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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 HEALTH SERVICES BULLETIN NO. 15.05.05 Page 2 of 36 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. HEALTH SERVICES BULLETIN NO. 15.05.05 Page 3 of 36 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 Page 4 of 36 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 HEALTH SERVICES BULLETIN NO. 15.05.05 Page 5 of 36 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. HEALTH SERVICES BULLETIN NO. 15.05.05 Page 6 of 36 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 HEALTH SERVICES BULLETIN NO. 15.05.05 Page 7 of 36 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 HEALTH SERVICES BULLETIN NO. 15.05.05 Page 8 of 36 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. HEALTH SERVICES BULLETIN NO. 15.05.05 Page 9 of 36 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 HEALTH SERVICES BULLETIN NO. 15.05.05 Page 10 of 36 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 HEALTH SERVICES BULLETIN NO. 15.05.05 Page 11 of 36 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 HEALTH SERVICES BULLETIN NO. 15.05.05 Page 12 of 36 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. HEALTH SERVICES BULLETIN NO. 15.05.05 Page 13 of 36 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: HEALTH SERVICES BULLETIN NO. 15.05.05 Page 14 of 36 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 HEALTH SERVICES BULLETIN NO. 15.05.05 Page 15 of 36 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. HEALTH SERVICES BULLETIN NO. 15.05.05 Page 16 of 36 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. HEALTH SERVICES BULLETIN NO. 15.05.05 Page 17 of 36 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). HEALTH SERVICES BULLETIN NO. 15.05.05 Page 18 of 36 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; HEALTH SERVICES BULLETIN NO. 15.05.05 Page 19 of 36 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. HEALTH SERVICES BULLETIN NO. 15.05.05 Page 20 of 36 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. HEALTH SERVICES BULLETIN NO. 15.05.05 Page 21 of 36 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 HEALTH SERVICES BULLETIN NO. 15.05.05 Page 22 of 36 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 HEALTH SERVICES BULLETIN NO. 15.05.05 Page 23 of 36 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. HEALTH SERVICES BULLETIN NO. 15.05.05 Page 24 of 36 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 HEALTH SERVICES BULLETIN NO. 15.05.05 Page 25 of 36 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 HEALTH SERVICES BULLETIN NO. 15.05.05 Page 26 of 36 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… . HEALTH SERVICES BULLETIN NO. 15.05.05 Page 27 of 36 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. HEALTH SERVICES BULLETIN NO. 15.05.05 Page 28 of 36 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 HEALTH SERVICES BULLETIN NO. 15.05.05 Page 29 of 36 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. HEALTH SERVICES BULLETIN NO. 15.05.05 Page 30 of 36 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: HEALTH SERVICES BULLETIN NO. 15.05.05 Page 31 of 36 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 HEALTH SERVICES BULLETIN NO. 15.05.05 Page 32 of 36 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 HEALTH SERVICES BULLETIN NO. 15.05.05 Page 33 of 36 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. HEALTH SERVICES BULLETIN NO. 15.05.05 Page 34 of 36 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 HEALTH SERVICES BULLETIN NO. 15.05.05 Page 35 of 36 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