Ala. Admin. Code r. 560-X-41-.09

Current through Register Vol. 43, No. 02, November 27, 2024

Section 560-X-41-.09 - Inpatient Review Criteria

(1) All patients seeking admission to a psychiatric hospital must require psychiatric services that can only be provided on an inpatient basis. These psychiatric services must involve implementation of a professionally developed and supervised individualized plan of care.

(2) The inpatient admission criteria utilized by Medicaid require a documented need for inpatient psychiatric services. A patient seeking admission to a psychiatric hospital must meet at least one of the following criteria:

(a) Inappropriate performance of activities of daily living as evidenced by:

1. inappropriate hygiene or grooming;

2. psychomotor agitation or retardation;

3. severe disturbances in appetite or sleep.

(b) Impaired safety as evidenced by:

1. inappropriate, depressed, agitated mood;

2. suicidal ideation, threat, gesture, or attempt;

3. substance abuse;

4. inappropriate behavior requiring intervention;

5. noncompliance with medication or treatment regimen.

(c) Impaired thought process as evidenced by:

1. verbal or behavioral disorganization;

2. thought disorganization, hallucinations, paranoid ideation, phobias, etc.;

3. impaired reality testing;

4. bizarre or delusional behavior;

5. disorientation or memory impairment to the degree of endangering patient's welfare;

6. severe withdrawal or catatonia.

(d) Inpatient treatment required due to:

1. failure of outpatient therapy;

2. failure of social or family functioning which places patient at increased risk;

3. treatment in a less restrictive environment not feasible due to patient's behavior;

4. need for intensive inpatient evaluation;

5. need for 24-hour skilled and intensive observation;

6. need for evaluation of drug tolerance;

7. recurrence of psychosis not responding to outpatient treatment;

8. toxic effects from therapeutic psychotropic drugs;

9. blood or urine positive for barbiturates, narcotics, alcohol, or other toxic agents in a patient displaying physical symptoms.

(3) All patients receiving inpatient psychiatric services must be involved with active treatment. "Active treatment" is defined as implementation of a professionally developed and supervised individualized plan of care. At least one professional member of the interdisciplinary treatment team must be involved in providing active intervention for an unresolved or active problem as noted on the plan of care. Appropriate members of the treatment team must document active intervention when a patient's placement options are unresolved.

(4) The continued stay criteria utilized by Medicaid require a documented need for continuation of inpatient psychiatric services. A patient seeking continued stay in a psychiatric hospital must meet at least one of the following criteria:

(a) Active intervention by at least one member of the interdisciplinary treatment team for an unresolved problem on the patient's treatment plan;

(b) Medication changes, administration of PRN medications, medications in liquid form (for suspected noncompliance);

(c) Episodes of inappropriate behavior requiring intervention;

(d) Noncompliance with treatment regimen;

(e) Suicidal ideation, threat, gesture, or attempt;

(f) No availability of placement options appropriate to patient's needs.

Author: Lynn Sharp, Associate Director, Policy Development Unit

Ala. Admin. Code r. 560-X-41-.09

Rule effective September 13, 1989. Repealed and New Rule: Filed August 7, 2000; effective September 11, 2000. Amended: Filed November 8, 2001; effective December 13, 2001.

Statutory Authority: State Plan, Attachments 3.1-A, p. 7.16 and 4.19-B, p. 8; 42 CFR, §441, Subpart D.