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FLORIDA DEPARTMENT OF CORRECTIONS
OFFICE OF HEALTH SERVICES
HEALTH SERVICES BULLETIN NO. 15.05.05
Page 1 of 36
SUBJECT: INPATIENT MENTAL HEALTH SERVICES
EFFECTIVE DATE: 4/7/99
I.
PURPOSE:
A.
The purpose of this health services bulletin is to:
1.
Define the four levels of care that comprise the inpatient mental health care
delivery system: isolation management rooms, transitional care units, crisis
stabilization units, and acute hospital (Corrections Mental Health Institution
[CMHI]).
2.
Outline procedures by which patients can be referred and transferred to
inpatient mental health care within Department of Corrections facilities and,
when warranted, to inpatient mental health care in the community upon
expiration of sentence.
3.
Define the following three conditions which shall be excluded as a basis for
admission to inpatient mental health care:
a.
Threats or acts of aggression or assaultiveness toward property,
patients, or staff by patients who have no signs or symptoms of
significant mental disorder/retardation.
b.
Threats or acts of superficial self-mutilation with obvious persuasive
intent toward staff, either in terms of attention or secondary gain
based on clinical assessment. Superficial self-mutilation means that
the wounds, perforations or acts (e.g., swallowing of inert
substances) do not pose significant threat to the patient's health
and/or life.
c.
A clear production of symptoms for secondary gain, such as
manipulating, factitious disorders with psychological symptoms, or
other conscious manifestations of pseudopsychosis.
B.
This bulletin describes aftercare procedures for continuity of care purposes.
C.
The clinical reasoning for care provided in a way that differs from that in this HSB
must be clearly documented.
D.
Specifically for section IA3a-c: There must be clear documentation for not
providing inpatient care. There must be pertinent observations from more than one
health care provider. The evaluation or other summary note shall describe patient
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
statements or behavior that is inconsistent with diagnosing a mental illness requiring
inpatient care.
II.
CHANGES:
This HSB is a compilation of HSBs 15.05.02 Use of Infirmary Isolation Rooms, 15.05.12
Criteria for Admission to Infirmary Isolation Rooms, Transitional Care Units, and Crisis
Stabilization Units, and 15.05.16 Referral of an Inmate for Admission to Inpatient Mental
Health Care. This compilation also includes sections of 15.05.04 Continuity of Care
Planning for Inmates with Mental Disorders and/or Mental Retardation that pertain to
aftercare for inmates requiring hospitalization after release. This HSB supersedes the
above-reference HSBs and should be read carefully and in its entirety.
III.
IV.
DEFINITIONS:
A.
Isolation Management Room (IMR) is a certified cell within the infirmary setting.
B.
Designated alternative is an infirmary bed.
LEVELS OF CARE:
A.
Isolation Management Rooms
1.
Policy
It is the policy of the Department of Corrections to protect the well-being of
patients and staff by providing sufficient numbers of appropriate observation
rooms in which acutely mentally disordered patients may be safely and
humanely housed. These rooms shall meet the standards of HSB 15.03.14
Standards for Isolation Management Rooms and shall be available at all
major institutions, including the Corrections Mental Health Institution.
While an isolation management room (IMR) shall be available at any major
institution which houses more than 500 inmates, the use of such as described
in section IVA of this bulletin shall apply only to major institutions that lack
transitional and crisis stabilization care. Each facility with an IMR shall
have written procedures governing the use of such.
Use of IMRs requires written clinical justification and determination that
less restrictive techniques have been, or will be, inadequate to afford the
degree of protection and care necessary. These rooms shall be used only as
adjuncts to less restrictive interventions and only so long as use continues to
be justified by patient clinical and behavioral status. When clinical
circumstances permit, patients housed in IMRs shall be afforded time
outside the room to attend supervised therapy and leisure activities.
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
2.
3.
Criteria For Admission to an IMR
a.
The patient shows symptomatology of emotional or mental
impairment which cannot be safely assessed on an outpatient basis
while the patient remains in general population housing or in
confinement as determined by mental health staff, or in their
absence, by a physician, registered nurse, or LPN, in that order; or
b.
The patient has been assessed as needing crisis stabilization care and
requires safe housing while awaiting transfer.
c.
The guidelines herein are not exhaustive and should serve only as a
foundation on which the sound clinical judgment of the responsible
mental health or medical professional is based. Other factors when
present (e.g., psychosis, severe personality disorders, temporary
confusion states) may increase the level of severity and required
care. The decision trees (see appendices A and B, Placement on
SOS Decision Tree and Decision Tree for After-Hours Emergencies,
respectively) attached herein can assist the clinician in making an
appropriate disposition.
Referral for Admission to an IMR
a.
When patient speech or behavior suggests the possibility of
emotional or mental impairment, the patient shall be referred to
mental health staff. In the absence of mental health staff, e.g., after
hours, on-site senior medical staff are responsible for managing the
crisis. Nursing staff shall complete an assessment of the patient (see
attachment #1 DC4-683A Mental Health Emergency Nursing
Assessment) and report the findings to the institutional psychiatrist
on call (if the institution has that availability) or to the senior
physician. The physician shall determine disposition based on the
assessment by on-site staff.
b.
The patient shall be scheduled for a mental status examination
(MSE) on the day of admission that should be performed by a
psychiatrist, psychologist, psychological specialist, registered nurse
specialist, or physician. If the patient is placed in an IMR after hours
or on weekends, the MSE shall be conducted on the next working
day. After the assessment of the patient, a request for consultation
can be made, if needed, to the institutional psychiatrist, or the
regional on-call psychiatrist if there is no institutional psychiatrist
available.
HEALTH SERVICES BULLETIN NO. 15.05.05
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
Mental health emergencies (such as suicide attempts and acute
psychotic breaks) may necessitate immediate admission to an IMR,
the infirmary, or other specialized housing arrangement to protect the
patient while the necessary evaluation is being arranged, especially
when mental health staff are not immediately available, such as after
normal working hours. The safety of the inmate shall be maintained
by the removal of objects that might be used for self-harm, and by
observations as per physician order. These areas should be
designated in advance by the superintendent in consultation with the
chief health officer/medical executive director. Determination of
suitability of a particular housing area for this purpose shall be in
accordance with guidelines for IMRs in HSB 15.03.14 Standards for
Isolation Management Rooms. When alternative housing areas are
needed, an inmate being considered for placement in an IMR or other
designated area shall be placed in an IMR or designated area in
accordance with assessed clinical need; e.g., an inmate in need of
SOS1 may be given a higher priority for IMR, whereas an inmate on
SOS2 may be placed in the infirmary. When an inmate is placed in a
safe setting, including IMRs, s/he should be reassessed for any
clinical changes that may prompt a change in the disposition or
management of the inmate. Any placement outside an isolation
management room must include continuous observation of the
patient. Otherwise, the frequency of observation shall be determined
by the physician giving/writing the order but shall not exceed 30
minutes. Complete documentation is required whether placement is
in an IMR or a designated alternative. Observations shall be
documented on DC4-650 Observation Checklist (see attachment #2)
which shall be filed in the infirmary record.
c.
The MSE must include a behaviorally descriptive assessment in at
least the following areas:
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
Appearance and behavior
Orientation
Memory (immediate, recent, and remote)
Mood
Affect
Perception
Thinking
Suicidal or homicidal ideation/intent/plan
Vegetative functions
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
d.
If the clinical assessment is conducted by a psychological specialist,
the outcome will be reviewed by the senior psychologist. The senior
psychologist or any other nonphysician completing the assessment
will then consult with the chief health officer or physician designee if
after hours. The evaluating staff person (if not a physician, in
consultation with the chief health officer) shall make one of four
decisions (see appendix B Decision Tree for After-Hours
Emergencies):
(1)
(2)
(3)
(4)
e.
4.
Admit or refer the patient for admission to an IMR or a crisis
stabilization unit (CSU); or
Refer the patient for follow-up evaluation and/or treatment
on an outpatient basis; or
Determine that there is some risk that the patient is likely to
engage in self-injurious behavior for secondary gain, rather
than due to genuine suicidal ideation or intent, and that the
patient should be placed in a specified area of the institution
with observation intervals specified by the physician to
minimize risk of self-harm, while also minimizing
opportunities for secondary gain; or
Determine that no debilitating mental disorder is present and
inform the referring staff that no mental health treatment is
necessary.
If it is determined that the patient needs care at a CSU, the evaluating
staff person shall complete DC4-656 Referral for Inpatient Mental
Health Care (available as an electronic form) and arrange transfer of
the patient in accordance with HSB 15.05.07 Transfer for Mental
Health Reasons. Staff shall advise the patient of the need for
inpatient care and the intent to transfer.
Procedure for Use of IMR
a.
To place a patient in an IMR for mental health reasons constitutes an
infirmary admission and shall require physician or clinical associate
written order, except after normal duty hours when an RN may admit
the patient without written physician order. However, physician
verbal order must be obtained immediately (within one hour of
admission). A physician must countersign the verbal order within 72
hours with the date and time of signature duly noted. An admission
chart shall be opened within two (2) hours of admission.
Placement in the infirmary, or other specified area for the purpose of
further observation and/or the avoidance of self-harm, shall be
documented in the health record.
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
b.
Within 30 minutes of admission, the patient shall be asked to grant
consent to inpatient mental health care via DC4-649 Consent to
Inpatient Mental Health Care (attachment #3) if mentally capable of
giving informed consent. If the patient refuses or is unable to give
informed consent, the patient shall be considered an involuntary
admission. Other admission procedures shall be the same as for
patients admitted to the infirmary (see HSB 15.03.26 Infirmary
Services).
Note: The patient may refuse treatment but may not refuse
admission.
c.
A patient who is assessed as at risk for intentional self-injury for
mental health reasons should be housed in a room that has been
certified by the Regional Health Services Office or Office of Health
Services as being in compliance with HSB 15.03.14 Standards for
Isolation Management Rooms. However, if a certified room is not
available, the patient may be admitted to a regular infirmary bed or
an alternative housing situation within the facility including
designated confinement, close management or protective
management cells. The physician order for this placement must
specify allowable property, if any, and the frequency of staff
observation, from continuous one-on-one in the infirmary to a
maximum interval of 30 minutes between observations in a
designated IMR. The physician order shall also note any and all
other special considerations. When alternative institutional housing
is used, the observation intervals specified may be effected by
security staff. DC4-650 shall be initiated by nursing staff (top
portion completed) before security staff begins observation. Health
care staff shall continue to monitor and intervene as specified in all
other HSBs. Should patient behavior or condition change, security
staff shall immediately notify the appropriate health care staff who
shall reassess the patient, consult as necessary, and reevaluate
previously ordered disposition.
d.
The clinical assessment of the patient and the order for admission to
an IMR shall be documented as a SOAP note in the mental health
portion of the health record.
e.
A patient placed in an IMR shall be observed at 15-minute intervals
on SOS-1, or 30-minute intervals on SOS-2, or more frequently if
clinically required. The physician ordering IMR placement must
include the frequency of observation required. Observations shall be
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
documented on DC4-650 Observation Checklist which shall be filed
in the infirmary record.
5.
f.
Institutional mental health staff shall assess the inmate at least once
every 24 hours excluding weekends, and provide counseling to
attempt to resolve the crisis. This shall be documented in a SOAP
note on DC4-642 Chronological Record of Outpatient Mental
Health Care.
g.
When available, the psychiatrist is the responsible health care
professional. If a psychiatrist is not available, the attending
physician or clinical associate (in consultation with the senior
psychologist and, if needed, by telephone consultation with an oncall psychiatrist) shall assume treatment and care responsibility.
h.
The length of stay in IMRs or alternative housing located at S-1-2
and S-1-2-3 institutions shall not exceed 72 and 96 hours,
respectively. If the patient crisis is not resolved within the time
indicated, the patient shall be considered for transfer to a CSU. All
cases staying beyond the time specified shall continue to be reviewed
every 24 hours by a general physician or psychiatrist. If the review
is done by a general physician, it must be in consultation with the
most senior mental health staff. The psychiatrist or non-psychiatric
physician shall document the findings of each review in the
infirmary record, stating whether additional isolation is approved and
the reason(s) for the physician’s decision. The review should
include a personal examination of the patient, but may consist of
consultation by telephone after regular work hours, on weekends,
and on holidays.
Discharge from IMR
a.
A patient shall be discharged from an IMR or alternative housing to
the general patient population with an aftercare plan when the
attending physician, in consultation with the mental health staff
determines that patient mental status and adaptive skills will enable
the patient to make a satisfactory adjustment within that setting.
Similarly, any patient who requires a higher level of care shall be
transferred to a CSU in a timely manner.
b.
When a patient is discharged from an IMR, a DC4-657 Discharge
Summary for Inpatient Mental Health Care (see attachment #4) shall
be completed within 72 hours by the attending non-psychiatric
physician in consultation with the mental health staff. Both the
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
attending physician and the senior psychologist must sign the
discharge summary. A medical discharge summary is not required if
a patient is admitted to the IMR for mental health reasons only and
there are no attendant medical problems.
B.
c.
Immediately after discharge of the patient, the case manager (in
consultation with the senior psychologist) shall review the patient’s
individualized service plan and revise as necessary in order to
provide appropriate follow-up care for the patient, based on the
infirmary admission.
d.
The S-1, S-2 or S-3 patient who has been taken off either SOS-1 or
SOS-2 must remain within the institution for at least seven (7)
calendar days (via a mental health hold) after discontinuation of the
suicide precaution unless otherwise clinically indicated. The patient
can be taken off the hold by the senior psychologist or psychiatrist.
An inmate from a work camp setting must not be returned to the
work camp for at least seven (7) calendar days after discontinuation
of suicide observation status unless the return is clinically indicated.
e.
A patient discharged from an IMR shall be discharged with an S
grade of 2 or higher if clinically appropriate. Regardless of S grade
upon discharge, the case manager shall follow up within seven (7)
days of discharge or sooner as clinically indicated.
Crisis Stabilization Unit
1.
Policy
Crisis stabilization care, consisting of brief (typically 15 to 30 days) but
intensive psychological and psychiatric services provided within a highly
structured inpatient setting, shall be provided to patients whose mental
disorders or symptoms cannot be safely and adequately treated within the
general patient population or in a TCU. The primary purpose of care in a
crisis stabilization unit (CSU) is rapid alleviation of acute symptoms of
mental disorder. The CSU is also an appropriate setting for comprehensive
evaluation of patients with complex clinical presentation. This type of
assessment may lengthen the patient’s course of treatment in the CSU.
Patients in crisis stabilization care shall be assigned an S grade of S-5.
Each CSU shall be guided by a set of written policies and procedures which
include a level system that has been approved by the Regional Mental
Health Consultant and the Director of Mental Health Services.
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
2.
Criteria for Admission to a CSU
Presence of acute and severely debilitating symptomatology which is
primarily associated with an Axis I diagnosis in the Diagnostic and
Statistical Manual of Mental Disorders and which cannot be safely and
adequately treated within an infirmary isolation management room, as
determined by mental health staff or (in their absence) by a registered nurse
or physician.
Note that patients with mental retardation and at least moderately impaired
adaptive behavior are candidates for transitional versus crisis stabilization
care, unless they also have a coexisting mental disorder that requires crisis
stabilization care.
3.
Transfers to CSU
The procedures for transfer to a CSU during and after regular working hours
are outlined in HSB 15.05.07 Transfers for Mental Health Reasons.
Note: Youthful male offenders committed under Chapter 958, FS, shall not
be placed at Union Correctional Institution CSU/TCU under any
circumstances.
4.
Pre- and Postadmission Procedures
a.
Emergent referrals may be made by the on-call physician after
regular work hours in consultation with senior medical staff on site.
An after-hours transfer must have approval of the central office duty
officer. Patients shall be admitted to a CSU by order of a physician.
The nurse in attendance at the CSU shall accept the patient and shall
obtain verbal orders for admission within one hour by telephone
from a physician. Furthermore, a physician must countersign the
verbal order within 72 hours noting the date and time of
countersignature.
b.
Upon arrival at the institution, the patient may be placed in a holding
cell for a period not to exceed two hours. Observations shall be
documented at least every 30 minutes on DC4-650 Observation
Checklist.
Upon admission, the patient may be placed in an observation cell
with a clear door for a further period not to exceed four (4) hours.
Observations shall be documented at least every 30 minutes on
DC4-650 Observation Checklist. This observation period is not the
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
same as placing the patient in time-out or psychiatric seclusion.
Orientation to the unit, nursing assessment, psychiatric evaluation,
and other evaluations shall be attempted at this time.
c.
After admission, each patient is assigned a case manager, informed
of the reason(s) for admission and given a verbal and written
orientation to the unit. Orientation shall be documented as part of
the nursing assessment.
d.
Following orientation to the CSU, informed consent shall be
obtained by completing DC4-649 Consent to Inpatient Mental
Health Care. If the patient does not give written consent, the patient
shall be asked to sign a refusal form (DC4-711A Affidavit of Refusal
for Health Care Services). If the patient refuses to sign the refusal
form, a note to that effect shall be written on the form and witnessed
by another staff member.
Note: The patient may refuse treatment but may not refuse
admission.
e.
An infirmary record shall be opened at the time of admission, and a
nursing assessment shall be completed within four (4) hours of
admission. The nursing assessment shall be written on DC4-673
Mental Health Inpatient Nursing Assessment (see attachment #5)
and shall include at least the following:
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Documented reason for admission and a quoted statement
from the patient, if possible, relating the patient’s
understanding of why the patient is being admitted.
Description of physical health problems.
Description of patient mood, appearance, cooperativeness,
and behavior.
Description of patient hygiene and grooming.
Whether or not patient speech is coherent and relevant.
Expression or denial of suicidal/homicidal thoughts/
intent/plan.
Explanation of treatment modalities to be provided including
medications, if applicable, as noted in the admission order or
provided generally on the unit.
Other objective observations noted and actions taken.
Strengths, needs, and problems derived from the above.
Orientation to the unit including how medical and dental care
can be obtained during patient stay; or reason why
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
(11)
(12)
(13)
(14)
f.
A physician admission note shall be completed within 24 hours of a
patient admission to the CSU (except on weekends and holidays).
The note shall include:
(1)
(2)
(3)
(4)
(5)
g.
orientation was not given. (Note: the patient must also be
given a written orientation to the unit.)
Inform the patient of the name of the patient’s case manager
assigned by the senior psychologist (based on an established
rotation list) and briefly describe the role of the case
manager.
Explanation of unit rules provided or reason not provided.
Referrals, recommended interventions and other follow-up
action to be taken. Note that if any of the tasks in (10), (11),
or (12) above were not completed, follow-up action to
complete the tasks must be stated.
Signature, title, and name stamp.
Chief complaint
History of presenting illness
Mental status exam
Diagnoses
Plan/orders
All patients shall receive a psychiatric evaluation within 72 hours of
admission. The psychiatric evaluation may be completed in lieu of
the admission note if completed within 24 hours. The evaluation
shall be typed on DC4-655 Psychiatric Evaluation (attachment #6
and shall include at least the following:
(1)
(2)
Identifying Information
(Name; age; ethnicity; sex; crime; sentence)
Reason For Referral/Present Problem
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
(3)
(4)
(5)
(6)
(7)
Relevant History
(Present psychiatric history; past psychiatric history; history
of sexual abuse, domestic violence, violence, suicide, and
drug use; family psychiatric history; medication history)
Mental Status Exam
(Appearance; behavior; alertness; speech; activity; thinking;
perception; mood; affect; orientation; memory; judgment;
suicidal/homicidal ideas; and vegetative functions)
DSM Diagnoses and Codes
(Axes I, II, III, IV, and V)
Recommendations/Treatments
(Precautions; labs; medications; other therapies and services;
and referrals.)
Name, Title, and Signature
h.
Within 72 hours of admission, the case manager shall meet with the
patient to explain the reason(s) for admission, unit rules,
levels/privileges system.
i.
A risk assessment shall be completed within 72 hours by a team
comprised of mental health staff, security staff, and classification
staff.
j.
The psychiatrist shall change the S grade to S-5 within 72 hours of
admission.
k.
Within 96 hours, education staff will be contacted to determine if the
patient is classified as a special education student. If so, an
immediate referral shall be issued to education staff.
l.
On the first non-weekend, nonholiday day following admission, a
nurse will notify the senior psychologist and case manager of all case
management assignments from the rotation list.
m.
Within five (5) calendar days of admission, the case manager shall
review the current mental health assessments including DC4-655
Psychiatric Evaluation (attachment #6), DC4-673 Mental Health
Inpatient Nursing Assessment, past mental health records, and
interview the patient to obtain his/her input for the individualized
service plan (ISP). The case manager shall document the needs and
goals that were identified by the patient as well as those that were
identified by the staff with an indication in a SOAP note titled
Service Planning Interview as to whether the patient concurred.
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
Next the case manager shall complete a draft DC4-643C BioPsychosocial Assessment (if one was not prepared within the past six
months), consult the Problem Index and the Intervention Index
(Appendices I and II respectively of HSB 15.05.11 Implementation
of Individualized Mental Health Services) and prepare a draft update
for the existing ISP, or develop a draft ISP on DC4-643A
Individualized Service Plan, and schedule a service planning
conference.
5.
n.
On or before the fifth (5th) calendar day after admission, the patient
and the MDST shall meet to finalize and sign the ISP. Each ISP
shall address self-image.
o.
If clinically indicated and the patient is able to meaningfully
participate in testing (due to clinical condition, literacy, and other
factors), a psychological evaluation, to include personality and
cognitive tests, shall be completed within ten (10) days of admission
and typed on DC4-685 Psychological Evaluation (attachment #7).
p.
The patient and the MDST shall meet to review and, if necessary,
update the ISP at the following intervals: seven (7) days, and every
seven (7) days thereafter following the finalizing of the ISP. The ISP
shall be revised as indicated and the review documented on the ISP
review (DC4-643B Individualized Service Plan Review).
q.
The patient shall be present, whenever feasible, at the service
planning conference. The patient shall also attend ISP review
meetings unless the patient chooses to attend a concurrent therapy
group and his/her signature has been obtained on the signature sheet.
The patient's decision to attend therapy as an alternative shall be
documented in the medical record. The absence and the reason for
the absence of the patient at such meetings shall be documented in
an incidental note.
r.
A physical examination shall be completed within 72 hours of
admission.
Program Requirements
a.
Each CSU shall offer a range of planned scheduled services to
address patient needs which typically include the following:
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
b.
Psychotropic Medication that shall be prescribed only by
the psychiatrist or appropriately qualified and credentialed
clinical associate.
Medication Management that can range from teaching the
patient the reasons for medication compliance and effects of
medications to programs designed to reduce or eliminate use
of medication. Use of this intervention with a particular
patient shall require concurrence of the psychiatrist or
clinical associate.
Cognitive Retraining a structured group learning program
which is intended to enhance self-awareness, self-control,
problem solving, and interpersonal communication.
Stress Management that teaches stress recognition and
appropriate methods of managing stress, such as use of
relaxation techniques.
Anger Management that teaches awareness of the
experience of anger, knowledge of its sources, and how to
appropriately manage anger.
Activity Therapy that includes planned supervised group
and/or individual activities that provide appropriate physical
release, an opportunity to learn group cooperation, and to
enhance attention/concentration.
Biblio and Video Therapy which includes the use of books,
pamphlets, and videotapes to facilitate a desirable change in
behavior and/or attitude.
Adult Daily Living Skills Training consists of group and/or
individual instruction/exercises designed to promote
satisfactory bathing, hygiene and grooming, dressing, eating,
and toileting.
Therapeutic Community which provides for a block of
time, at least once a week, in which patients have a vehicle to
communicate concerns as a community to staff as a group,
and to facilitate two-way exchange of information.
Social Skills Training (optional), depending on average
length of stay and staff resources. A series of group and/or
individual exercises designed to enhance awareness of one's
interpersonal impact on others, reduce negative interpersonal
interaction and increase positive (desirable) interpersonal
interaction.
A minimum of 12 hours of planned scheduled services per week
shall be available to each patient in accordance with the ISP. At
least two (2) of the 12 hours shall be available on the weekends.
Planned scheduled services include scheduled activities for the
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
patient as planned by the MDST. Tutoring or special education
classes, substance abuse treatment, and other services provided by
non-health care staff may be counted as planned scheduled services
if reflected in the ISP and if monitored and documented
appropriately in accordance with the policies and procedures of that
discipline or specialty.
c.
Each patient's participation in planned scheduled services or lack
thereof shall be recorded daily on DC4-664 Mental Health
Attendance Record (see attachment #8). Each mental health care
provider shall write a weekly SOAP note to document ratio of
activities attended, the patient's relative participation, and observed
progress made toward treatment goals. Patient participation or lack
thereof in activities and services provided by non-health care staff
shall be documented by those providers in accordance with policies
and procedures of each specialty.
d.
The case manager shall review DC4-664 Mental Health Attendance
Record and the medication administration record at least weekly to
ensure implementation of the ISP.
e.
The case manager shall review other relevant documentation,
interview the patient, and then prepare a case management summary
for scheduled multidisciplinary services team staffing to summarize
treatments and services received from mental health and non-mental
health staff, patient's relative compliance, and progress made toward
each short-term goal on the ISP.
f.
When a patient enters a CSU on confinement or close management
status, such status shall be suspended until the patient is discharged.
A patient who is admitted from protective management must not be
indefinitely confined to an individual room. When patient behavior,
level of clinical function and security considerations permit, the
patient must be allowed to attend treatment activities and access the
day room with other patients. Restrictions of normal access to
treatment activity within the unit must be justified in the clinical
record even if the restriction is for security reasons only. Every
precaution shall be taken to protect a patient when there is good
reason to believe that the patient may be in danger. This may
include separation from other specific patients, but not to the point
that the patient is denied access to needed treatment via seclusion. In
the rare event that the patient must be protected from most or all
other patients, the patient shall be transferred to another CSU for
treatment.
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
g.
Each CSU shall have a clearly delineated system of patient levels
and privileges that emphasize and reinforce positive (desirable)
behavior. The levels, associated privileges, and the criteria for level
changes must be posted in the unit at a location that is readily
accessible to patients.
h.
Each CSU shall utilize a MDST to develop and implement the ISP,
assign and modify levels/privileges, and review patient progress
relative to possible discharge from the unit. The MDST shall at least
be composed of a psychiatrist, a senior psychologist, a registered
nurse specialist, a psychological specialist, a human services
counselor, and a correctional officer.
i.
Nursing observations shall be documented at least once per shift
(night shift by exception) on DC4-642 Chronological Record of
Outpatient Mental Health Care in SOAP format. Each note on the
day and evening shifts shall address appearance, behavior, mood,
suicidal/homicidal ideation, if stated and evidence of side effects of
medications. Nursing notes shall note nursing interventions and
their effect on identified problems. At least one of the notes
written each day shall state whether the patient made any
medical or dental complaints on that day. Vital signs shall be
taken and charted daily for five days and twice a week
thereafter unless otherwise ordered by psychiatrist/physician
(i.e., change in medication, medical problem). Patient weight
shall be recorded weekly unless increased frequency is clinically
indicated. Active acute medical problems must be reflected in a
daily nursing entry until resolved.
j.
Medical screening and care and nursing interventions shall be
provided in accordance with that specified in HSB 15.05.20 Medical
and Dental Care for Mentally Disordered Inmates.
k.
Prior to receiving psychotropic medication, a patient must give
informed consent on the appropriate form in accordance with HSB
15.05.06 Informed Consent for Inmates Receiving Psychotropic
Medication for Mental Problems or Antiparkinsonian Medication
for Side Effects of Psychotropic Medication.
l.
Use of psychotropic medications within the CSU shall be in
accordance with HSB 15.05.19 Psychotropic Medication Use
Standards.
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
m.
6.
The assigned psychiatrist shall conduct daily rounds (except on
weekends and holidays) to review patient general functioning in the
unit. The psychiatrist shall write at least three (3) SOAP notes
during the first week, and at least one per week thereafter to
document relevant mental status, presence or absence of side effects,
and progress made toward specific treatment goals, covering all the
areas outlined in HSB 15.05.18 Outpatient Mental Health Services
for outpatient psychiatric follow-up. Patients on SOS shall be seen
daily (except weekends and holidays) with a progress note.
Criteria for Transfer or Discharge from a CSU
a.
TRANSFER TO CMHI:
Patient must require a treatment regime or level of care not available
in the CSU, as indicated by any one of the following:
(1)
(2)
(3)
b.
The patient continues to suffer from symptoms of a
debilitating mental disorder for 20 days and during this
period, the patient is noncompliant and/or refuses treatment.
Management of acute symptoms has required use of at least
three (3) occasions of four-point restraints or forced
psychotropic medication on an emergency basis in any two(2) week period, when patient behavior is related to
noncompliance with medication.
The patient requires transfer to CMHI because the patient is
in emergent need of care and treatment that cannot be
adequately provided in the CSU, and the lack of such
treatment poses a serious and/or imminent danger to the
safety and well-being of the patient and/or that of others.
TRANSFER TO TCU:
Patient must meet the criteria for admission to a TCU (see section
IVC2a-d).
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
c.
DISCHARGE TO OUTPATIENT:
(1)
(2)
7.
C.
Patient level of functioning will enable satisfactory
adjustment within the general patient population, and an
aftercare plan has been developed and initiated, AND
At least seven (7) days must have elapsed since the end of
the last episode of psychiatric seclusion, restraints, or suicide
observation status unless an exception is clinically
indicated. The clinical rationale for exceptions shall be
documented in the health record.
Procedures for CSU Transfer or Discharge
a.
When a patient is discharged from a CSU to general population, a
DC4-657 Discharge Summary for Inpatient Mental Health Care
shall be completed before discharge.
b.
When a patient is transferred to TCU or CMHI, a DC4-657A
Transfer Summary For Inpatient Mental Health Care (see
attachment #9) shall be completed at the time of transfer.
c.
The discharge or transfer summary shall be placed in the health
record at the time of discharge or transfer, the infirmary record shall
be packaged separately, clearly marked, and forwarded with the
health record.
d.
A patient being discharged from a CSU to a TCU shall be discharged
with an S grade of 4, a patient being discharged to the general patient
population shall be discharged with an S grade of 3. The patient
shall continue on a mental health hold and not be transferred to
another institution for at least 30 days after discharge from the CSU.
Exceptions shall be documented with sufficient clinical justification
in the health record. Removal of the mental health hold shall be
determined by the multidisciplinary services team, but may be
effected by the senior psychologist.
Transitional Care
1.
Policy
Transitional care consists of psychological and psychiatric treatment
provided in the context of a structured residential setting. Some patients
may only require this level of care as a transition back to general population;
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
however, some patients with severe and persistent mental illness may
require this level of care indefinitely. Transitional care is indicated for
mental and/or intellectual impairments that are not so severe as to require
crisis stabilization care, but which compromise the patient's ability to adjust
within the general patient population. Patients in transitional care shall be
assigned an S grade of S-4.
Each transitional care unit (TCU) shall be guided by a set of written policies
and procedures including a level system that has been approved by the
Regional Mental Health Consultant and the Director of Mental Health
Services.
2.
Criteria for Admission to a TCU
a.
Criterion for admission to a TCU is the significant impairment in
patient ability to adjust satisfactorily within the general patient
population. The impairment is primarily associated with an Axis I
diagnosis in the Diagnostic and Statistical Manual of Mental
Disorders or a significant Axis II developmental disorder;
b.
The mental disorder and its impact on behavioral functioning is not
so severe as to require crisis stabilization care but nevertheless
compromises the ability to meet the normal requirements of
everyday living in the general patient population; AND
c.
The patient meets the following:
(1)
(2)
(3)
d.
Absence of acute exacerbation of psychotic and/or affective
symptomatology
(chronic
psychotic
or
affective
sympomatology may be present if the patient is adaptive and
functioning is sufficient to participate in TCU activities).
Absence of acute medical condition.
Ability to communicate needs and respond to staff in a
socially appropriate manner, AND
The patient has been recommended for transitional care by an
outpatient, CSU, or Corrections Mental Health Institution (CMHI)
multidisciplinary services team.
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
3.
Transfer to TCU
The procedure for transfer to a TCU is outlined in HSB 15.05.07 Transfer
for Mental Health Reasons.
Note: Youthful male offenders committed under Chapter 958, FS, shall not
be placed at the Union Correctional Institution CSU/TCU under any
circumstances.
4.
Pre- and Postadmission Procedures
a.
Patients shall be admitted to a TCU by written order of a physician.
b.
Upon arrival at the institution, the patient may be placed in a
holding cell for a period not to exceed two (2) hours. Observations
shall be documented at least every 30 minutes on DC4-650
Observation Checklist.
c.
Upon admission the patient may be placed in an observation cell
with a clear door for a further period not to exceed four (4) hours.
This observation period is not SOS status. Observations shall be
documented at least every 30 minutes on DC4-650 Observation
Checklist. This observation period is not the same as placing the
patient in time-out or psychiatric seclusion. Orientation to the unit,
nursing assessment, psychiatric evaluation, and other evaluations
shall be attempted at this time.
d.
After admission, each patient is assigned a case manager, informed
about the reason(s) for admission and given a verbal and written
orientation to the unit. Orientation shall be documented as part of
the Nursing Assessment.
e.
Following orientation to the TCU, informed consent shall be
obtained by completing DC4-649. If the patient does not give
written consent, the patient shall be asked to sign a refusal form
(DC4-711A Affidavit of Refusal for Health Care Services). If the
patient refuses to sign the refusal form, a note to that effect shall be
written on the form and witnessed by another staff member.
Note: The patient may refuse treatment but may not refuse
admission.
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
f.
An inpatient record shall be opened at the time of admission, and a
nursing assessment shall be completed within four (4) hours of
admission. The nursing assessment shall be written on DC4-673
Mental Health Inpatient Nursing Assessment and shall at least
include the following:
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
g.
Documented reason for admission and a quoted statement
from the patient, if possible, relating the patient’s
understanding of why the patient is being admitted.
Description of physical health problems.
Description of patient mood, appearance, cooperativeness,
and behavior.
Description of patient hygiene and grooming.
Whether or not patient speech is coherent and relevant.
Expression or denial of suicidal/homicidal thoughts/
intent/plan.
Explanation of treatment modalities to be provided including
medications, if applicable, as noted in the admission order or
provided generally on the unit.
Other objective observations noted and actions taken.
Strengths, needs, and problems derived from the above.
Orientation to the unit including how medical and dental care
can be obtained during patient stay; or reason why
orientation was not given. (Note: the patient must also be
given a written orientation to the unit.)
Inform the patient of the name of the patient’s case manager
and briefly describe the case manager's role.
Explanation of unit rules provided or reason not provided.
Referrals, recommended interventions and other follow-up
action to be taken. Note that if any of the tasks in (10), (11),
or (12) above were not completed, follow-up action to
complete the tasks must be stated.
Signature, title, and name stamp.
A physician admission note shall be completed within 24 hours of
patient admission to the TCU (except on weekends and
holidays). The note shall include:
(1)
(2)
(3)
(4)
(5)
Chief complaint
History of the presenting illness
Mental status examination
Diagnoses
Plan/orders
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
h.
Within 72 hours of admission, the case manager shall meet with the
patient to again explain the reason(s) for admission, unit rules, and
levels/privileges system. Within 96 hours the case manager shall
contact education staff to determine if the patient has been classified
as a special education student. If so, an immediate referral to
education shall be made.
i.
The psychiatrist shall change the S grade to S-4 within 72 hours of
admission.
j.
All patients shall receive a psychiatric evaluation within seven (7)
days of admission. The psychiatric evaluation may be completed in
lieu of the admission note (if completed within 24 hours of
admission). The evaluation shall be typed on DC4-655 Psychiatric
Evaluation (see attachment #6) and shall include:
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Identifying Information
(Name; age; ethnicity; sex; crime; sentence)
Reason For Referral/Present Problem
Relevant History
(Present psychiatric history; past psychiatric history; history
of sexual abuse, violence, suicide, and drug use; family
psychiatric history; medication history)
Mental Status Exam
(Appearance; behavior; alertness; speech; activity; thinking;
perception; mood; affect; orientation; memory; judgment;
suicidal/homicidal ideas; and vegetative functions)
DSM Diagnoses and Codes
(Axes I, II, III, IV, and V)
Recommendations/Treatments
(Precautions; labs; medications; other therapies and services;
and referrals.)
Name, Title, and Signature
k.
If clinically indicated and the patient is able to meaningfully
participate in testing (due to clinical condition, literacy, and other
factors, a psychological evaluation, to include personality and
cognitive tests, shall be completed within ten (10) days of admission
and typed on DC4-685 Psychological Evaluation.
l.
Within 14 calendar days of admission, the case manager shall review
the current mental health assessments, including DC4-655
Psychiatric Evaluation (see attachment #6) DC4-673 Mental Health
Inpatient Nursing Assessment, past mental health records, and
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
interview the patient to obtain patient input for the individualized
service plan (ISP). The case manager shall document the needs and
goals that were identified by the patient as well as those that were
identified by the staff with an indication in a SOAP note titled
Service Planning Interview as to whether the patient concurred.
Next, the case manager shall complete DC4-643C Bio-Psychosocial
Assessment or draft an update of the bio-psychosocial assessment if
the current bio-psychosocial assessment has not been updated within
six months, consult the Problem Index and the Intervention Index
(appendices I and II respectively of HSB 15.05.11 Implementation of
Individualized Mental Health Services), prepare a draft update for
the existing ISP or develop a draft ISP on DC4-643A Individualized
Service Plan, and schedule a service planning conference.
5.
m.
On or before the 14th calendar day after admission, the patient and
the multidisciplinary services team (MDST) shall meet to finalize
and sign the ISP.
n.
The patient and the MDST shall meet to review and, if necessary,
update the ISP at the following intervals: 30 days, 90 days, and
every 90 days thereafter following the finalizing of the initial ISP.
The ISP shall be revised as required and the review documented on
the ISP review (DC4-643B Individualized Service Plan Review).
o.
The patient should be present, whenever this is feasible, at the
service planning conference and at ISP reviews. The absence and
the reason for the absence of the patient at such meetings shall be
documented in an incidental note.
Program Requirements
a.
Each TCU shall offer a range of planned scheduled services to
address patient needs, which typically include the following:
(1)
(2)
Psychotropic Medication which shall be prescribed only by
the psychiatrist or clinical associate.
Medication Management which can range from teaching
the patient about the reasons for and effects of medications,
to programs designed to reduce or eliminate use of
medication. Use of this intervention with a particular patient
shall require concurrence of the psychiatrist or clinical
associate.
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
Cognitive Retraining which is a structured group learning
program which is intended to enhance self-awareness, selfcontrol, problem solving, and interpersonal communication.
Stress Management that teaches stress recognition and
appropriate methods of managing stress, such as use of
relaxation techniques.
Anger Management that teaches awareness of the
experience of anger, knowledge of its sources, and how to
manage it appropriately.
Activity Therapy that includes planned supervised group
and/or individual activities that provide appropriate physical
release, an opportunity to learn group cooperation, and to
enhance attention/concentration.
Social Skills Training is a series of group and/or individual
exercises designed to enhance awareness of one's
interpersonal impact on others, reduce negative interpersonal
interaction and increase positive (desirable) interpersonal
interaction.
Biblio and Video Therapy which includes the use of books,
pamphlets, and videotapes to facilitate a desirable change in
behavior and/or attitude.
Adult Daily Living Skills Training consists of group and/or
individual instruction/exercises designed to promote
satisfactory bathing, hygiene and grooming, dressing, eating,
and toileting.
Therapeutic Community which provides for a block of
time, at least once a week, in which patients have a vehicle to
communicate concerns as a community to staff as a group,
and to facilitate two-way exchange of information.
b.
A minimum of 17 hours of planned scheduled services per week
shall be available to each patient, in accordance with the ISP. At
least two (2) of the 17 hours shall be available on weekends.
Planned scheduled services include scheduled activities for the
patient as planned by the MDST. Tutoring or special education
classes, substance abuse treatment, other services provided by nonhealth care staff should be considered planned scheduled services if
reflected in the ISP and if monitored and documented in accordance
with the policies and procedures of that discipline or specialty.
c.
Patient participation in, or lack thereof, shall be recorded daily on
DC4-664 Mental Health Attendance Record by the provider.
Provider shall write a weekly SOAP note to document the ratio of
activities attended (e.g., three of three medication management
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
groups), patient relative participation, and observed progress made
toward treatment goals. Patient participation or lack thereof in
activities and services provided by non-health care staff shall be
documented in accordance with the policies and procedures of that
discipline or specialty.
d.
The case manager shall review DC4-664 Mental Health Attendance
Record and the medication administration record at least once every
two weeks to ensure implementation of the ISP.
e.
The case manager shall review other relevant documentation,
interview the patient, and then prepare a case management summary
to be presented at multidisciplinary services planning staffing at the
time of the patient’s ISP update to summarize treatments and
services received from mental health and non-mental health staff,
patient's relative compliance, and progress made toward each of the
short- and long-term goals on the ISP. The team members shall
revise treatment goals and services accordingly.
f.
When a patient enters a TCU on confinement or close management
status, such status shall be suspended until the patient is discharged.
A patient who is admitted from protective management must not be
indefinitely confined to an individual room. When patient behavior,
clinical level of function, and security considerations permit, the
patient must be allowed to attend treatment activities and access the
day room with other patients. Restrictions of normal access to
treatment activity within the unit must be justified in the clinical
record even if restrictions are for security reasons only. Every
precaution shall be taken to protect a patient when there is good
reason to believe the patient may be in danger. This may include
separation from other specific patients, but not to the point that the
patient is denied access to needed treatment via seclusion. In the rare
event that the patient must be protected from most or all other
patients, the patient shall be transferred to another TCU for
treatment.
g.
Each TCU shall have a clearly delineated system of patient levels
and privileges that emphasize and reinforce positive (desirable)
behavior. The levels, associated privileges, and the criteria for level
changes must be posted in the unit, at a location that is readily
accessible to patients.
The levels and privileges will be designed and utilized in such a
manner as to approximate the daily demands and expectations of
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
general population living, especially for patients who are approaching
discharge. For example, when clinical and behavioral status permit, a
TCU patient will report to the regular outpatient clinic for medical
care and to take psychotropic medication. Patients shall also eat
meals in the cafeteria and have access to other resources within the
general institutional compound, such as school, library, recreation,
chapel, and work.
h.
Each TCU shall utilize a MDST to develop and implement the ISP,
assign and modify levels/privileges, and review patient progress
relative to possible discharge from the unit. The MDST shall be
composed of the psychiatrist, the senior psychologist, psychological
specialist, a human services counselor, a registered nurse specialist,
and a member of the security staff.
i.
Nursing observations shall be documented at least once per day on
DC4-642 Chronological Record of Outpatient Mental Health Care
in SOAP format. Each note shall address:
(1)
(2)
(3)
(4)
(5)
Description of patient appearance, behavior, mood, and
suicidal/homicidal ideation if stated.
Description of any medical or dental complaints and actions
taken to address these.
Description of any side effects of psychotropic medications.
Note patient vital signs daily for five days and twice a week
thereafter; note weight on a weekly basis. Frequency shall be
increased if clinically indicated.
A summary of nursing interventions and their effects on
identified problems.
j.
Note that medical, dental and medication complaints, and unusual
events shall be documented in chronological order on the progress
note form (DC4-642 Chronological Record of Outpatient Mental
Health Care).
k.
Medical screening and care shall be provided in accordance with that
specified in HSB 15.05.20 Medical and Dental Care for Mentally
Disordered Inmates.
l.
Prior to receiving psychotropic medication, a patient must give
informed consent on the appropriate form in accordance with
HSB 15.05.06 Informed Consent for Inmates Receiving
Psychotropic Medication… .
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
6.
7.
m.
Use of psychotropic medications within the TCU shall be in
accordance with HSB 15.05.19 Psychotropic Medication Use
Standards.
n.
The assigned psychiatrist shall conduct daily rounds (except on
weekends and holidays) to review patient general functioning in the
unit. During the first 60 days, the psychiatrist shall write a SOAP
note at least once every two weeks on each patient after a formal
psychiatric follow-up to document relevant mental status, presence
or absence of side effects, and progress made toward specific
treatment goals. The progress notes shall cover all the areas outlined
in HSB 15.05.18 Outpatient Mental Health Services for outpatient
psychiatric follow-up. Thereafter, the psychiatrist shall write a
SOAP note every month on each patient, as clinically indicated.
Criteria for Discharge from a TCU
a.
Patient requires a higher level of care; OR
b.
Patient level of functioning will enable satisfactory adjustment
within the general patient population; AND
c.
An aftercare plan has been developed and initiated.
d.
At least seven (7) days have lapsed since the end of the last episode
of psychiatric seclusion, restraints or suicide observation status,
unless an exception is clinically indicated. The clinical rationale for
discharge prior to seven (7) days shall be documented in the health
record.
Discharge from TCU
a.
A patient of a TCU shall be discharged to the general patient
population, with an aftercare plan, when the MDST determines that
patient mental status and adaptive skills will enable the patient to
make a satisfactory adjustment within that setting.
DC4-657 Discharge Summary for Inpatient Mental Health Care
shall be completed before discharge.
b.
A patient who requires a higher level of care shall be transferred to a
CSU in a timely manner, and a DC4-657A Transfer Summary For
Inpatient Mental Health Care must be completed at the time of
transfer.
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
D.
c.
The transfer summary shall be placed into the health record at the
time of discharge, the inpatient record shall be packaged separately,
clearly marked, and forwarded with the health record.
d.
A patient being discharged from the TCU to the general patient
population shall be discharged with an S grade of 3, unless an
exception is clinically indicated. The clinical rationale shall be
documented in the health care record. The patient shall continue on
a mental health hold in general population and must not be
transferred to another institution for at least 30 days after discharge,
unless an exception is clinically indicated. Exceptions shall be
documented with sufficient clinical justification in the chart.
Removing the patient from hold shall be decided by the multidisciplinary services team.
Acute Hospital
1.
Policy
Acute hospital care consists of a broad range of inpatient services provided
at the Corrections Mental Health Institution (CMHI). Admission to CMHI
can only be made from a CSU and, except for emergencies (see HSB
15.05.07 Transfers for Mental Health Reasons), all admissions must be
accompanied by a court order or signed waiver (DCMH-12).
2.
3.
Criteria for Admission to CMHI
a.
Presence of acute/chronic symptoms of a mental disorder that
substantially interferes with patient ability to exercise conscious
control of the patient’s actions, to perceive or correctly interpret
reality, AND
b.
The patient evidences an impairment that is primarily associated
with an Axis I diagnosis in the Diagnostic and Statistical Manual of
Mental Disorders. In addition, the patient must be in need of care
that cannot be provided at the referring institution, or another CSU.
Criteria for Emergency Referral to CMHI:
a.
Presence of a mental illness as in A2 above, AND
b.
The patient is in need of immediate care which cannot be
appropriately provided at a CSU, AND
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
4.
c.
Without this care the patient poses an immediate threat of substantial
harm to the well-being and safety of self or others, OR
d.
Continued rapid deterioration of a psychotic disorder has occurred
and stabilization cannot be effected without involuntary medications
and the act of obtaining a court order poses a substantial and harmful
delay in treatment.
Transfers to CMHI
The procedures for routine and emergency transfers to CMHI are outlined in
HSB 15.05.07 Transfer for Mental Health Reasons.
Upon authorization of the transfer by the Population Management
Administrator, the referring CSU psychiatrist shall telephone CMHI and brief
the admitting psychiatrist on the overall clinical assessment of the patient
being referred and the rationale for the emergency referral.
5.
Discharge from CMHI
A patient deemed appropriate for discharge from CMHI shall generally be
referred to a TCU. Exceptions shall be documented with sufficient clinical
justification in the chart. A patient transferred to the TCU shall be treated
for at least 30 days prior to being discharged to the general patient
population. The clinical rationale for exceptions shall be documented in the
health care record. Transport from CMHI shall be direct.
V.
POSTRELEASE AFTERCARE PLANNING:
A.
Patients Who Require Inpatient Care After Release
1.
Inpatient care after EOS requires judicial commitment pursuant to
Chapter 394, Florida Statutes (The Baker Act). Civil commitment
procedures (Chapter 394) shall be initiated only from a CSU or from the
Corrections Mental Health Institution.
2.
The CSU or CMHI shall identify members of the patient population who are
within 60 days of EOS or earlier and who are likely to need additional
inpatient care after EOS. The ISP must address aftercare needs (see
problem #309 Discharge/Aftercare Planning from the Problem Index in
HSB 15.05.11 Implementation of Individualized Mental Health Services).
CSU patients within 60 days of EOS shall not be transferred to CMHI
without prior consultation with the director of mental health services.
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
3.
The CSU or CMHI staff shall request a placement hearing on involuntary
commitment, pursuant to Chapter 394, within the judicial circuit where the
DC institution is located. Staff shall immediately notify the home district
forensic specialist that these proceedings have begun (see appendix C
Contacts for Accessing Alcohol, Drug Abuse, and Mental Health Services
for Persons Leaving the Correctional System and appendix D Department of
Children and Families District Structure). Home district refers to the
Department of Children and Families district that encompasses the patient's
identified county of residence, or if the patient was a transient, the county in
which the crime was committed. DC staff shall also notify the forensic
specialist in the Department of Children and Families district where the
correctional institution is located.
4.
The case manager shall secure a release of information form from the
inmate. The case manager shall then prepare an information packet to
include the most recent biopsychosocial assessment, individualized service
plan, and psychiatric evaluation along with any summary or progress note
detailing recent changes in the inmate’s mental status, medication changes,
or other significant aspects of the inmate’s mental health and behavior.
5.
Prior to the placement hearing, the case manager shall forward the
information packet to the district forensic specialist in the Department of
Children and Families district where the correctional institution is located.
The forensic specialist will review the patient data and arrange for a local
community mental health center (CMHC) or clinic to interview the patient
and review the clinical record, if needed. The forensic specialist or
interviewing CMHC staff member will contact the home district forensic
specialist to discuss patient needs and determine whether or not
hospitalization is the only alternative. If hospitalization is not appropriate,
the home district will arrange for admission to the less restrictive treatment
setting selected. (If no less restrictive setting is available, the district
forensic specialist will arrange for the completion will initiate Department of
Children and Families form CF-MH 3089 and forward it to the court).
The district forensic specialist or designee shall communicate the results of
the above actions at the placement hearing. Following the hearing, the
designated forensic specialist will notify the home district forensic specialist
that the order has been issued and that admission procedures at the
appropriate state hospital shall be initiated. The designated forensic
specialist will notify the home district Hospital Liaison regarding the
admission. The designated forensic specialist will also contact the DC
institution and request that the following records, if available, be sent
immediately to the designated hospital:
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
a.
b.
c.
d.
e.
f.
Petition for Involuntary Examination and Court Order for
Involuntary Placement;
Clinical summary;
Psychiatric evaluation;
Bio-psychosocial assessment, including criminal history;
Medical history, including current medication; and
EOS or projected release date.
6.
An additional copy of the Petition for Involuntary Examination and Court
Order for Involuntary Placement shall be forwarded to the forensic
specialist in the district in which the inmate will receive treatment.
7.
The home district forensic specialist or designee will coordinate the hospital
admission with the patient EOS date. The DC institution shall transport the
patient to the hospital on the admission date.
8.
Civil involuntary placements from CMHI shall follow the same procedure
above.
9.
If the hospital waiting list precludes immediate placement, the patient shall
be transported to a receiving facility or crisis stabilization center designated
and coordinated by the district forensic specialist with the clinical
information above (IIIA5a-e) preceding the admission. The DC institution
shall transport the patient on the date of admission.
10.
If any patient needing hospitalization agrees to a voluntary placement, the
same procedures above shall be followed except that a hearing before the
local DC institution judicial circuit shall not be required.
With a voluntary placement, DC psychiatrist shall assess the inmate’s
clinical competence for fully informed consent and the inmate’s
commitment to treatment.
11.
When a mentally disordered patient's release is imminent because of
provisional credits or awareness of mental illness only shortly before
expected release, the following emergency placement procedures shall
apply:
a.
DC staff shall contact the Department of Children and Families
mental health program office, specifying whether the request is
voluntary or involuntary and specifying presumptive release date.
b.
The Department of Children and Families mental health program
office will assist the DC staff member and the forensic specialist in
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
both the local and Department of Children and Families home
district in expediting the request according to the previous
procedures.
12.
Classification staff shall notify mental health staff (180 days prior to EOS or
tentative release date, whichever is sooner) of the name and DC# of each
patient who will be released to probation and parole supervision.
Classification will also advise as to which probation and parole circuit office
the patient will be reporting.
If any patient received sexual disorder treatment during incarceration, mental
health staff shall forward (via regular mail) a copy of DC4-661 Summary of
Outpatient Mental Health Care (see attachment #10) to the designated
probation and parole circuit office at least 30 days prior to release.
If a patient is classified as S-4, or S-5, mental health staff shall forward (via
regular mail) a completed copy of DC4-657 Discharge Summary for
Inpatient Mental Health Care to the designated probation and parole circuit
office at least 30 days prior to release. This action shall be documented in an
incidental note in the health record. If the DC4-657 has been completed, but
lacks relevant and current information, an addendum shall be prepared titled
Addendum to Summary of Inpatient Mental Health Care of (date) and
forwarded together with the DC4-657.
In the case of those few S-5s who will be released directly to a community
crisis stabilization unit (pursuant to the Baker Act), mental health staff shall
forward the following to the probation and parole circuit office:
B.
a.
Patient name; DC number; anticipated date/time of release; and
name, address and telephone number of the community crisis
stabilization unit, all via DC-Mail at least 24 hours prior to release.
b.
Copy of the DC4-657 via regular mail by the date of release.
Patients Who are Committed to the Department of Children and Families as
Incompetent to Proceed (ICP) or Not Guilty by Reason of Insanity (NGRI) or the
Jimmy Ryce Act.
When commitment orders (e.g., Incompetent to Proceed or Not Guilty by Reason of
Insanity) to state mental health treatment facilities are to take effect upon EOS, DC
staff must arrange the placement by using section VA9 of this bulletin, i.e., staff
shall notify the Department of Children and Families Mental Health Program Office
within one work day of receiving the court order. In addition, DC staff must again
notify the Department of Children and Families 30 days before EOS date. Each
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
telephone contact must be documented in the health record as an incidental note on
DC4-642 Chronological Record of Outpatient Mental Health Care and followed up
with a letter of confirmation to the Department of Children and Families. Patients
who are identified as sexual predators and who are in need of inpatient
hospitalization after EOS shall immediately and in writing brought to the attention
of the Director of Mental Health Services and the Regional Mental Health
Consultant. Full and expedient cooperation with the Department of Children and
Families shall be rendered with regard to Jimmy Ryce Act and Baker Act issues.
C.
Patients Who Require Outpatient Care After Release
1.
Each case manager shall monitor the EOS dates of all patients on his/her
caseload who are currently receiving mental health services. The case
manager shall begin the process of developing a continuity of care plan for
each such patient not later than 180 days prior to EOS.
2.
The case manager shall contact the forensic specialist (see appendices) in the
patient home district to determine the proper referral community mental
health center or clinic.
3.
The Department of Children and Families forensic specialist will designate
the community mental health center (CMHC) or clinic to be called by the
case manager for an initial client appointment.
4.
The case manager shall obtain the appropriate release of information from
the patient and contact the designated CMHC or clinic to make a referral and
to obtain an initial appointment for the patient.
When CMHC or the clinic is contacted, the case manager shall be prepared to
provide such patient information as identifying information, current
diagnosis, current treatment, and compliance with treatment. The CMHC or
clinic should also be advised that a treatment summary shall be forwarded
before EOS. After the telephone call, the case manager shall send a letter (to
the CMHC staff person who received the verbal referral) advising of the
patient's current diagnosis, the treatment the patient is receiving, anticipated
treatment needs in the community, the estimated date the patient will be
released, and the patient's anticipated residential address. The letter should
also state that a treatment summary will be forwarded before EOS.
5.
The case manager shall inform the patient verbally and in writing of patient
appointment date and time, and if indicated, consults with the patient's
treating psychiatrist to ensure that an ample supply of psychotropic
medication will be given to the patient at the time of release.
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
6.
The case manager shall complete DC4-657 Discharge Summary for
Inpatient Mental Health Care not later than 30 days prior to EOS and send a
copy to the CMHC or clinic contact person (via regular mail).
7.
The case manager shall document all contacts with the Department of
Children and Families forensic specialist and CMHC or clinic staff via
incidental notes in the health record on DC4-642 Chronological Record of
Outpatient Mental Health Care. In addition, a copy of all written
correspondence shall be filed under Other Mental Health Related
Correspondence subdivider.
8.
Classification staff shall notify mental health (180 days prior to EOS or
tentative release date, whichever is sooner) of the name and DC# of each
patient who will be released to probation and parole supervision.
Classification will also advise as to which probation and parole circuit office
the patient will report.
Mental health staff shall forward (via regular mail) a copy of DC4-657
Discharge Summary for Inpatient Mental Health Care to the designated
probation and parole circuit office at least 30 days prior to release. This
action shall be documented in the health record. If the DC4-657 has been
completed, but lacks relevant and current information, an addendum shall be
prepared titled Addendum to Summary of Inpatient Mental Health Care of
(date) and forwarded with DC4-657.
VI.
9.
If any patient received sexual disorder treatment during incarceration, mental
health staff shall forward (via regular mail) a copy of DC4-661 Summary of
Outpatient Mental Health Care (see attachment #10) to the designated
probation and parole circuit office at least 30 days prior to release.
10.
A completed DC4-711B Consent for Inspection and/or Release of
Confidential Information shall be obtained before releasing information.
IMPLEMENTATION DATE:
Each institution is expected to implement this HSB no later than 30 days after signature.
Acting Assistant Secretary for Health Services
See next page for a listing of appendices and attachments.
Date
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SUBJECT: INPATIENT MENTAL HEALTH SERVICES
Appendices:
A Placement on SOS Decision Tree
B Decision Tree for After-Hours Emergencies
C Contacts for Accessing Alcohol, Drug Abuse, and Mental Health Services for Persons
Leaving the Correctional System
D Department of Children and Families District Structure
Attachments:
#1 DC4-683A Mental Health Emergency Nursing Assessment
#2 DC4-650 Observation Checklist/Restraint Observation Checklist
#3 DC4-649 Consent to Inpatient Mental Health Care
DC4-649 Permiso a cuidado de salud mental para reos
#4 DC4-657 Discharge Summary for Inpatient Mental Health Care
#5 DC4-673 Mental Health Inpatient Nursing Assessment
#6 DC4-655 Psychiatric Evaluation
#7 DC4-685 Psychological Evaluation
#8 DC4-664 Mental Health Attendance Record
#9 DC4-657A Transfer Summary for Inpatient Mental Health Care
#10 DC4-661 Summary of Outpatient Mental Health Care
This Bulletin Supersedes:
HSOI No. 85-1 dated 1/18/89
HSB 15.05.02 dated 4/15/91
HSB 15.05.12 dated 4/15/91
HSB 15.05.16 dated 4/15/91
HSB 15.05.05 dated 12/5/88,
4/19/89, and 4/15/91