C.M.R. 14, 193, ch. 6, INPATIENT SERVICE STANDARDS
These standards, in addition to the core standards, are applied to agencies providing inpatient services.
Access
IN.1 The agency has policies and procedures governing the establishment of a waiting list for non-emergency admissions, that minimally includes the following: prioritizing clients, selecting clients from the waiting list, and referring clients to other providers.
Assessment
IN.2 A comprehensive assessment is conducted by an individual chosen or agreed to by client, with the client's participation, within 10 working days of the client's admission.
IN. 2. A The comprehensive assessment minimally addresses the following:
IN. 2. A.1 the client's strengths and weaknesses;
IN. 2. A.2 the client's perception of his or her needs, including housing and financial assistance;
IN. 2. A.3 the family/guardian's input and perception of the client's needs when appropriate, and with the client's consent;
IN. 2. A.4 a personal, family, and social history;
IN. 2. A.5 emotional and psychological strengths and needs;
IN. 2. A.6 a psychiatric status and history, including, subject to the client's consent, records of previous psychiatric hospitalizations and services received by the client in the community, including crisis services;
IN. 2. A.7 a physical health status and history, including current prescription and over-the-counter medication use;
IN. 2. A.8 past and current drug/alcohol use;
IN. 2. A.9 a developmental history;
IN. 2. A.10 possible sources of assistance and support in meeting the needs expressed by the client or legally responsible party, including state and federal entitlement programs;
IN. 2. A.11 physical and environmental barriers that may impede the client and family's ability to obtain services;
IN. 2. A.12 history of physical and/or sexual abuse;
IN. 2. A.13 the vocational, educational, social, living, leisure/recreation and medical domains;
IN. 2. A.14 the signature of the person who performed the assessment.
Interpretive Guideline for IN.2.A.1 thru IN.2.A.14
The Division of Licensing recognizes that in some cases no all of the information requested in these standards will be able to be obtained. The Division also recognizes that the level of detail required will vary given a variety of factors (the client's level of cooperation, the integrity of information sources, the length of services or treatment, the condition being addressed. the practitioner's training, etc.). Although the Division will attempt to be sensitive to these factors and flexible in surveying this area, the agency should assure that assessments that do not address all these standards have accompanying documentation that justifies abbreviated or absent information.
IN. 2. B. The agency will establish policies and procedures establishing criteria for the performance of the following assessments:
IN. 2. B.1 a nutritional assessment;
IN. 2. B.2 a cognitive functioning assessment:
Interpretive Guideline for IN.2.B.2
The client's cognitive functioning assessment should include assessment of the following functions: problem solving, decision making, organization, self-direction, system negotiation skills, concentration, and abstract reasoning. For individuals over 60 years of age, this assessment should also include memory, language, orientation, and visuo-spatial abilities.
IN. 2. B.3 an assessment of the client's capacity to make reasoned decisions;
IN. 2. B.4 a neurological assessment.
Interpretive Guideline for IN.2.B thru IN.2.B.4
These assessments do not necessarily have to be performed in the agency or by agency staff. the intent of these standards are assure that the agency has mechanisms by which to evaluate the need for these assessments and to perform or refer for assessment those clients whose symptomatology suggests the need for these assessments.
IN. 2. C The assessment(s) shall be obtained from the client, legally responsible party, community service agencies, and to the extent possible, from other individuals in the community as authorized by the client or legally responsible party.
IN. 2. C.1. In instances in which the client receives community support services and/or has an Individualized Support Plan, the agency will, subject to the client's consent, attempt to coordinate the assessment and subsequent treatment planning with the community support provider.
IN. 2. C.1.a. Services provided to these clients will be consistent with the targets and objectives of the Individualized Support Plan.
IN. 2. D The client record contains a summary evaluation of the data collected in the comprehensive assessment.
IN.3 The agency has a documented policy and procedure on updating assessments that assures that assessments are current and in no case exceed annual updates.
Treatment Planning
IN.4 There is documented evidence that the treatment planning and revision process involves the client, legally responsible party, and other representatives and professionals whom the client designates.
IN.5 A treatment plan is developed for each client, with the client's consent, and within 3 working days of admission.
IN. 5. A. The treatment plan minimally contains the following:
Interpretive Guideline for IN.4
The client and legally designated guardian shall be fully and actively involved in the development or revision or the service plan, if possible. If the client consents, the client's representative, family members or significant others shall be included in the development and revision of the service plan, unless contraindicated. When these individuals do not attend, their absence is noted. Each agency shall document good faith efforts, including 24 hour notice of any service planning meeting, to involve guardians, representatives or legally responsible parents.
IN. 5. A.1 problem statements;
IN. 5. A.2 short- and long-range goals based upon client needs with a projection of when such goals will be attained;
IN. 5. A.3 objectives stated in terms which allow objective measurement of progress;
IN. 5. A.4 multidisciplinary input and specification of treatment responsibilities;
IN. 5. A.5 client input and signature;
IN. 5. A.6 signatures of all people participating;
IN. 5. A.7 the methods and frequency of treatment, rehabilitation, support;
IN. 5. A.8 a description of any physical handicap and any accommodations necessary to provide the same or equal services and benefits as those afforded non-disabled individuals; and
IN. 5. A.9 criteria for discharge or release to a less restrictive setting.
IN. 5. B. Justification for not addressing problems identified in the assessments is documented in the client record.
IN.6 The treatment plan is designed so that the client's progress towards treatment plan goals can be monitored and evaluated.
IN.7 The treatment plan is reviewed at major decision points in each client's treatment course, upon client request, & no less frequently than every 30 days.
Standards
Interpretive Guideline for IN.5.B
The intent of this standard is to assure that the clinical staff considers all of the client's identified problems in formulating the service plan. Problems that are not reflected on the service plan should have accompanying documentation identifying the rationale for not addressing the problems at this time. This documentation can take many forms including progress notes, service plan narratives, etc.
Interpretive Guideline for IN.6
Service plans should have measurable goals and some means for reflecting, when, or to what degree, a goal has been attained. The organization should also have mechanisms that document monitoring and evaluation or client goals, e.g., quality assessment, treatment plan review documents.
Interpretive Guideline for IN.7
Major decision points may include, but are not necessarily limited to the following: when there is a change in the client's condition, when a service appears not to benefit the client, when the client is under- or over-utilizing services.
IN.8 Unmet service needs are documented in the treatment plan.
Interpretive Guideline for IN.8
If at the time of the service planning meeting, team members know on the basis of reliable information that the needed services are unavailable, they shall note them as "unmet service needs" on the service plan and develop an interim plan based upon available services that meet, as nearly as possible, the actual needs of the client. The organization should also document notification of the organization's leadership and the Commissioner regarding the unavailability of service that is causing the unmet service need.
IN.9 The agency has a policy and procedure for providing clients with a copy of their treatment plan within one week following its formulation, review or revision and notification of client recourse should they disagree with any aspect of the plan.
IN. 9. A. The agency will not fail to provide a copy of the client's treatment plan and/or notify them of recourse should they disagree.
IN.10 The hospital has a policy and procedure for developing hospital treatment and discharge plans in coordination with Individualized Support Plans for clients whose admissions are funded by the Department of Mental Health and Mental Retardation.
Discharge Planning
IN.11 Each client record contains documentation of current discharge or termination planning as required by IN.5.
IN. 11. A. Each discharge summary minimally addresses, but need not be limited to the following:
IN. 11. A.1 the reasons for termination of service;
IN. 11. A.2 the final assessment, including the general observations and significant findings of the client's condition initially, while services were being provided and at discharge;
IN. 11. A.3 the course and progress of the client with regard to each identified problem;
IN. 11. A.4 the recommendations and arrangements for further continued service needs.
IN.12 A discharge summary is entered in the client record within 15 days of discharge and includes the client's course of treatment and ongoing needs at discharge.
IN.13 The agency documents the client's stated preference for living situation in the discharge plan.
Interpretive Guideline for IN.13
When the client's preference for living situation cannot be accommodated, the reasons are documented.
IN.14 Applicants who are not eligible for services will be referred to appropriate services, if required, available and desired.
IN. 14. A The agency has a policy and procedure on referral and/or transfers of individuals deemed inappropriate for services offered by the agency that minimally includes communicating the rationale for the referral/transfer to the applicant and providing them with a list of alternative service providers and advocacy services.
IN. 14. B. The agency provides and documents other assistance as required to assist the individual to obtain/access the services to which they are referring him/her.
Health
IN.15 If food services are provided, the facilities for the preparation and serving of food shall be inspected and approved by the Department of Human Services.
IN. 15. A. If food is either prepared or served at the facility, then the agency shall either a DHS Eating Establishment license or show written evidence from DHS indicating that they need no such license.
IN. 15. B. When the agency requires a DHS license, the agency's Eating Establishment license is current.
IN.16 The agency shall have methods for obtaining on- or off-site medical services for all clients.
IN. 16. A. The agency defines in policy and procedure those medical services delivered on-site. For those medical services not provided on-site, letters of agreement and/or procedures for accessing medical service provider(s) are in effect.
Physical Plant
IN.17 A secure and readily accessible storage area of adequate size is available to accommodate client belongings.
IN. 17. A. The agency has a policy and procedure related to what personal belongings may be brought to the agency.
Inpatient Services
IN.18 Inpatient agencies meet all other mandatory regulatory standards applicable to their organization, e.g., Medicare, Medicaid, DHS Hospital Licensure.
IN.19 Clients who request community support services while in an inpatient psychiatric facility are assigned a community support worker within two working days.
IN. 19. A. The clients request for community support services is documented in the client record and minimally includes the date and time of the request
IN. 19. B. The agency documents contacting a community support agency within one working day to allow the community support agency adequate time to assign a community support worker.
IN. 19. C. The requesting client's record reflects the date and time when a community support worker was assigned and the community support worker's name.
IN. 19. D. There is evidence that the community support worker has participated in treatment and discharge planning meetings to coordinate service planning.
IN.20 For clients with prior inpatient hospitalizations, the admitting hospital requests the client's consent to release previous records, obtains them in a timely fashion, and considers them in treatment and discharge planning.
IN. 20. A. Upon learning that a client has had a prior psychiatric hospitalization, the individual coordinating the client's treatment shall request the client's consent to the release of records.
IN. 20. B. Within two days of consent to release, the individual coordinating the client's treatment, sends for copies of the records.
IN. 20. C. Where prior records are obtained, there is evidence in the treatment and discharge planning that the team considered additional information from records of previous hospitalizations.
IN.21 Each inpatient service minimally provides the following treatment services: individual, group, and family therapy, medication evaluation and administration.
IN. 21. A. The agency can document that each client is offered individual counseling with a psychiatrist, psychologist, clinical social worker, psychiatric nurse, or a psychiatric physician extender for sessions totaling no less than 3 hours per week.
IN. 21. B. Each client is evaluated for the need for medication.
C.M.R. 14, 193, ch. 6, INPATIENT SERVICE STANDARDS