Rule 24-2-19.6 - Crisis Residential Services - Crisis Residential UnitsA. Crisis Residential Services are short-term residential treatment services provided in a Crisis Residential Unit (sometimes referred to as a Crisis Stabilization Unit) which provide psychiatric supervision, nursing services, structured therapeutic activities, and intensive psychotherapy (person, family and/or group) to people who are experiencing a period of acute psychiatric distress which severely impairs their ability to cope with normal life circumstances. Crisis Residential Services are provided 24 hours a day, seven (7) days a week in a secure environment. Services are provided by medical personnel and mental health professionals, as per their scopes of practice, as well as support staff. Crisis Residential Services are designed to reduce a person's acute mental health symptoms and to prevent the need for a higher level of care, including long-term inpatient psychiatric hospitalization. Crisis Residential Services content may vary based on each person's needs but must include close observation/supervision and intensive support with a focus on the reduction/elimination of acute symptoms. Crisis Residential Services must comply with all applicable Health, Environment, and Safety rules in Chapter 13.
B. Crisis Residential Services may be provided to people experiencing a mental health crisis.C. Children/youth receiving Crisis Residential Services must be a minimum of six (6) years of age. Children/youth up to age 18 cannot be served in the same facility as adults. DMH may require a higher minimum age to increase accessibility for other youth and/or to improve the therapeutic environment. Requests to serve a person whose age falls outside of the Crisis Residential Unit's stipulated population must be submitted to DMH for approval prior to admission.D. Crisis Residential Services must be designed to accept admissions (voluntary and involuntary) 24 hours per day, seven (7) days per week. Admission denial must be in accordance with Crisis Residential Units denial criteria and guidelines, as may be issued by DMH.E. Crisis Residential Services must provide the following within 24 hours of admission to determine the need for Crisis Residential Services and to rule out the presence of mental symptoms that are judged to be the direct physiological consequence of a general medical condition and/or illicit substance/medication use: 3. Drug toxicology screening; and4. Psychiatric consultation.F. Crisis Residential Services must consist of:1. Evaluation, to include, but is not limited to, treatment plan development and review, Nursing Assessment, and Medication Management.3. Substance use counseling.4. Individual, Group and Family Therapy.5. Targeted Case Management and/or Community Support Services.7. Therapeutic Activities (i.e., recreational, psycho-educational, social/interpersonal).8. Peer Bridger Services.9. Skills building programming which focuses on a range of topics including, but not limited to: (b) Symptom reduction and management.(c) Appropriate social behavior.(d) Improving peer interactions.(e) Improving stress tolerance.(f) Development of coping skills.(h) Mental health education.G. Direct services (i.e., therapy, recreational, psychoeducation, social/interpersonal activities, educational activities [for children/youth]) must at a minimum be:1. Provided seven (7) days per week.2. Provided five (5) hours per day.H. Prior to discharge from Crisis Residential Services, an appointment must be made for the person to begin or continue services from the CMHC/LMHA or other mental health provider.I. Crisis Residential Services must have a full-time on-site director, as defined by DMH.J. Crisis Residential Services must have a full-time on-site employee with either: (1) a professional license, or(2) a DMH credential as a Mental Health Therapist.K. Crisis Residential Services must maintain at least one (1) direct service personnel or Certified Peer Support Specialist Professional (CPSSP) to four (4) people ratio 24 hours per day, seven (7) days per week. A RN must be on-site during all shifts and may be counted in the required staffing ratio.L. DMH only allows seclusion to be used in Crisis Residential Services with people over the age of 18.M. If a service location uses a room for seclusion(s), the service location must be inspected by DMH and written approval for the use of such room obtained from the DMH CRC prior to its use for seclusion. A room must meet the following minimum specifications in order to be considered for approval by DMH for use in seclusion: 1. Be constructed and located to allow visual and auditory supervision of the person. Visual and auditory supervision means that the person can be seen and heard the entire time of seclusion, with no break in this level of monitoring;2. Have room dimensions of at least 48 square feet; and3. Be ligature/harm resistant and have break resistant glass (if any is utilized).N. Crisis Residential Unit providers utilizing seclusion must establish and implement written policies and procedures specifying appropriate use of seclusion. The policies and procedures must include, at a minimum:1. A clear definition of seclusion and the appropriate conditions and documentation associated with its use. Seclusion is defined as a behavioral control technique involving locked isolation. This does not include a time-out.2. A requirement that seclusion is used only in emergencies to protect the person from injuring self or others. "Emergency," in this context, is defined as a situation where the person's behavior is violent or aggressive and where the behavior presents an immediate danger to the safety of the person being served, other people served by the service location, employees, or others.3. A requirement that seclusion is used only when all other less restrictive alternatives have been determined to be ineffective to protect the person or others from harm and a requirement of documentation in the person's record.4. A requirement that seclusion is used only in accordance with the order of a physician or other licensed independent practitioner, as permitted by state licensure rules/regulations governing the scope of practice of the independent practitioner and the provider. This order must be documented in the person's record. The following requirements must be addressed in the policies and procedures regarding the use and implementation of seclusion (as applicable) and be documented in the person's record: (a) Orders for the use of seclusion must never be written as a standing order or on an as needed basis (i.e., PRN).(b) The treating physician or other licensed independent practitioner, as appropriate to scope of practice, must be consulted as soon as possible if the seclusion is not ordered by the person's treating physician.(c) A physician or other licensed independent practitioner must see and evaluate the need for seclusion within one (1) hour after the initiation of seclusion.(d) Each written order for seclusion must be limited to four (4) hours. After the original order expires, a physician or licensed independent practitioner (as permitted by state licensure rules/regulations governing scope of practice of the independent practitioner and the provider) must see and assess the person in seclusion before issuing a new order.(e) Seclusion must be in accordance with a written modification to the Individual Service Plan of the person being served.(f) Seclusion must be implemented in the least restrictive manner possible.(g) Seclusion must be in accordance with safe, appropriate techniques. (h) Seclusion must be ended at the earliest possible time.(i) People may request calming isolation without a locked door.5. Requirements that seclusion is not used as a form of punishment, coercion, or for the employee's convenience.6. Requirements that employees trained in the proper and safe use of seclusion record observation of the person at intervals of 15 minutes or less and that they record the observation in a behavior management log that is maintained in the record of the person being served.7. Requirements that the original authorization order of the seclusion may only be renewed for up to a total of 24 hours by a licensed physician or licensed independent practitioner, if less restrictive measures have failed.O. Time-out, as defined in the glossary, may be utilized for people under the age of 18. While the person is in time-out, staff must have visual and auditory supervision of the person; visual and auditory supervision means that the person can be seen and heard the entire time with no break in this level of monitoring. Any room used for time-out must be ligature/harm resistant and have break resistant glass (if any is utilized). Additionally, the same conditions for seclusion outlined above (stipulations concerning policies/procedures, implementation, and the practitioner's order) apply to time-out administration. Additionally, the consecutive amount of time a person spends in time-out must be ordered by the prescribing licensed practitioner, as their scope of practice allows.P. Prescribing licensed practitioners may prescribe adults oral medications to treat symptoms of mental illness consistent with standards of clinical practice, including prescribing oral medications to be given on an "as needed" basis. In emergencies, such as when a person's condition presents an imminent, significant risk of physical harm to the person or others and the person refuses to take oral medications, prescribers may prescribe appropriate intramuscular psychotropic medications to be given to the person without their consent, also consistent with standards of clinical practice. Non-emergent forced medications shall not be prescribed to persons admitted to a Crisis Residential Unit. The type of medication administration outlined in this rule is not considered by DMH to be a chemical restraint, as defined in the glossary.Q. The maximum capacity for which DMH will certify a Crisis Residential Service Unit is 16.