Rule 24-2-19.6 - Crisis Residential Services - Crisis Residential UnitsA. Crisis Residential Services are time-limited residential treatment services provided in a Crisis Residential Unit which provides psychiatric supervision, nursing services, structured therapeutic activities and intensive psychotherapy (individual, 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 must be designed to prevent civil commitment and/or longer term inpatient psychiatric hospitalization by addressing acute symptoms, distress and further decomposition. 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.B. Crisis Residential Services may be provided to children/youth with serious emotional/behavioral disturbance or adults with a serious and persistent mental illness.C. Children/youth receiving Crisis Residential Services must be a minimum of six (6) years of age. Children/youth up to age eighteen (18) cannot be served in the same facility as adults. DMH may require a higher minimum age in order to increase accessibility for other youth and/or to improve the therapeutic environment.D. Crisis Residential Services must be designed to accept admissions (voluntary and involuntary) twenty-four (24) hours per day, seven (7) days per week.E. Crisis Residential Services must provide the following within twenty-four (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; and,4. Psychiatric consultation. F. Crisis Residential Services must consist of:3. Supportive counseling;4. Substance use counseling;5. Individual, Group and Family Therapy;6. Targeted Case Management and/or Community Support Services;7. Family Education; and,8. Therapeutic Activities (i.e., recreational, psycho-educational, social/interpersonal).G. Direct services (i.e., supportive counseling, therapy, recreational, psycho-education, social/interpersonal activities) can be provided seven (7) days per week but must at a minimum be: 1. Provided five (5) days per week;2. Provided five (5) hours per day; and,3. Provided two (2) hours per day for children/youth if attending school.H. A daily schedule must be maintained and posted in a prominent location. The schedule must show the entire day (24 hours).I. Crisis Residential Services must also provide adequate nursing and psychiatric services to all people served. At a minimum, these services must be provided every seven (7) days (or more often if clinically indicated).J. An initial individual therapy session must be provided to each person admitted within the first seventy-two (72) hours of his/her admission.K. Prior to discharge from Crisis Residential Services, an appointment must be made for the person to begin or continue services from the local Community Mental Health Center or other mental health provider. L. Crisis Residential Services must have a full-time (forty [40] hours per week) on-site director.M. Crisis Residential Services must have a full-time (forty [40] hours per week) on-site Mental Health Therapist.N. Crisis Residential Services must maintain at least one (1) direct service personnel to four (4) people ratio twenty-four (24) hours per day, seven (7) days per week. A registered nurse must be on-site during all shifts and may be counted in the required staffing ratio.O. All Crisis Residential Services personnel must successfully complete training and hold certification in a nationally recognized or DMH approved program for managing aggressive or risk-to-self behavior.P. DMH only allows seclusion to be used in Crisis Residential Services with people over the age of eighteen (18). Time-out may be utilized for people under the age of eighteen (18).Q. 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 Review Committee 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;2. Have room dimensions of at least forty-eight (48) square feet; and,3. Be suicide resistant and have break resistant glass (if any is utilized in the room or door to the room).R. 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 him/herself or others. "Emergency" is defined as a situation where the person's behavior is violent or aggressive and where the behavior presents an immediate and serious 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 (that is, PRN).(b) The treating physician 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.5. Requirements that seclusion is not used as a form of punishment, coercion, or for the employee's convenience. 6. Requirements that all employees who have direct contact with people being served must have ongoing education and training in the proper, safe use of seclusion.7. Requirements that trained employees (as described above) observe the person and record such observation at intervals of fifteen (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.8. Requirements that the original authorization order of the seclusion may only be renewed for up to a total of twenty-four (24) hours by a licensed physician or licensed independent practitioner, if less restrictive measures have failed. S. DMH states, "Providers are prohibited from the use of chemical restraints." A chemical restraint incapacitates a person rendering them unable to function as a result of the medication. However, a therapeutic agent may be used to treat behavioral symptoms during a crisis. The therapeutic agent can be used to calm agitation, to help the person concentrate, and make him/her more accessible to interpersonal intervention. Regardless of indication, medication administration during a crisis must be preceded by an appropriate clinical assessment, and documentation of the assessment must be maintained in the person's record.T. An "as needed," prescription for a therapeutic agent at admission for all people is prohibited. If the clinical assessment at admission indicates the need for a therapeutic agent then it may be administered. A verbal approval for the use of a therapeutic agent by the psychiatrist or psychiatric nurse practitioner must be documented in the person's record as soon as possible. U. Smoking is not permitted within ten (10) feet of the entrance of a Crisis Residential Unit.V. All Crisis Residential Service providers must conduct an assessment, at least annually, of the following; 1. Evaluation of the level of observation that is required for all people receiving services at the Crisis Residential Unit. Policy and procedures should allow for assessment upon admission and at regular intervals during the course of treatment. If the assessment or clinical judgement indicates a greater frequency of observation is necessary, policies and procedures should reflect those practices. Policies and procedures should identify who is responsible for conducting the assessment(s).2. Review of the physical environment of care to assess for potential risks and/or access to lethal means. Mitigation efforts must be put into place when risks are identified. Section 41-4-7 of the Mississippi Code, 1972, as Amended