Data RequirementsData Requirements (continued)

Number of patients receiving involuntary medsNumber of patients receiving restraints/seclusion Number of patients receiving ECTNumber of patients on ILD’S

Staff Training RequirementsStaff Training Requirements

New requirements

Facilities must develop a curriculum and schedule for training/competency

Facilities must develop policies and testing to assure competency

All staff must be trained and competent on the provisions of these rules and the statute

Staff who administer involuntary meds must be trained and competent on those rules

Staff Training RequirementsStaff Training Requirements (continued)

All direct care staff must be trained in recognition and response to common side effects of psychiatric meds and trained to respond to emergency medication reactions

Staff in non-JCAHO or CMS facilities who administer restraint/seclusion techniques must have annual training in lower level behavioral interventions and the seclusion/restraint rules

Staff must be trained on needs identified via QI Program

Staff Training RequirementsStaff Training Requirements (continued)

Administrative staff shall be trained and competent on alternative or representative medical decision making, i.e., advance directives, medical durable powers of attorney, proxy decision making and guardianships

Appropriate placement facilities staff must be trained and competent on the provisions in these rules and the statute

ConfidentialityConfidentiality

HIPAA guidelines must be followed

Limits information to family members previously authorized in statute (27-10-120.5)

Access remains for authorized representatives of CDHS

Confidentiality Confidentiality (continued)

Observed criminal behavior committed on the premises of a designated or placement facility or any criminal offense committed against any person while performing or receiving services is not considered privileged or confidential

Information that concerns child abuse/neglect or therapist abuse shall be reported to appropriate authorities

Treatment ProvisionsTreatment Provisions

CMHCs – Only follow for certified individuals

Hospitals and RTCs – Follow for all individuals

Medical/Dental CareMedical/Dental Care

Each patient must have access to emergency medical care and written plan for providing emergency care that includes physical exams within 24 hours of admission and availability of a physician or emergency medical facility at all times

Must be able to access emergency treatment within 1 hour

Medical/Dental Care Medical/Dental Care (continued)

Patients to be referred to appropriate specialists for further treatment/evaluation and the information will be documented in the record

Must be ongoing appraisals of the general health of each patient and documentation in clinical

No facility obligation to pay for such services – only to secure the services for each patient

Psychiatric MedicationsPsychiatric Medications

Informed consent required

Facility policy required regarding informed consent and documentation of such in record

Must follow advance directives to extent possible

Psychiatric meds may be administered by any professional authorized by law – not just MD

Psychiatric Medications Psychiatric Medications (continued)

Facility must have policies on:Administration of meds, errors and adverse reactionsDiscontinuance of medsDisposal of medsAcceptance of verbal, fax or electronically transmitted med orders

Psychiatric Medications Psychiatric Medications (continued)

Individual clinical records must contain following information:

Name and dosage of med Reason for medicationTime, date and dosage when administeredName and credentials of person administering medName of prescribing professionalNotation if emergency or court-ordered

Involuntary Psychiatric Involuntary Psychiatric MedicationsMedications

Rules DO NOT APPLY to refusal of non-psychiatric medications or medical emergencies

Persons must be on a hold or certification to be given emergency psychiatric meds

Involuntary Psychiatric Medications Involuntary Psychiatric Medications (continued)

Emergency is defined as:Imminent danger of hurting self or others (can rely on symptoms if predicted dangerousness in past)A recent overt act such as credible threat of bodily harm, assault or self-destructive behavior

Involuntary Psychiatric Medications Involuntary Psychiatric Medications (continued)

Under the Colorado Department of Public Health and Environment statute (CRS 26-20-104), only physicians can administer emergency medications

Involuntary Psychiatric Medications Involuntary Psychiatric Medications (continued)

If the emergency has abated because of meds but the MD deems it necessary to continue the meds to keep the emergency in abeyance, within 72 hours:

A written request must be submitted for a court hearingMust be documentation concurring consultation with another MD with their opinion regarding the emergency – if not obtained within 72 hours the medication must be stopped unless the medication must be titrated

Involuntary Psychiatric Medications Involuntary Psychiatric Medications (continued)

Cannot give emergency meds beyond 10 days without a continuation order from the court

Patient must be notified of right to contact attorney and this must be noted in record

Involuntary Psychiatric MedicationsInvoluntary Psychiatric Medications (continued)

Specific facts outlining behaviors supporting the use of emergency meds must be detailed in clinical record

Must be documented every 24 hours until a court order is obtained or the emergency is resolved or the patient accepts medications voluntarily

Involuntary Psychiatric MedicationsInvoluntary Psychiatric Medications (continued)

Patient must be offered emergency meds on a voluntary basis each time they are given – if patient consents and the MD determines they will likely continue to accept the meds, this must be documented in the record and emergency meds

If the patient refuses again and an emergency situation arises, emergency med procedures may be re-instituted (no time frame)

Non-Emergency Involuntary Non-Emergency Involuntary MedicationsMedications

If a person is certified and would benefit but will not consent to psychiatric meds, the facility may petition the court for involuntary meds if the following conditions are met:

Patient is incompetent to participate in the decisionMedication is necessary to prevent significant deterioration in mental condition or to prevent patient from causing harm to self or others

Non-Emergency Involuntary Non-Emergency Involuntary Medications Medications (continued)

Less intrusive appropriate treatment is not availablePatient’s need for medication is sufficiently compelling to override interest of patient in refusing treatmentPetition must specify recommended medicationsCannot administer until court order is received

Seclusion/ RestraintSeclusion/ Restraint

JCAHO and CMS approved facilities to follow those standards

Staff shall ensure no person will harm or harass a person who is secluded or restrained

Only certified persons can be restrained against their objection unless there is a signed informed consent form for using special procedures

SeclusionSeclusion

Use only for preventing imminent injury to self/others or eliminate prolonged, serious disruption to treatment environment

Any time a person is alone in a room and not allowed to leave, that is seclusion

An unlocked designated facility may place a person in seclusion to prevent departure if person is dangerous to self/others

Seclusion Seclusion (continued)

Must be based on current clinical assessment

Use only when other less restrictive methods fail

Can only be ordered by a professional person

RestraintRestraint

Cannot restrain single limb unless court ordered

Chemical spray is not permissible

Type of restraint must be appropriate to type of behavior, physical condition of person, age and effect restraint may have on the person

Restraint Restraint (continued)

Only if alternative interventions have failed unless they would be unsafe or ineffective

Only ordered by professional person

Does not apply to transportation of certain patients under criminal status

Informed Consent for Therapy or Informed Consent for Therapy or Treatments Using Special Treatments Using Special

ProceduresProcedures

Written consent must be obtained for ECT and/or behavior modifications using physically painful, aversive or noxious stimuli

Guardians cannot consent to ECT

ECT cannot be administered to anyone under age 16

ECT requires use of the DMH consent form

Informed Consent for Therapy or Informed Consent for Therapy or Treatments Using Special Treatments Using Special

Procedures Procedures (continued)

ECT requires use of the DMH consent form

Can be administered under a court order if consent is not obtained

Can be administered under emergency conditions if the life of the person is in imminent danger because of the person’s condition

Continuity of Care and Continuity of Care and Transfer of CareTransfer of Care

Facilities must have written policy including:

Access to all necessary care and services within the facilityCoordination with previous care providersCoordination with family members, guardians and other appropriate persons reflecting patient’s culture and ethnicity

Continuity of Care and Continuity of Care and Transfer of CareTransfer of Care (continued)

Facilitation of access to proper medical careTransfer to another facility when adequate arrangements are made24 hour notice of transfer to persons under certification unless it is an emergencyNotification of transfer to 2 persons as indicated by patient

TransportationTransportation

Assessment for dangerousness and potential for escape is required

Can be transported (no restraints) by ambulance, care van, private vehicle if clinically appropriate and safe

TransportationTransportation (continued)

If dangerous to self/others or escape risk, may request transportation by Sheriff:

Must include recommendation for use of restraint Recommendations include consideration of age, physical abilities, culture and medical status Sheriff is not required to follow these rules

Outpatient CertificationOutpatient Certification

Must be certified inpatient first

Must continue to meet requirements for certification

Must have recent physical exam

Outpatient CertificationOutpatient Certification (continued)

Arrangements must be made for access to:

Case managementMedical managementEssential food, clothing, shelterMedical care and emergency dental care

Outpatient Certification Outpatient Certification (continued)

Service plan must reflect those arrangements and reflect outpatient certification status

If patient fails to comply with service plan, patient may be taken into custody and assessed for current clinical needs

Outpatient Certification Outpatient Certification (continued)

Cannot force medication on person unless it is an emergency or it is court-ordered

If patient is not detained, facility must assist patient in returning to a reasonable location

Treatment RecordsTreatment Records

Electronic records are permitted, need to capture signatures as required

Entries must be signed, dated with degree and title

Must be kept in secure location

Treatment Records Treatment Records (continued)

Facilities must have policy that keeps records for:

Outpatient – 7 years after discharge or 7 years beyond reaching age 18 after discharge

Inpatient – 10 years after discharge or 10 years beyond reaching age 18 after discharge

Treatment Records Treatment Records (continued)

Records must include:

Written assessment informationIndividualized, integrated comprehensive service plan (except for persons being evaluated under CRS 16-8-103.7)Treatment progress documentationDischarge planning information Discharge summary

New Assessment Data New Assessment Data RequirementsRequirements

Cultural factors relating to age, ethnicity, linguistic/communication needs, gender, sexual orientation, relational roles and spiritual beliefsIssues specific to older adults such as hearing loss, strength, mobility and other aging issues Issues specific to children/adolescents such as growth and development, daily activities, educational activities and legal guardians

New Assessment Data New Assessment Data RequirementsRequirements (continued)

History of use of restraint, emergency meds, ECT and their impact on patient and patient’s preference if emergency procedures are necessary

Information on advance directives, medical proxies, etc.

New Service Planning New Service Planning RequirementsRequirements

Written to promote patient’s highest possible level of independent functioning

Written in a manner that is understandable to the patient

New Service Planning New Service Planning Requirements Requirements (continued)

Planning done in a manner appropriate to the cultural factors of the patient

When under age 18 patient will participate in planning and sign and be offered a copy

New Requirements for New Requirements for Treatment Progress Treatment Progress

DocumentationDocumentation

Ongoing assessment information

Any serious injury of or by the patient and the circumstances and outcome

Use or non-use of advance directives

New Requirements for New Requirements for Discharge SummaryDischarge Summary

Advance Directives

Patient’s attitude toward discharge

Contact InformationContact Information

For information on statute, rules, DMH monitoring, additional copies of this training or a copy of the training CD, etc., please contact

Lori Banks, 303-866-7424, or lori.banks@state.co.usOr your facility’s DMH liaison