Download AdoptedRules02007-00836 - Colorado Secretary of State

Tracking #2007-00836
FA/P 9/7/07, eff. 11/1/07
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(2 CCR 502-1)
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Addition of rules concerning Acute Treatment Units, Sections 19.500 through 19.568.2 were adopted
following publication at the 9/7/2007 State Board of Human Services meeting, with an effective date of
11/1/2007 (Rule-making #07-3-22-2). Statement of Basis and Purpose, fiscal impact, and specific
statutory authority for these revisions were incorporated by reference into the rule. These materials are
available for review by the public during normal working hours at the Colorado Department of Human
Services, Office of Performance Improvement, Boards and Commissions Division, State Board
Administration.
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19.500 ACUTE TREATMENT UNITS [Eff. 11/1/07]
The Division of Mental Health is authorized to establish minimum standards through regulation and to
administer and enforce such regulations.
19.510 DEFINITIONS [Eff. 11/1/07]
For purposes of this chapter, the following definitions shall apply, unless the context requires otherwise:
"27-10 designated facility” means a facility approved under 2 CCR 502-1 pursuant to Section 27-10-101,
et seq., C.R.S., by the Division of Mental Health within the Colorado Department of Human Services as
one of the following:
A. A seventy-two (72) hour treatment and evaluation facility;
B. A short-term treatment facility;
C. A long-term treatment facility; or,
D. A combination of the above designations.
"Abuse” means emotional, physical and sexual abuse, as defined in this section.
“Activities of daily living” include but are not limited to the following:
A. Assisting client or providing reminders for the following:
1. Personal hygiene such as bathing, shaving, dental hygiene, caring for hair;
2. Dressing;
3. Eating; and,
4. Getting in or out of bed.
B. Making available, either directly or indirectly through the client agreement, at least the following:
1. Meals;
2. Laundry;
3. Cleaning of all common areas, bedrooms, and bathrooms;
4. Managing money, as necessary and by agreement;
5. Making telephone calls;
6. Arranging appointments and schedules;
7. Shopping;
8. Writing letters; and,
9. Recreational and leisure activities.
“Acute Treatment Unit” means a facility or a distinct part of a facility for short-term psychiatric care, which
may include substance abuse treatment, that provides a total, twenty-four (24) hour therapeutically
planned and professionally staffed environment for persons who do not require inpatient hospitalization
but need more intense and individual services, such as crisis management and stabilization services,
than are available on an outpatient basis.
“Assess or assessment” as used herein means recognizing a significant change in the client’s condition
through a clinical judgment. It does not mean making clinical judgments unless the person conducting
such assessment is licensed to make such judgments.
“Auxiliary aid” means any device used by persons to overcome a physical disability and includes, but is
not limited to, a wheelchair, walker or orthopedic appliance.
“Bedridden” means a client who is unable to ambulate or move about independently or with the
assistance of an auxiliary aid, who also requires assistance in turning and repositioning in bed.
“Certification/compliance review letter” means a listing of site review findings from the division of mental
health which contains:
A. A statement of the statute or regulation violated; and,
B. A statement of the findings, with evidence to support the deficiency.
“Client” means an individual who is age eighteen (18) and over, and in need of short-term psychiatric
care.
“Client’s legal representative” means one of the following:
A. The legal guardian of the client, where proof is offered that such guardian has been duly appointed by
a court of law, acting within the scope of such guardianship;
B. An individual named as the agent in a Power of Attorney (POA) that authorizes the individual to act on
the client’s behalf, as enumerated in the POA;
C. An individual selected as a proxy decision-maker pursuant to section 15-18.5-101, C.R.S., et seq., to
make medical treatment decisions. For the purposes of these rules, the proxy decision-maker
serves as the client’s legal representative for the purposes of medical treatment decisions only;
or,
D. A conservator, where proof is offered that such conservator has been duly appointed by a court of
law, acting with the scope of such conservatorship.
"Crisis management" means to stabilize and manage the mental illness crisis that led to admission.
“Critical incident” means an incident that must be reported in a timely manner to the executive director of
the facility and the individual or group responsible for quality improvement, and include, but are not limited
to:
A. Deaths of clients or staff as a result of accidents, suicides, murders, assaults, or any causes other
than natural while staff are on duty at the facility or for clients who are enrolled at the facility;
B. Accidents that occur at the facility or suicide attempts resulting in injuries that require medical
attention;
C. Assaults occurring at the facility that result in summoning of law enforcement officials;
D. Abuse, neglect or exploitation of clients while at any facility operated by the organization that result in
investigation by law enforcement or social services agencies; or,
E. Fires or destruction of property that are deemed to be critical in the judgment of the executive director
of the organization.
"Deficiency” means a violation of regulatory and/or statutory requirements governing acute treatment
units, as cited by the Division of Mental Health.
“Director” means a person who is responsible for the overall operation and daily administration,
management and maintenance of the facility.
“Discharge” means termination of the client agreement and the client’s permanent departure from the
facility.
“Division” means the Division of Mental Health within the Colorado Department of Human Services.
"Division oversight" means management by overseeing the performance or operation of an agency, using
a system for addressing questions of potential risk through guidelines, regulations or other structures.
“Emergency contact” means one of the individuals identified on the face sheet of the client record to be
contacted in the case of an emergency.
“Emotional abuse” means harassment, threats of punishment, harm or deprivation directed toward the
client.
“Facility” means an acute treatment unit.
“Licensee” means the person or entity to whom a license is issued by the Colorado Department of Public
Health and Environment pursuant to Section 25-1.5-103(1)(a), C.R.S., and certification as a 27-10
designated facility has been granted by the Division to operate a facility within the definition herein
provided.
“Medical or nursing care” means care provided under the direction of a physician and maintained by onsite nursing personnel.
“Medication administration” means assisting a client in the use of medication in accordance with state
law.
“Neglect” means failure to fulfill a caretaking responsibility that leads to physical harm. Caretaker neglect
can occur when adequate food, clothing, shelter, psychological care, physical care, medical care, or
supervision is not provided by a caretaker in a timely manner and with the degree of care that a
reasonable person in the same situation would exercise.
“Owner” means the entity in whose name the certification is issued. The entity is responsible for the
financial and contractual obligations of the facility. "Entity" means any corporation, limited liability
corporation, firm, partnership, or other legally formed body, however organized.
“Personal services” means those services which the director and employees of an acute treatment unit
provide for each client including, but not limited to:
A. An environment that is sanitary and safe from physical harm;
B. Assistance with transportation whether by providing transportation or assisting in making
arrangements for the client to obtain transportation; and,
C. Assistance with activities of daily living, as defined in section 19.510.
“Physical abuse” means causing physical harm in a situation other than an accident. Physical abuse
means behavior including, but not limited to, hitting, slapping, kicking or pinching.
“Plan of correction” means a written plan to be submitted by facilities to the division for approval, detailing
the measures that shall be taken to correct all cited deficiencies.
“Protective oversight” means guidance of a client as required by the needs of the client or legal
representative or as reasonably requested by the client including the following:
A. Being aware of a client’s general whereabouts, although the client may travel independently in the
facility; and,
B. Monitoring the activities of the client on the premises to ensure the client’s health, safety, and wellbeing, including monitoring the client’s needs and ensuring that the client receives the services
and care necessary to protect the client’s health, safety, and well-being.
“Restraints" means any involuntary mechanical and/or physical restraint as defined in 2 CCR 502-1. A
secure environment that meets the requirements in Section 101.4 of these regulations shall not be
considered a restraint.
“Service plan” means a written description in layman's terminology of the psychosocial functional
capabilities of an individual, the individual’s need for personal assistance, and the services to be provided
by the facility in order to meet the individual’s needs to stabilize and manage the mental illness crisis that
led to admission.
“Sexual abuse” means non-consensual sexual contact as defined in section 18-3-401(4), C.R.S., and
sexual contact with any person incapable of giving consent. Sexual abuse includes, but is not limited to,
sexual harassment, sexual coercion, or sexual assault.
“Short-term psychiatric care" means services that average from three to seven (3-7) days provided to
persons with mental illness in accordance with Title 27, Section 10, C.R.S.
“Site review” means a programmatic review conducted by the Division of Mental Health to review and
monitor standards and practices pursuant to Section 27-10-101, et seq., C.R.S., and these rules.
“Staff” means employees and contract staff intended to substitute for, or supplement, staff who provide
client care services.
“Unit” means a locked treatment setting that serves a maximum of sixteen clients.
“Volunteer” means a person who performs or gives his services of his/her own free will, without monetary
compensation, and includes interns and academic volunteers.
19.520 CERTIFICATION PROCESS
19.521 CERTIFICATION [Eff. 11/1/07]
A. The division shall issue or renew a certification when it is satisfied that the applicant or facility is in
compliance with the requirements set out in these regulations. Such certification issued or
renewed pursuant to this section, other than a provisional certification, shall expire one year from
the date of issuance or renewal. The facility shall apply for certification on a form prescribed by
the Division.
B. No certification shall be issued or renewed by the Division if the facility is not in compliance with the
rules in Section 19.100 for the care and treatment of the mentally ill.
C. Provisional certification:
1. The Division may issue a provisional certification to a facility for the purpose of operating an
acute treatment unit for a period of ninety (90) days if the facility is temporarily unable to
conform to all the minimum standards required under these rules. No certification shall be
issued to a facility if the operation of the facility may adversely affect the health, safety,
and welfare of the clients of such facility.
2. As a condition of obtaining a provisional certification, the facility shall show proof to the
Division that attempts are being made to conform and comply with applicable standards.
No provisional certification shall be granted prior to the submission of a criminal
background check in accordance with Section 27-10-103(ii)(3)(e), C.R.S.
3. A provisional certification shall not be renewed.
D. Action against a certification
1. General
The Division may suspend, revoke, or not renew the certification of any facility that is out
of compliance with the requirements of these rules in conformance with the provisions
and procedures specified in Article 10 of Title 27, C.R.S.
2. Denials
When an application for original certification has been denied by the Division, the
applicant shall be notified in writing of the denial by mailing a notice to the applicant at the
address shown on the application. Any applicant aggrieved by such a denial may pursue
the remedy for review provided in Article 1 of Title 27, 201 through 208, C.R.S., by
petitioning the Division, within thirty (30) days after the mailing of the notice.
E. Plans of Correction (POCs)
The Division shall require a plan of correction by facilities pursuant to Section 27-1-201, C.R.S.
1. General
a. The facility shall develop a POC, in the format required by the Division, for every
deficiency cited by the Division with regard to certification requirements.
b. The POC shall be typed or printed legibly in ink.
c. The date of correction shall be no longer than 30 calendar days from the date of the
mailing of the deficiency to the facility, unless otherwise required or approved by
the Division.
2. Process for Submission and Approval of POC
A facility shall submit a POC to the Division no later than ten (10) working days of the
date of the certification/compliance review letter sent by the Division.
If an extension of time is needed to complete the POC, the facility shall request an
extension in writing from the Division. The request must be postmarked prior to the POC
due date. An extension of time may be granted by the Division not to exceed seven (7)
calendar days.
The POC is subject to Division approval and the facility shall be notified of the decision
within thirty (30) calendar days of receipt of the plan.
3. Intermediate Restrictions or Conditions
The Division may impose intermediate restrictions or conditions on a certification, as
provided in the rules and regulations for the Colorado Public Mental Health System,
Administrative Procedures Section 2 CCR 502-2. Failure to comply with these rules shall
result in enforcement against an organization as provided in Section .5.
19.522 FACILITY REPORTING REQUIREMENTS – CRITICAL INCIDENTS [Eff. 11/1/07]
A. Reporting
For emergency conditions, or critical incidents, as defined in the Quality Improvement Section
(QI.1 – QI.4) of the Colorado Rules and Regulations for the Public Mental Health System (6 CCR
1008-1, Section 15.215), the Director or designee must notify the Division within twenty-four (24)
hours of the incident.
B. Facility Investigation of Incidents
1. The Director and/or clinical designee of the facility will schedule a clinical review of the incident
with facility staff, particularly the staff on duty at the time of the incident, and will develop
recommendations that will be instituted to prevent similar future situations.
2. Documentation regarding the critical incident, including the appropriate measures to be
instituted, shall be made available to the Division, upon request.
3. A report with the investigation findings shall be available for review by the Division within five
(5) working days of the incidence.
4. Nothing in this section shall be construed to limit or modify any statutory or common law right,
privilege, confidentiality or immunity.
19.530 ORGANIZATION AND STAFFING [Eff. 11/1/07]
The organization and staffing of an ATU shall facilitate and ensure high quality care in the least restrictive
setting for consumers receiving services.
19.531 DIRECTOR [Eff. 11/1/07]
The facility director is the person who is responsible for the operation of the facility on behalf of the entity
that is legally responsible for the ATU.
19.531.1 Director Qualifications [Eff. 11/1/07]
Training must be documented and shall be approved by the Division if all of the following requirements
are met:
A. The program or program components are conducted by:
1. An accredited college, university or vocational school, or;
2. An organization, association, corporation, group, or agency with specific expertise in that area;
and,
B. The curriculum includes at least thirty (30) actual hours.
1. At least fifteen (15) hours shall comprise a discussion of each the following topics:
a. Client rights;
b. Environment and fire safety, including emergency procedures and First Aid;
c. Assessment skills;
d. Identifying and dealing with difficult situations and behaviors; and,
e. Nutrition.
2. The remaining fifteen (15) hours shall provide emphasis on meeting the personal, social and
emotional care needs of the client population served.
19.531.2 Minimum Education, Training and Experience Requirements [Eff. 11/1/07]
Any person serving as a director shall meet the minimum education, training, and experience
requirements in one of the following ways:
A. The director shall have received a bachelor’s degree from an accredited college or university and
have three years of verified experience in the human services field, one of which was in a
supervisory or administrative position; or,
B. The director shall have received a master’s degree from an accredited college or university and have
two years of verified experience in the human services field, one of which was in a supervisory or
administrative position.
19.531.3 Responsibilities [Eff. 11/1/07]
The director shall be responsible for the following:
A. Overall direction and responsibility for the clients, program, facility, and fiscal management;
B. Overall direction and responsibility for supervision of staff;
C. The selection and training of a capable staff member who can assume responsibility for management
of the facility in the director’s absence; and,
D. The establishment of relationships and maintaining contact with allied agencies, services, and
mental health resources within the community.
19.531.4 Assistant or Acting Director [Eff. 11/1/07]
In each facility, there shall be a specifically designated staff member, age twenty-one (21) or over,
capable of acting as a substitute for the director during his/her absence. The duties and responsibilities of
the substitute director shall be clearly defined in order to avoid confusion and conflict among other staff
and clients.
If the director is regularly absent from the facility more than fifty percent (50%) of his/her working hours,
an assistant director shall be appointed who meets the same qualifications as the director found at
Sections 19.531.1 and 19.531.2.
19.531.5 Administrative Coverage [Eff. 11/1/07]
When there is a change in director, or when he/she has left the facility permanently without a
replacement, the facility shall notify the Division within twenty-four (24) hours in writing; or when a
possible change in director is anticipated, the facility shall notify the Division prior to the change.
The director, or assistant or acting director, shall be available at all times.
19.532 Clinical Director [Eff. 11/1/07]
The facility clinical director and/or designee shall be responsible for meeting the requirements in these
rules. Nothing in these rules preclude the clinical director from also serving as the facility director, as long
as all qualifications, training, and oversight requirements are met.
A. Oversight of Staff
The facility clinical director and/or designee is responsible for assuring that there is adequate
training and supervision for staff.
B. Qualifications of a Facility Clinical Director
1. The facility clinical director shall possess a master’s degree or Ph.D. in a mental health related
field or a bachelor’s degree in a mental health related field or a bachelor’s degree in a
mental health related field and five (5) years work experience.
2. Additionally, the clinical director shall receive training on:
a. Client rights;
b. Environment and fire safety, including emergency procedures and First Aid;
c. Assessment skills; and,
d. Identifying and treating clients who have received complex mental illness diagnoses
and who display behaviors that are common to people with severe and persistent
mental illness.
19.540 PERSONNEL
19.541 PHYSICAL/MENTAL IMPAIRMENT [Eff. 11/1/07]
Any person who is physically or mentally unable to adequately and safely perform duties that are
essential functions may not be assigned duties as a direct care staff member or volunteer at an ATU.
19.542 ALCOHOL OR SUBSTANCE ABUSE [Eff. 11/1/07]
The facility shall not employ or allow to volunteer any person who is under the influence of a controlled
substance, as defined in Sections 18-18-203, 18-18-204, 18-18-205, 18-18-206, and 18-18-207, C.R.S.,
or who is under the influence of alcohol in the workplace. This does not apply to employees using
controlled substances under the direction of a physician and in accordance with their health care
provider’s instructions, as long as it does not pose a safety risk to the employee, other employees, or
clients.
19.543 ACCESS TO POLICIES AND PROCEDURES [Eff. 11/1/07]
All staff and all volunteers shall have access to the facility’s policies, procedure manuals, and other
information necessary to perform their duties and to carry out their responsibilities.
A. The facility shall have a written statement of personnel policies that include:
1. Job descriptions for all positions required, which shall detail the supervisory structure for all
positions.
2. Salary range and provisions for increases;
3. Hours of work and holiday, vacation, sick and other applicable leave information;
4. Conditions of employment, tenure and promotion;
5. Employment benefits; including medical/dental/life insurance, workers compensation
insurance, retirement plan, and any other available benefits;
6. Employee performance evaluation procedures;
7. Grievance procedures that may be used by staff; and,
8. Discipline and/or termination procedures.
B. A copy of the personnel policy shall be given to each staff member at the time of his/her employment.
19.544 PERSONNEL FILES [Eff. 11/1/07]
The facility shall maintain personnel files for staff providing treatment under the auspices of the facility.
A. Files of current employees shall be available onsite for review by the Division.
B. Files shall include documentation required in these personnel rules, evidencing:
1. Education and work experience;
2. Background checks through the Colorado Bureau of Investigation;
3. A reference from the appropriate licensing board for licensed persons; and,
4. A check of references from former employers, including verification of dates of employment.
19.545 BACKGROUND CHECKS
19.545.1 Clinical Director [Eff. 11/1/07]
The director must ascertain if the clinical director has been convicted of a felony or a misdemeanor that
could pose a risk to the health, safety, and welfare of the clients, when making employment decisions.
A background check shall be conducted for all of the following situations:
A. As part of the application process for initial facility certification.
B. For existing clinical directors who have not conducted a background check in accordance with these
rules.
C. When there is a change in clinical directors and a new clinical director is appointed.
19.545.2 Staff and Volunteers [Eff. 11/1/07]
A background check shall be conducted for all staff or volunteers with direct personal contact with the
clients of an ATU, prior to such staff or volunteers performing duties. This check shall include any criminal
history record information from a criminal agency, subject to any restrictions imposed by such agency.
19.545.3 Contract Staff [Eff. 11/1/07]
Evidence that a background check has been conducted within 12 months prior to the date of hire by the
facility shall be required for all contract staff positions.
19.545.4 Documentation of Background Checks [Eff. 11/1/07]
The facility shall maintain evidence of background checks in personnel files.
A. The facility must determine if a prospective staff member has been convicted of a felony or a
misdemeanor that could pose a risk to the health, safety, and welfare of the clients, when making
employment decisions.
B. Cost of background checks: all costs of obtaining a criminal history record pursuant to the
requirement shall be borne by the facility.
19.546 QUALIFICATIONS [Eff. 11/1/07]
All staff and/or academic volunteers and interns shall have sufficient skill and ability to perform their
respective duties, services, and functions.
A. Licensed or certified staff shall perform duties in accordance with applicable statutes, rules and
regulations. Staff and/or academic volunteers and interns shall not perform duties that they are
not licensed or certified to provide.
B. To be qualified to administer medication, an individual shall be a licensed practical nurse, registered
nurse, physician, physician’s assistant, or pharmacist.
19.547 TRAINING [Eff. 11/1/07]
The facility shall document the evaluation of previous related experience for volunteers, as applicable,
and for staff and that these personnel have all of the training, including on-the-job training, required in this
section.
A. All staff and all volunteers shall be given on-the-job training, or have related experience in the job
assigned to them, and shall be supervised until they have completed on-the-job training
appropriate to their duties and responsibilities, or have had previous related experience
evaluated.
B. The facility shall maintain records documenting completion of all required training, or review of
evaluation of previous related experience.
C. Volunteers having direct client contact shall receive training appropriate to their duties and
responsibilities.
19.547.1 Personnel Timeframes for Training [Eff. 11/1/07]
Staff shall receive the following training, as appropriate.
A. Prior to providing direct care, the facility shall provide an orientation of the physical plant and adequate
training on each of the following topics:
1. Training specific to the particular needs of the populations served;
2. Client rights;
3. First Aid and injury response;
4. The care and services for the current clients;
5. The recognition and response to common side effects of psychiatric medications, and
response to emergency drug reactions in accordance with facility policies; and,
6. Confidentiality of information obtained and records prepared in the course of treatment.
B. Within one month of the date of hire, the facility shall provide adequate training for staff on each of the
following topics:
1. Assessment skills;
2. Infection control;
3. Identifying and dealing with difficult situations and behaviors;
4. Clients rights, unless previously covered through other training;
5. Health emergency response, unless previously covered through other training; and
6. Behavioral/psychiatric emergency response, unless previously covered through other training.
19.548 STAFFING REQUIREMENTS [Eff. 11/1/07]
A. The owner shall employ sufficient staff to ensure that the provision of services meets the needs of the
clients. In addition to the requirements set forth in Section 19.546, the facility shall always
maintain at least a one to six (1:6) trained staff member(s) to client ratio at all times.
B. In determining the staffing levels, the facility shall give consideration to factors including, but not
limited to:
1. Services to meet the clients’ needs,
2. Services to be provided under the service plan, and,
3. Services to be provided under the client service plan.
C. Each facility shall ensure that, at minimum, a person qualified as described in Section 19.546, B, is
available to administer medications at all times.
D. Clients may participate voluntarily in performing housekeeping duties and other tasks suited to the
client’s needs and abilities; however, clients who provide services for the facility on a regular
basis, or on an exchange or fee-for-service basis may not be included in the facility’s staffing plan
in lieu of facility employees except for trained, tested, and supervised clients in those facilities that
are certified to provide services specifically for persons with mental illness.
E. Volunteers may be utilized in the facility, but may not be included in the facility’s staffing plan in lieu of
facility employees.
19.550 POLICIES AND PROCEDURES [Eff. 11/1/07]
All facilities shall develop, adopt, and follow written policies and procedures that include all of the
requirements listed below and comply with all applicable state and federal statutes, rules and regulations.
Required disclosures to clients or their legal representative, as appropriate, regarding the policies and
procedures shall be documented in the client record.
19.551 EMERGENCY PLAN AND FIRE ESCAPE PROCEDURES [Eff. 11/1/07]
A. Emergency plan: The emergency plan shall include planned responses to fire, gas explosion, bomb
threat, power outages, and tornado. Such plan shall include provisions for alternate housing in
the event evacuation is necessary.
B. Fire escape procedures: The fire escape procedures shall include a diagram developed with local fire
department officials which shall be posted in a conspicuous place.
C. Disclosure to clients: Within three (3) days of admission, the plan and diagram shall be explained to
each client or legal representative, as appropriate.
19.552 SERIOUS ILLNESS, SERIOUS INJURY, OR DEATH OF THE CLIENT [Eff. 11/1/07]
A. The policy shall describe the procedures to be followed by the facility in the event of serious illness,
serious injury, or death of a client, including incident reporting requirements.
B. The policy shall include a requirement that the facility notify an emergency contact when the client’s
injury or illness warrants medical treatment or face-to-face medical evaluation. In the case of an
emergency room visit or unscheduled hospitalization, a facility must notify an emergency contact
immediately.
19.553 PHYSICIAN ASSESSMENT [Eff. 11/1/07]
The facility shall identify when a physician’s assessment will be required, based upon at least the
following indicators:
A. A significant change in the client’s condition;
B. Evidence of possible infection (open sores, etc.);
C. Injury or accident sustained by the client which might cause a change in the client’s condition;
D. Known exposure of the client to a communicable disease; or,
E. Development of any condition which would have initially precluded admission to the facility.
19.554 CLIENT RIGHTS [Eff. 11/1/07]
Policies developed by the facility shall not exclude, take precedence over, or in any way abrogate legal
and constitutional rights enjoyed by all adult citizens.
A. The policy on client’s rights shall be posted in a conspicuous place.
B. Upon admission, the facility shall document the client or legal representative, as appropriate, has read
or had explained the policy on clients’ rights.
19.555 SMOKING [Eff. 11/1/07]
A. Facilities policies for smoking shall address clients, staff, volunteers and visitors, and shall comply with
applicable state laws and regulations.
B. Prior to admission or employment, clients and staff shall be informed of any prohibitions.
19.556 DISCHARGE [Eff. 11/1/07]
A. Facility's discharge policy shall include all of the following:
1. Circumstances and conditions under which the facility may require the client to be involuntarily
transferred or discharged;
2. An explanation of the notice requirements;
3. A description of the relocation assistance offered by the facility; and,
4. The right to call advocates, such as the governors protection and advocacy for individuals
with mental illness, the adult protection services of the appropriate county department of
social or human services, and/or the Colorado Department of Human Services, Division
of Mental Health.
B. Disclosure to clients
Upon admission, the facility shall document that the client or legal representative, as appropriate,
has read or had explained this policy.
19.557 MANAGEMENT OF CLIENT FUNDS AND PERSONAL PROPERTY [Eff. 11/1/07]
This policy shall address the procedures for managing client funds or property.
A. Upon admission, a written inventory of all client belongings shall be conducted. This inventory shall be
signed and reviewed by facility staff and the client, and shall be maintained in the client’s clinical
record.
B. All inventoried items shall be stored in a secure location during the client’s stay in the facility.
C. All inventoried property shall be returned to the client upon discharge. The client and facility staff shall
sign the inventory form indicating that all items were returned.
19.558 INTERNAL GRIEVANCE PROCESS [Eff. 11/1/07]
A. The facility policy shall establish a process for routine and prompt handling of grievances brought by
clients and their families. Such policy shall also indicate that clients and their families may contact
any of the following agencies and shall provide the telephone number and address of each of the
following:
1. The state and or mental health ombudsman; the adult protection services of the appropriate
county department of social/human services;
2. The advocacy services of the Area Agency on Aging;
3. The Colorado Department of Public Health and Environment on issues pertaining to fire
safety, nutrition, sanitary environment, and communicable diseases;
4. The Legal Center for People with Disabilities and Older Persons Protection and Advocacy for
People with Mental Illness; and,
5. The Colorado Department of Human Services, Division of Mental Health.
B. The internal grievance policy and procedure shall be posted in a conspicuous place.
C. Upon admission, the facility shall document that the client or the client’s representative, as
appropriate, has read or had the policy for the internal grievance process explained.
19.559 ALLEGATIONS OF ABUSE AND NEGLECT [Eff. 11/1/07]
The facility shall investigate all allegations of abuse and neglect involving clients in accordance with its
written policy, which shall include, but not be limited to:
A. Reporting requirements to the appropriate agencies such as the adult protection services of the
appropriate county department of social services, the facility director, and the state Division of
Mental Health, as warranted;
B. A requirement that the facility notify an emergency contact about the allegation within twenty-four (24)
hours of the facility becoming aware of the allegation;
C. The process for investigating such allegations;
D. How the facility will document the investigation process to evidence the required reporting and that a
thorough investigation was conducted;
E. A requirement that the client shall be protected from potential future abuse and neglect while the
investigation is being conducted;
F. A requirement that if the alleged neglect or abuse is verified, the facility shall take appropriate
corrective action; and,
G. A requirement that a report with the investigation findings will be available for review by the Division
not later than five (5) working days of the allegation being lodged with a staff member of the
facility.
19.560 ADMINISTRATIVE FUNCTIONS
19.561 ADMISSIONS [Eff. 11/1/07]
A. Only adults whose needs can be met by the facility within its licensure category shall be admitted. The
facility’s ability to meet client needs shall be based upon a comprehensive pre-admission
assessment of the client’s mental health, physical health, substance use, and capacity for self
care. The mental health assessment shall determine the extent that the client's behavior requires
intervention and/or supervision by mental health professionals, including medication
management, behavioral modification, and stabilization prior to return to the community.
B. The facility’s criteria for admission shall be based upon its ability to meet all the identified care needs
of clients. The facility shall consider at least all of the following in making its admission decision:
1. The facility’s physical plant;
2. The facilities financial resources; and,
3. Availability of adequately trained staff.
C. Acute treatment units shall not admit persons with mental illness into a locked setting unless there is
no less restrictive alternative and unless they are otherwise in compliance with the requirements
of Article 10 of Title 27, Colorado Revised Statutes.
D. Clients may be admitted to a locked setting as a voluntary or involuntary client.
1. If voluntary, the client must sign a form that documents the following information:
a. The client is aware that the facility is locked.
b. The client may exit the facility with staff assistance and/or permission.
c. The client may leave the facility at any point in time, unless he/she presents as a
danger to self or others, or is gravely disabled as defined in Section 27-10-101,
et seq., C.R.S.
2. If the client is involuntary, the paperwork required by Section 27-10-101, et seq., C.R.S., must
be contained in the client’s clinical record.
E. Only those clients who need an acute treatment facility and whose needs can be met by the facility, as
determined by an assessment, may be admitted. A client who is imminently suicidal or homicidal
shall only be admitted to the locked facility, upon completion of the facility’s assessment and the
facility’s determination that the client’s safety and the safety of others can be maintained by the
facility. If a client is admitted and facility staff determine that his/her behavior cannot be safely and
successfully treated at the ATU, then staff will make arrangements to transfer the client to the
nearest hospital for further assessment and disposition.
F. A facility shall not admit or keep any client requiring a level of care or type of service which the facility
does not provide or is unable to provide, and in no event shall a facility admit or keep a client
who:
1. Is consistently, uncontrollably incontinent unless the client or staff is capable of preventing
such incontinence from becoming a health hazard.
2. Is under the age of eighteen (18).
3. Is totally bedridden with limited potential for improvement. A facility may keep a client who
becomes bedridden after admission if there is documented evidence of each of the
following:
a. An order by a physician describing the services required to meet the health needs of
the client including, but not limited to, the frequency of assessment and
monitoring by the physician or by other licensed medical professionals.
b. Ongoing assessment and monitoring by a licensed or Medicare/Medicaid certified
home health agency or hospice service. The assessment and monitoring shall
ensure that client’s physical, mental health, and psychosocial needs are being
met. The frequency of the assessment and monitoring shall be in accordance
with client needs, but shall be conducted no less frequently than weekly.
c. Adequate staffing, with staff who are trained in the provision of caring for bedridden
clients, and provision of services to meet the needs of the client.
4. Needs restraints of any kind except as otherwise provided in Section 27-10-101, et seq.
C.R.S. The placement of a client in his or her room for the night and the use of time-out,
as provided for in Section 26-20-102(6), C.R.S., shall be conducted only as part of a
treatment plan developed in consultation with a physician and/or licensed psychologist.
The appropriateness of these provisions in the treatment plan shall be reassessed by
either one of these psychiatric clinicians every three months.
5. Needs continuous or long term medical or nursing services on a twenty-four (24) hour basis,
except for psychiatric care provided specifically for persons with mental illness.
6. Has a communicable disease or infection that is:
a. Reportable under the Department of Public Health and Environment's regulations (6
CCR 1009-1 and 2); and,
b. Potentially transmittable in a facility, unless the client is receiving medical or drug
treatment for the condition and the admission is approved by a physician.
7. Has acute withdrawal symptoms, is at risk of withdrawal symptoms, or is incapacitated due to
a substance abuse disorder.
G. Facilities shall not admit an individual diagnosed with a developmental disability unless he/she also
carries a mental illness diagnosis, and whose behaviors can be managed and/or modified by
facility staff during the designated length of stay, and whose behaviors will not endanger the
safety of the client, staff or other clients.
19.562 CLIENT AGREEMENT [Eff. 11/1/07]
A. A written agreement shall be executed between the facility and the client or the client’s legal
representative at the time of admission. The parties may amend the agreement provided such
amendment is evidenced by the written consent of both parties. No agreement shall be construed
to relieve the facility of any requirement or obligation imposed by law or regulation.
B. The written agreement shall specify the understanding between the parties regarding, at a minimum,
the following:
1. Charges;
2. Services included in the rates and charges;
3. Types of services provided by the facility, those services which are not provided, and those
which the facility will assist the client in obtaining;
4. Transportation services;
5. Therapeutic diets; and,
6. A provision that the facility must give clients thirty (30) calendar days notice of closure.
C. The written agreement shall have as addenda:
1. The service plan; and,
2. Facility rules, established pursuant to Section 19.549.
D. There shall be written evidence that the following have been disclosed, upon admission unless
otherwise specified, to the client or the client’s legal representative, as appropriate:
1. The facility policies and procedures listed under Section 19.549.
2. Staffing levels based on client needs; and the extent to which certified or licensed health care
professionals are available onsite.
3. Types of daily activities, including examples of such activities that will be provided for the
clients.
4. Whether or not the facility has automatic fire sprinkler systems.
19.563 FACILITY RULES [Eff. 11/1/07]
The facility shall establish written policies which shall list all possible actions that may be taken by the
facility if any policy is knowingly violated by a client. Facility policies may not violate or contravene any
rule herein, or in any way discourage or hinder a client’s rights. Such policies shall address at least the
following:
A. Smoking;
B. Cooking;
C. Visitors;
D. Telephone usage including frequency and duration of calls;
E. Use of common areas, including the use of television, radio;
F. Consumption of alcohol and/or illicit drugs;
G. Dress;
H. Pets which shall not be allowed in the facility; however, in no event shall such rules prohibit service or
guide animals.
1. The facility shall prominently post written facility policies which shall be available at all times to
clients.
2. There shall be documentation in the client’s record that a copy of the facility policies was
provided to the client or the legal representative, as appropriate, prior to admission.
19.564 CLIENT RECORD [Eff. 11/1/07]
A confidential record shall be maintained for each client. Records shall be dated and legibly recorded in
ink or in electronic format.
A. Client records shall contain at least, but not be limited to, the following:
1. Demographic and medical information
2. A face sheet to contain the following information:
a. Client’s full name, including maiden name if applicable;
b. Client’s sex, date of birth, marital status and social security number, where needed for
Medicaid or employment purposes;
c. Client’s current address of residence;
d. Date of admission;
e. Name, address and telephone number of relatives or legal representative(s), or other
person(s) to be notified in an emergency;
f. Name, address and telephone number of client’s primary physician, and case manager
if applicable, and an indication of religious preference, if any, for use in
emergency;
g. Client’s diagnoses, at the time of admission;
h. Current record of the client’s allergies.
3. Progress notes of any significant change in physical, behavioral, cognitive and functional
condition and action taken by staff to address the client’s changing needs;
4. Medication administration record;
5. Documentation of on-going services provided by external services providers, such as physical
therapy;
6. Advance directives, if applicable;
7. Physician’s orders;
8. The client agreement;
9. The service plan, as that term is defined herein;
10. The legal status as defined by the care and treatment of the mentally ill (Article 10 of Title 27,
Colorado Revised Statutes) as certified by the Division of Mental Health;
11. The assessment;
12. The reassessment(s).
B. Records shall be available for inspection by and released to authorized individuals and/or
organizations in accordance with Health Insurance Portability and Accountability (HIPAA) privacy
rules and Section 27-10-120, C.R.S., such as:
1. The client or the client’s legal representative, if so authorized;
2. The client’s attorney of record, if so authorized;
3. The Legal Center for People with Disabilities and Older People (PAMI), if so authorized;
4. The Division of Mental Health for the purpose of auditing compliance with these rules; and,
5. Those otherwise authorized by law and/or the client.
C. Client record storage and retention.
1. Records shall be maintained and stored in such a manner as to be protected from loss,
damage, or unauthorized use.
2. Records shall be maintained in the facility or in a central administrative location readily
available to facility staff and the Division. Records necessary to respond to the current
care needs of the client shall be maintained onsite at the facility.
3. Records for discharged clients shall be complete and maintained for a period of seven years
following the termination of the client’s stay in the facility.
D. The confidentiality of the client record, including all medical, mental health, substance abuse,
psychological and sociological information shall be protected at all times, in accordance with all
applicable state and federal laws and regulations.
19.565 DISCHARGE [Eff. 11/1/07]
A. A client shall be discharged for one or more of the following reasons:
1. When the facility cannot protect the client from harming him or herself or others;
2. When the facility is no longer able to meet the client’s identified needs;
3. When the client is no longer in need of this level of care; or,
4. Failure of the client to comply with the client agreement, which contains notice that discharge
may result from violation of the agreement.
B. Notice of discharge shall be provided to the client or client’s legal representatives as follows:
1. At least twenty four (24) hours in advance or discharge or transfer, in accordance with the
rules governing the care and treatment of the mentally ill (2 CCR 502-1).
2. In cases of a medical or psychiatric emergency, the responsible party shall be notified as soon
as possible.
C. Discharge shall be coordinated with the client, and, with permission, the client’s family, legal
representative, or the appropriate agency.
19.566 CLIENT RIGHTS [Eff. 11/1/07]
A. Clients shall have the following rights:
1. Treatment with respect and dignity.
2. Privacy.
3. Not to be isolated or kept apart from other clients, and to live free from financial exploitation,
involuntary confinement, and/or physical or chemical restraints as defined within these
regulations, except as otherwise provided in Section 27-10-101, et seq., C.R.S.
4. Not to be sexually, verbally, physically or emotionally abused, humiliated, intimidated, or
punished.
5. Free from neglect.
6. Full use of the facility common areas, in compliance with the documented house rules.
7. Voice grievances and recommend changes in policies and services.
8. Communicate privately including, but not limited to, communicating by mail or telephone with
anyone.
9. Reasonable use of the telephone, in accordance with facility policies, which includes access to
operator assistance for placing collect telephone calls. At least one telephone accessible
to clients utilizing an auxiliary aid shall be available if the facility is occupied by one or
more clients utilizing such an aid.
10. Visitors, in accordance with facility policies, including the right to privacy during such visits.
11. Visits outside the facility in which case the treatment team and the client shall share
responsibility for communicating with respect to scheduling.
12. Decisions and choices regarding their care and treatment, in the management of personal
affairs, funds, and property in accordance with their abilities.
13. Expectation of cooperation of the facility in achieving the maximum degree of benefit from
those services which are made available by the facility.
14. Exercise choice in attending and participating in religious activities.
15. Reimbursed at an appropriate rate for work performed on the premises for the benefit of the
director, staff, or other clients, in accordance with the client’s service plan.
16. Advocates, including members of community organizations whose purposes include
rendering assistance to the clients.
17. Wear clothing of choice unless otherwise indicated in the client’s care plan and in
accordance with reasonable facility policies.
18. Participate in social activities, in accordance with the care plan.
19. Receive services in accordance with the client agreement and the service plan.
B. A facility shall permit access during reasonable hours to the premises and clients by the agency
designated pursuant to the federal "Protection and Advocacy for the Mentally Ill Act" in
accordance with Section 27-10-120(1)(h),(i), C.R.S.
C. Restraints as defined within these rules are prohibited except as otherwise provided in Section 27-10101, et seq., C.R.S. These measures may only be used in accordance with a treatment plan
developed in consultation with and based on a written order by a professional person as defined
in Section 27-10-102, C.R.S. The treatment plan, which shall document if less restrictive
measures were unsuccessful, shall be evaluated by a professional person every twenty four (24)
hours.
D. A facility shall disclose to the client and the client’s legal representative, if applicable, prior to the
client’s admission to the facility, whether the facility operates a locked setting. The disclosure
shall include information about the types of client diagnoses or behaviors that the facility serves
and for which staff of the locked setting is trained to provide services.
E. Mechanisms to address client/client family concerns:
1. The facility shall implement an internal process for the routine and prompt handling of
grievances brought by clients and their families.
2. A client may file a complaint or grievance with the facility’s patient representative, the
Colorado Department of Public Health and Environment and/or the Colorado Division of
Mental Health at any point in time during the admission. Upon such request, the facility
shall assist the client in making such contact.
3. The facility shall establish a mechanism for family members of clients to voice suggestions,
concerns and grievances. This mechanism shall allow families to meet with the director
and a staff representative to make recommendations concerning facility policies,
grievances, incidents, and other matters of concern to the clients. Staff shall respond to
these suggestions within a timely manner.
4. Families may contact the facility’s patient representative to make recommendations
concerning facility policies, grievances, incidents, and other matters of concern to the
clients. Families may also contact the office of consumer and family affairs within the
Division of Mental Health. Upon such request the facility shall assist the client and/or
family members in making such contact.
5. Families shall be given the opportunity to meet with facility staff without clients present, upon
request. Such meetings shall be in compliance with applicable state and federal
confidentiality laws.
6. Should the client and/or family express dissatisfaction with the course of treatment, they may
request a transfer to another facility as determined appropriate by the client’s psychiatrist.
19.567 CLIENT CARE SERVICES [Eff. 11/1/07]
A. General
The facility shall maintain a current list of clients and their assigned room.
The facility shall make available, either directly or indirectly through a client agreement, the
following services, sufficient to meet the needs of the clients:
1. A physically safe and sanitary environment;
2. Room and board;
3. Personal services;
4. Protective oversight; and,
5. Social care.
B. The facility shall develop and implement a written service plan for each client to stabilize the client and
allow discharge to lower level placement or community, to monitor for safety and to oversee the
client's care needs.
1. An initial written safety and stabilization plan for each client detailing risk issues and the
stabilization process resulting in discharge shall be completed at the time of admission.
2. Within 24 hours of admission, an individualized service plan for each client shall be written and
shall include at least the following:
a. A comprehensive assessment of the clients mental health, behavioral and physical
needs; and the capacity for self care.
b. The assessment shall include, but not be limited to:
1) Special dietary instructions, if any;
2) Any physical or cognitive limitations; and,
3) A description of the services which the facility will provide to meet the needs
identified in the comprehensive assessment.
3. The client may request a modification of the services identified in the service plan at any time.
4. The client and his/her care plan shall be reassessed on an ongoing basis to address
significant changes in the client’s physical, behavioral, cognitive and functional condition,
and identify the services that the facility shall provide to address the client’s changing
needs. The care plan shall be updated to reflect the results of the reassessment.
C. If the client is receiving therapeutic services from an external services provider(s), the facility shall
coordinate and document in the service plan the services that are to be provided by the external
services provider(s) as well as the services to be provided by the facility to ensure that the client
needs are met.
19.568 MEDICATION ADMINISTRATION [Eff. 11/1/07]
A. Storage, Disposition, and Disposal
1. All personal medication must be surrendered to the facility to be logged in and stored by the
facility. Clients are not allowed to self-administer medication in the facility.
2. Personal medication shall be returned to the client or client’s legal representative, upon
discharge or death, except that return of medication to the client may be withheld if
specified in the care plan of a client of an ATU if a physician or other authorized medical
practitioner has determined that the client lacks the decisional capacity to possess or
administer such medication safely.
3. Medications shall be labeled with the client’s full name, pursuant to Article 22 of Title 12.
4. Any medication container that has a detached, excessively soiled or damaged label shall be
returned to the issuing pharmacy for re-labeling or disposed of appropriately.
5. All medication shall be stored in a manner that ensures the safety of the clients.
6. Medication shall be stored in a central location, including refrigerators, and shall be kept under
lock and shall be stored in separate or compartmentalized packages, containers, or
shelves for each client in order to prevent intermingling of medication.
7. Clients shall not have access to medication which is kept in a central location.
8. Medications which require refrigeration shall be stored separately in locked containers in the
refrigerator. If medication is stored in a refrigerator dedicated to that purpose, and the
refrigerator is in a locked room, then the medications do not need to be stored in locked
containers.
9. Prescription and over the counter medication shall not be kept in stock or bulk quantities,
unless such medication is administered by a licensed medical practitioner.
B. Disposal
1. The return of medication shall be documented by the facility.
2. Medication which has a specific expiration date shall not be administered after that date and
shall be disposed of appropriately.
19.568.1 Administration of Medication and Treatment [Eff. 11/1/07]
A. Medication may be administered by staff as described in Section 19.546, B.
B. A current record shall be maintained of the client’s medications including the name of drug, dosage,
route of administration of medication and directions for administration of medication.
C. The administration of medication shall be documented at the time of administration.
D. The facility shall only administer medications upon the written order of a licensed physician or other
authorized practitioner.
E. Only a licensed nurse may accept telephone orders for medication from a physician or other
authorized practitioner. All telephone orders shall be evidenced by a written and signed order and
documented in client’s record and the facility’s medication administration record.
F. These rules apply to medications and treatment which do not conflict with state law and regulations
pertaining to acute treatment units and which are within the scope of services provided by the
facility, as outlined in the client agreement or the facility rules.
G. The facility shall be responsible for complying with physician orders associated with the administration
of medication or treatment. The facility shall implement a system that obtains clarification from the
physician, as necessary and documents that the physician:
1. Has been asked whether refusal of the medication or treatment should result in physician
notification.
2. Has been notified, where such notification is appropriate.
3. Documentation of such notification shall be made in the client’s clinical record.
4. Coordinates with external providers or accepts responsibility to perform the care using facility
staff.
5. Trains staff regarding the parameters of the ordered care as appropriate.
6. Documents the delivery of the care, including refusal by the client, of the medication or
treatment.
19.568.2 Administration of Oxygen [Eff. 11/1/07]
Clients may administer oxygen, if the client is able to manage the administration himself or herself and
staff shall assist with the administration as needed for safety, when prescribed by a physician and if the
facility follows appropriate safety requirements regarding oxygen herein.
A. Oxygen tanks shall be secured upright at all times to prevent falling over and secured in a manner to
prevent tanks from being dropped or from striking violently against each other.
B. Tank valves shall be closed except when in use.
C. Transferring oxygen from one container to another shall be conducted in a well-ventilated room with
the door shut. Transfer shall be conducted by a trained staff member or by the client for whom the
oxygen is being transferred, if the client is capable of performing this task safely. When the
transfer is being conducted, no client, except for a client conducting such transfer, shall be
present in the room.
D. Tanks and other oxygen containers shall not be exposed to electrical sparks, cigarettes or open
flames.
E. Tanks shall not be placed against electrical panels or live electrical cords where the cylinder can
become part of an electric circuit.
F. Tanks shall not be rolled on their side or dragged.
G. Smoking shall be prohibited in rooms where oxygen is used or stored. Rooms in which oxygen is used
shall be posted with a conspicuous “no smoking” sign.
H. Tanks shall not be stored near radiators or other heat sources. If stored outdoors, tanks shall be
protected from weather extremes and damp ground to prevent corrosion.