Ala. Admin. Code r. 420-5-7-.26

Current through Register Vol. 43, No. 1, October 31, 2024

Section 420-5-7-.26 - Psychiatric Hospitals

(1) A psychiatric hospital, or an inpatient psychiatric program within a hospital that is not a psychiatric hospital, shall be primarily engaged in providing, by or under the supervision of a doctor of medicine or osteopathy, psychiatric services for the diagnosis and treatment of mentally ill persons.

(2) Special medical record requirements.

(a) The medical records maintained by a psychiatric hospital shall permit determination of the degree and intensity of the treatment provided to individuals who are furnished services in the institution.

(b) Development of assessment and diagnostic data. Medical records shall stress the psychiatric components of the record, including history of findings and treatment provided for the psychiatric condition for which the patient is hospitalized.

1. The identification data shall include the circumstances under which the patient was admitted and/or is being treated - i.e., voluntary, involuntary, committed by court, evaluation and recertification.

2. A provisional or admitting diagnosis shall be made on every patient at the time of admission, and shall include the diagnoses of intercurrent diseases as well as the psychiatric diagnoses.

3. The reasons for admission shall be clearly documented as stated by the patient and/or others significantly involved.

4. The social service records, including reports of interviews with patients, family members, and others, shall provide an assessment of home plans and family attitudes, and community resource contacts as well as a social history.

5. When indicated, a complete neurological examination shall be recorded at the time of the admission physical examination.

(c) Psychiatric evaluation. Each patient shall receive a psychiatric evaluation that shall:

1. Be completed within 60 hours of admission;

2. Include a medical history;

3. Contain a record of mental status;

4. Note the onset of illness and the circumstances leading to admission;

5. Describe attitudes and behavior;

6. Estimate intellectual functioning, memory functioning, and orientation; and

7. Include an inventory of the patient's assets in descriptive, not interpretative, fashion.

(d) Treatment plan.

1. Each patient shall have an individual comprehensive treatment plan that shall be based on an inventory of the patient's strengths and disabilities.

(i) The written plan shall include:

(I) A substantiated diagnosis;

(II) Short-term and long-range goals;

(III) The specific treatment modalities utilized;

(IV) The responsibilities of each member of the treatment team; and

(V) Adequate documentation to justify the diagnosis and the treatment and rehabilitation activities carried out.

(ii) The treatment received by the patient shall be documented in such a way to assure that all active therapeutic efforts are included.

(e) Recording progress. Progress notes shall be recorded by the doctor of medicine or osteopathy responsible for the care of the patient, nurse, social worker and, when appropriate, others significantly involved in active treatment modalities. The frequency of progress notes is determined by the condition of the patient but shall be recorded at least weekly for the first two months and at least once a month thereafter and shall contain recommendations for revisions in the treatment plan as indicated as well as precise assessment of the patient's progress in accordance with the original or revised treatment plan.

(f) Discharge planning and discharge summary. The record of each patient who has been discharged shall have a discharge summary that includes a recapitulation of the patient's hospitalization and recommendations from appropriate services concerning follow-up or aftercare as well as a brief summary of the patient's condition on discharge.

(3) Special staff requirements.

(a) The hospital shall have adequate numbers of qualified professional and supportive staff to evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures, and engage in discharge planning.

(b) Personnel. The hospital shall employ or undertake to provide adequate numbers of qualified professional, technical, and consultative personnel to:

1. Evaluate patients;

2. Formulate written individualized, comprehensive treatment plans;

3. Provide active treatment measures; and

4. Engage in discharge planning.

(c) Director of inpatient psychiatric services; medical staff. Inpatient psychiatric services shall be under the supervision of a clinical director, service chief, or equivalent, which is qualified to provide the leadership required for an intensive treatment program. The number and qualifications of doctors of medicine and osteopathy shall be adequate to provide essential psychiatric services.

1. The clinical director, service chief, or equivalent, shall meet the training and experience requirements for examination by the American Board of Psychiatry and Neurology or the American Osteopathic Board of Neurology and Psychiatry.

2. The director shall monitor and evaluate the quality and appropriateness of services and treatment provided by the medical staff.

(d) Availability of medical personnel. Doctors of medicine or osteopathy and other appropriate professional personnel shall be available to provide necessary medical and surgical diagnostic and treatment services. If medical and surgical diagnostic and treatment services are not available within the institution, the institution shall have an agreement with an outside source of these services to ensure that they are immediately available or a satisfactory agreement shall be established for transferring patients to a General Acute Care Hospital.

(e) Nursing services. The hospital shall have a qualified director of psychiatric nursing services. In addition to the director of nursing, there shall be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide nursing care necessary under each patient's active treatment program and to maintain progress notes on each patient.

1. The director of psychiatric nursing services shall be a registered nurse with an active, unencumbered Alabama license who has a master's degree in psychiatric or mental health nursing, or its equivalent, from a school of nursing accredited by the Commission on Collegiate Nursing Education, the National League for Nursing, or be qualified by education and experience in the care of the mentally ill. The director shall demonstrate competence to participate in interdisciplinary formulation of individual treatment plans; to give skilled nursing care and therapy; and to direct, monitor, and evaluate the nursing care furnished.

2. The staffing pattern shall insure the availability of a registered professional nurse 24 hours each day. There shall be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each patient's active treatment program.

(f) Psychological services. The hospital shall provide or have available psychological services to meet the needs of the patients.

(g) Social services. There shall be a director of social services who monitors and evaluates the quality and appropriateness of social services furnished. The services shall be furnished in accordance with accepted standards of practice and established policies and procedures.

1. The director of the social work department or service shall have a master's degree from an accredited school of social work or shall be qualified by education and experience in the social services needs of the mentally ill. If the director does not hold a masters degree in social work, at least one staff member shall have this qualification.

2. Social service staff responsibilities shall include, but are not limited to, participating in discharge planning, arranging for follow-up care, and developing mechanisms for exchange of appropriate, information with sources outside the hospital.

(h) Therapeutic activities. The hospital shall provide a therapeutic activities program.

1. The program shall be appropriate to the needs and interests of patients and be directed toward restoring and maintaining optimal levels of physical and psychosocial functioning.

2. The number of qualified therapists, support personnel, and consultants shall be adequate to provide comprehensive therapeutic activities consistent with each patient's active treatment program.

Ala. Admin. Code r. 420-5-7-.26

New Rule: Filed November 18, 1994; effective December 23, 1994. Repealed and New Rule: Filed August 24, 2012; effective September 28, 2012.

Author: W.T. Geary, Jr., M.D., Carter Sims

Statutory Authority:Code of Ala. 1975, §§ 22-21-20, et seq.