Colorado Mental Health Institute at Pueblo POLICY MANUAL ......Nov 01, 2014 · bedside procedures, and prior to the initiation of the procedure, the preoperative/invasive procedure

Colorado Mental Health Institute at Pueblo POLICY MANUAL

SECTION - CLINICAL RISK MANAGEMENT POLICY NO. 1.01

Effective Date: 1/9/13

TITLE: PATIENT IDENTIFICATION This policy replaces #1.01 dated 12/9/09. I. DEFINITION/PURPOSE

It is the policy of CMHIP to ensure that patients are accurately identified. The purpose of this policy is to ensure the accuracy of patient identification for the safe administration of medications and treatments, and to accurately account for the physical location of patients in emergency situations. (See Policy 1.02, Universal “Time Out” Protocol, for patient identification prior to invasive procedures.)

II. ACCOUNTABILITY Individuals responsible for implementing this policy include any clinical staff involved in the administration of medications and treatments, or accounting for patients’ whereabouts.

III. PROCEDURE A. Medications and Treatments

Prior to administration of medications and treatments, the patient shall be identified by a minimum of two methods. On the psychiatric units, the methods shall include the following: 1. Looking at one or more of the current patient photographs in the medical record,

medication book, or wellness sheet. Patient photographs must be updated by the Clinical Team Leader/Coordinator if the patient’s appearance changes.

2. Asking the patient his/her name, birth date, or social security number. 3. If the patient is disoriented or confused to the point that there is concern that

he/she may not accurately identify himself/herself, it is acceptable to ask another staff person familiar with the patient to identify the patient.

B. Blood or Blood Products

No procedure requiring the use of blood or blood products is performed at CMHIP. C. Wellness Sheets

Staff must accurately account for the physical location of patients using the patient photograph template, which accompanies the Wellness Sheet. (See Policy #1.56.)

________________________________ ______________________ William J. May Date Superintendent


SECTION - CLINICAL RISK MANAGEMENT POLICY NO. 1.02


TITLE: UNIVERSAL “TIME OUT” PROTOCOL This replaces policy 1.02 dated 5/09/12 I. DEFINITION/PURPOSE

It is the policy of CMHIP to ensure that patients are accurately identified. The purpose of this policy is to ensure the accuracy of patient identification before and during intrusive or invasive procedures. This may also be referred to as “Time Out” when referring to the process of identifying the patient at the time of a procedure. A list of procedures that require the use of this Protocol is located in Appendix 3 of this policy.

II. ACCOUNTABILITY Individuals responsible for implementing this policy include any clinical staff involved in an invasive or intrusive procedure.

III. PROCEDURE A. Intrusive or Invasive Dental Procedures

The time the patient arrives, the time the Universal Protocol is initiated, and the time the procedure begins shall be documented accurately and chronologically in the Medical Record.

1. Patient Identification Prior to entering the dental operatory/invasive procedure area, or, in the case of

bedside procedures, and prior to the initiation of the procedure, the preoperative/invasive procedure Verification Process will be followed and documented. a. Correct patient identification will be confirmed using two patient identifiers:

(1) Patient name; and (2) Medical Record Number, (3) Social Security Number, or (4) Patient Date of Birth

b. Correct procedure and correct site, as appropriate, will be confirmed by review of: (1) History and Physical, and (2) Consent document, if required, and (3) Verification by patient (or alternative decision-maker)

UNIVERSAL “TIME OUT” PROTOCOL POLICY NO. 1.02 PAGE 2

c. All discrepancies identified through the verification process shall be resolved prior to moving the patient to the operative/invasive procedure area, or in the case of a bedside procedure, prior to initiation of the procedure.

2. Identification of the procedure site process a. When possible, the identification of which tooth or teeth should include

involvement of the patient and/or family (or alternative decision-maker) to verify the correct procedure and site.

b. When a second procedure is performed during the same session, verification of which tooth (teeth), by number(s) for the second procedure should be done prior to initiation of the procedure and shall be done intra-operatively.

c. When the procedure does not involve a tooth, the location will be described in detail in regard to location (including side) and description.

3. Dental Assistant/Nurse/Invasive Procedure Staff a. Verifies that the tooth has (teeth have) or other lesion has been identified pre-

operatively/pre-invasive procedure, prior to induction of anesthesia and surgical/invasive procedural prep.

b. Verifies patient identity, surgery/invasive procedure and site are correctly documented on the consent form and on the surgical/invasive procedure schedule, if one has been prepared.

c. Notifies the procedure dentist if there is a discrepancy within the data review. d. Documents verification in the patient’s medical record, on Form 517.

4. Procedure Dentist If there is a discrepancy, the procedure dentist is responsible for verifying by number(s) which tooth is (teeth are) to have the procedure, prior to positioning the patient for the procedure.

5. Time Out Process All of the following individuals shall participate in the Time Out process: a. Dentist b. Anesthesiologist or Anesthetist c. Circulating nurse d. Individual functioning in the assistant or dental hygienist role Exception: The site-marking process is not required when the practitioner performing the procedure is in continuous attendance of the patient from the point of decision to do the procedure.

6. In all other settings in which procedures are performed, the Time Out is conducted and documented by the person performing the procedure, and/or other involved staff, as appropriate.

7. All discrepancies identified through the Time Out process shall be resolved prior to initiation of the procedure.


8. In the Dental Operatory, the circulating nurse will confirm with the team that the consent form correctly identifies the tooth (teeth) or lesion and procedure, and that any required special equipment is available.

9. The procedure dentist will confirm the imaging data and patient position is correct, as appropriate for the dental procedure.

10. Immediately prior to the start of the dental procedure, the elements of the formalized “Time Out” process shall be verified and DOCUMENTED. The Time Out elements are as follows: a. Verification of correct patient identity b. Verification of correct tooth (teeth) by number(s) or lesion and its location c. Verification and agreement on procedure to be done d. Correct patient position, as appropriate e. Availability of implants, as appropriate f. Availability of special equipment or requirements, e.g., imaging data, or

implants, as appropriate 11. In the Dental Operatory and invasive procedure areas, the first instrument will not

be passed until the team conducts and documents a formal "Time Out." 12. When a second procedure during the same session is performed, a second Time Out

process is required. 13. Documentation shall be on Form 517, Universal Protocol “Time Out” Checklist.

B. Intrusive or Invasive Surgical Procedures (Non-Dental) The time the patient arrives, the time the Universal Protocol is initiated, and the time the procedure begins shall be documented accurately and chronologically in the Medical Record. 1. Patient Identification

Prior to entering the invasive procedural area, or, in the case of bedside procedures prior to the initiation of the procedure, the invasive procedure verification process will be followed and documented. a. Correct patient identification will be confirmed using two patient identifiers:

(1) Patient name; and, (2) Medical Record number, (3) Social Security number, or, (4) Patient date of birth

b. Correct procedure and correct site, as appropriate, will be confirmed by review of: (1) History and Physical, and (2) Consent document, if required, and (3) Verification by patient or alternative decision-maker


c. All discrepancies identified through the verification process shall be resolved prior to moving the patient to the operative/invasive procedural area, or in the case of a bedside procedure, prior to initiation of the procedure.

2. Identification of the procedure site and site-marking process a. When possible, the site marking process should include involvement of the

patient and/or family, (or alternative decision-maker) to verify the correct procedure and site.

b. Patients having invasive procedures involving laterality, multiple sites, level(s) or digit(s), will have the correct site identified and marked with the word "yes.”

c. When there is only one site where a procedure can be done (e.g., the bladder for cystoscopy), it need not be marked and the documentation should indicate “Not Applicable.”

d. When a second procedure is performed during the same session, site marking for the second procedure should be done prior to initiation of the procedure and shall be done intra-operatively if site marking for the second procedure was not done before the initial procedure began.

3. Surgeon/Invasive Procedure Physician a. If sedation will be used, prior to sedation, the surgeon/invasive procedure

physician or designee will mark the site with the word “yes.” b. The surgeon/invasive procedure physician or designee marks the site(s) with a

permanent marker at or near the incision site. 4. Invasive Procedure Staff

a. Pre-invasive procedure, prior to induction of anesthesia and surgical/invasive procedural prep, the staff verifies that the correct site has been marked.

b. Verifies patient identity, invasive procedure and site are correctly documented on the consent form and on the invasive procedure schedule, if one was prepared.

c. If the site has not been marked or there is a discrepancy, the procedure physician will be notified.

d. Verification is documented in the patient’s medical record on Form 517. 5. Surgeon/Invasive Procedure Physician/Resident/Fellow

If the site is not marked, or there is a discrepancy, the procedure physician is responsible for marking site prior to positioning the patient for the procedure.

6. Time Out Process All of the following individuals shall participate in the Time Out process: a. Surgeon b. Anesthesiologist or Anesthetist c. Nurse or Assistant

7. In all other settings in which procedures are performed, the Time Out is conducted and documented by the person performing the procedure, and/or other involved staff, as appropriate.


8. All discrepancies identified through the Time Out process shall be resolved prior to initiation of the procedure.

9. The circulating nurse will confirm with the procedural physician that the marked site, procedure on the consent form and site are correct, and that any required special equipment is available.

10. The surgeon/invasive procedure physician and/or assisting physician will confirm the imaging data and patient position is correct, as appropriate for the invasive procedure.

11. Immediately prior to the start of the invasive procedure, the elements of the formalized “Time Out” process shall be verified and DOCUMENTED. The Time Out elements are as follows: a. Verification of correct patient identity b. Verification of correct site and side, as appropriate, including site marking c. Verification and agreement on procedure to be done d. Correct patient position, as appropriate e. Availability of implants, as appropriate f. Availability of special equipment or requirements, e.g., imaging data, as

appropriate 12. In the area where the invasive procedure is performed, the first instrument will not

be passed until the team conducts and documents a formal "Time Out." 13. When a second procedure during the same session is performed, a second Time Out

process is required. 14. Documentation shall be completed on Form 517, Universal Protocol “Time Out”

Checklist. 15. When the procedure is Electroconvulsive Therapy, and therefore not for a specific

location or side, it is the procedure itself that should be confirmed. It is understood that the use of anesthesia could include intratracheal intubation and extubation by an anesthesiologist.

C. Appendices

1. Appendix 1 – Universal Protocol “Time Out” Checklist – Form 517

2. Appendix 2 – Universal Protocol Procedures Log – Form 5170, Page 1

3. Appendix 3 – Universal Protocol Procedures Log – Form 5170, Page 2

________________________________ _______________________ William May Date Superintendent


APPENDIX ONE: UNIVERSAL PROTOCOL “TIME OUT” CHECKLIST The time the patient arrives, the time the Universal Protocol is initiated, and the time the procedure begins shall be documented accurately and chronologically in the Medical Record.

This form is for intrusive, invasive, surgical, dental, and/or medical procedures per Policy/Procedure 1.02.

1. Patient Identification Prior to entering the invasive procedural area or prior to the starting a procedure at a bedside or in the clinic, the

preoperative/invasive procedure verification process will be followed and documented by checking the appropriate boxes. Any discrepancies are to be resolved prior to a procedure being performed.

a. Correct patient identification was confirmed using two (2) patient identifiers: Patient name and Medical Record Number or Patient Date of Birth or Social Security Number b. Correct procedure and correct site, as appropriate, and any allergies were confirmed by review of: History and Physical, and Documented consent, and Verification by patient or alternative decision-maker 2. Identification of the procedure site and site-marking process for procedures other than ECT. a. Procedure and site verified with the patient, family, guardian, and/or surrogate decision-maker:

Procedure site(s) identified and Procedure site(s) marked or Not Applicable due to single location (e.g., bladder) or Patient refuses to have site marked. If so, the Reason: _______________________________

b. Prior to sedation, the site is (or sites are) confirmed: Confirmed and marked by physician or designee ______________________________ or Confirmed and marked (or tooth identified by number) by dentist or designee _______________ 3. For Electroconvulaive Therapy (ECT) Only: The procedure is confirmed 4. In Dental Operatory Only: Dental Operatory; Not Applicable

Pre-operatively/pre-invasive procedure, prior to induction of anesthesia and prior to the invasive procedural prep, the Invasive Procedure Staff verifies: Procedure site(s) marked (or tooth identified by number) and correctly documented on the procedure

form, schedule, and consent form. Verification was performed by ______________________________________

5. Time Out Process conducted by: Physician/Dentist Anesthesiologist/Anesthetist Assistant or Other ________________ 6. The Time Out elements were reviewed as follows: Verification of correct patient identity Verification of correct site and side, as appropriate, including site marking Verification and agreement on procedure to be done Correct patient position, as appropriate Availability of special equipment or requirements, e.g. imaging data or implants Form completed by: __________________________________ Date ____________ Time _________

Colorado Mental Health Institute at Pueblo Unit _______ UNIVERSAL PROTOCOL “TIME OUT” CHECKLIST 517 (9/12/12)


APPENDIX TWO: UNIVERSAL PROTOCOL PROCEDURES LOG

Location: Medical Clinic Surgical Clinic Dental Clinic HSFI Clinic ECT Room Other ______ The time the patient arrives, the time the Universal Protocol is initiated, and the time the procedure begins shall be documented accurately and chronologically in the Medical Record.

DATE AVATAR # PROCEDURE PHYSICIAN OR DENTIST

UNIVERSAL PROTOCOL (YES/NO)

RECORDED BY

See reverse side of this form for lists of procedures that require use of Universal Protocol, those that don’t, and those no longer performed at CMHIP.

5170 Page 1

9/12/12


APPENDIX THREE: LIST OF PROCEDURES THAT REQUIRE USE OF THE UNIVERSAL PROTOCOL

1. Apioectomy, excluding premolars and molars 2. Aveolectomy 3. Aveoloplasty 4. Avulsion of toenail 5. Biopsy of cervix, endometrium, or vulva 6. Closed reduction fracture-dislocation 7. Curettage of verruca(e) 8. Cystoscopy 9. Debridement of keratotic lesions and nails) 10. Dermabrasion nail excision with matrixectomy 11. Digital surgery (lesser digits) 12. Electroconvulsive Therapy with anesthesia 13. Excision of cyst 14. Excision of nail with matrixectomy, partial 15. Excision of nail with matrixectomy, total 16. Excision of skin lesions – dorsal 17. Excision of skin lesions – plantar 18. Excision of verruca(e) – dorsal 19. Excision of verruca(e) – plantar 20. Fixed prosthetic procedures 21. Flap and osseous procedures 22. Fulguration of verruca(e) 23. Incision and drainage of minor oral infections 24. Incision and drainage of abscesses 25. Insertion of Central lines (e.g., Groshong PICC,

subclavian) by a physician 26. Laryngoscopy 27. Lesion biopsy 28. Minor tongue surgery

29. Multiple uncomplicated extractions 30. Muscle biopsy 31. Nail surgery 32. Nonsurgical endodontic procedures 33. Onychoplasty 34. Re-implantation of teeth, including minor alveolar

reduction 35. Removal of benign tumors and minor cysts 36. Removal of foreign body by speculum, forceps, or

superficial incision 37. Removal of small lesions 38. Repair of minor lacerations, including the

vermillion border 39. Repair of severe lacerations 40. Restorative dentistry 41. Root resections 42. Simple excision of benign skin lesions 43. Simple intraoral biopsy of benign tumors and

minor cysts 44. Single uncomplicated extraction 45. Sinus perforation closures (<4 mm) 46. Small wound debridement 47. Soft tissue grafts 48. Steroid Injections 49. Surgical apical procedures 50. Surgical removal of teeth 51. Suture of laceration (simple) 52. Torus mandibularis removal

LIST OF PROCEDURES THAT DO NOT REQUIRE USE OF THE UNIVERSAL PROTOCOL

1. Bladder ultrasounds 2. Cryosurgery 3. Dermatological cultures 4. DMSO bladder treatment 5. Dressing changes 6. Ear irrigation 7. Electromyograms

8. Orthopedic splints and casts 9. Suprapubic catheter changes

10. Routine intravenous lines (including Hep-Lock) 11. Maintenance of previously inserted Central

intravenous lines (e.g., Groshong PICC, subclavian)

LIST OF PROCEDURES THAT ARE NO LONGER PERFORMED AT CMHIP

1. Closed fixation fracture-dislocation 2. Colposcopy 3. Esophageal dilatation 4. Insertion of Central intravenous lines (e.g.,

Groshong PICC, subclavian) by a non-physician

5. Intratracheal intubation and extubation by a

person who is not an anesthesiologist." 6. Intravenous pyelograms

5170 Page 2` 9/12/12


SECTION – TREATMENT PLANNING POLICY NO. 1.05


TITLE: PLAN OF CARE This replaces CMHIP policy 1.05 dated 6/13/12. I. PURPOSE/DEFINITION

It is the policy of CMHIP that patients admitted to CMHIP have a written, individualized Plan of Care. This plan is based on an interdisciplinary assessment as well as the ongoing review of the patient’s needs. The purpose of this policy is to describe the procedure for developing and reviewing the Plan of Care.

II. ACCOUNTABILITY Individuals responsible for implementing this policy include the treatment team, other medical and clinical staff and admitting personnel.

III. PROCEDURE A. Pre-Admission information, clinical assessments, information from outside agencies,

previous hospitalizations and interviews with the patient and/or family is used to develop the Plan of Care, including but not limited to: 1. Pre-admission Information (Form 100) 2. Pre-Assessment for Behavior Management (Form 139) 3. Interdisciplinary Assessment (Form 140) 4. Psychiatric Assessment (Form 152) 5. Pain Assessment (Form 174), if indicated 6. Health Assessment (Form 178/179) 7. Admissions Summary (Form 190) 8. Advance Directive/Organ Donor Screen (Form 665).

B. Annual assessments and/or interim updates (e.g., Health Assessment Form - 178/179,

Annual Psychiatric Assessment - Form 153, Annual Psychosocial Review Assessment - Form 140G, and Annual Nursing Assessment - Form 140N) will be reviewed in order to prepare subsequent Plan of Care Reviews (reflecting changes in the patient’s status on the Plan of Care Review - Form 107.3).

C. Reassessments or additional assessments may occur based on the patient’s diagnosis;

desire for care, treatment and services, response to previous care, and/or his/her setting requirements. Recommendations for treatment will be incorporated into the Plan of Care.

D. Patients receiving treatment of alcoholism or other substance use disorders receive a

comprehensive assessment that includes the history of substance use, age of onset, duration, intensity, patterns of use, consequences of use, types of previous treatment

PLAN OF CARE POLICY NO. 1.05 PAGE 2

and duration of previous treatment. Recommendations for treatment and/or education will be incorporated into the patient’s Plan of Care.

E. Initial/Interim Plan of Care

1. At admission, the unit Registered Nurse will initiate an Initial/Interim Plan (Form 107.5) based on the assessed needs of the patient. The Interim Plan is followed until the interdisciplinary treatment team and patient develop the Plan of Care Formulation Summary (form 107.4) and Plan of Care Objectives (Form 107.2-O) and Plan of Care Interventions (Form 107-I).

2. The Interim Plan remains in effect until the treatment team completes the Plan of Care Formulation Summary (Form 107.4) unless it is modified or discontinued prior to the formulation meeting. If the patient is discharged prior to the formulation meeting or within seven days of admission, a Plan of Care Formulation Summary (Form 107.4) is not required.

3. A registered nurse may initiate an Interim Plans of Care (107.5 forms) at anytime during the patient’s hospitalization to address issues/changes in the patient’s condition. The Interim Plan of Care can remain in effect for up to 30 days. If the identified problem continues after 30 days, it will be included on the formal Plan of Care (Form 107.2).

4. Interim Plan of Care, form 107.5-Initial/Interim Plan of Care - Legal,

Competency/Sanity Evaluation, may only be used as the principal plan of care document for patients in the HSFI building on Unit E2 (Department of Corrections unit) who have a legal status of competency or sanity evaluation.

F. Plan of Care Formulation and Problem List

1. Within five (5) days if possible, but no later than the seventh (7th) day of the patient's admission (as the situation dictates) the interdisciplinary treatment team shall meet with the patient, and authorized family or friends at the patient’s request, to formulate a Plan of Care.

2. Form 107.4 (Plan of Care Formulation Summary) will document critical clinical factors identified in the assessments and direct the development of: a Clinical objectives and interventions that will assist the patient in reasonable

and safe progression through discharge from CMHIP b Risk factor identification, symptoms and specific behaviors prompting the

admission c Anticipated plans for disposition (note where the patient will live and with

whom, if applicable, and scheduled/recommended follow-up care/appointments)

d Changes required to accomplish discharge e Progression and/or discharge plan to include assessed barriers f Further evaluations or diagnostic testing required g Staff observations of patient’s behavior h Input from the patient or family i Patient strengths that might aid in treatment j The treatment goals defined by the patient


3. The attending Psychiatrist, assigned Social Worker and a Registered Nurse must attend the meeting to formulate a Plan of Care. Other disciplines are encouraged to attend.

4. The Psychiatrist, with input from the interdisciplinary team, directs the formulation of the Problem List. a. Medicare recertification (medical necessity) for continued hospitalization

must be documented in the Plan of Care Formulation, form 107.4.

b. The Problem List Form 107.1 identifies the current presenting issues from general domains that will be the focus of individualized treatment.

c. The Problem List identifies barriers to discharge requiring intervention so the patient can improve and progress.

G. Plan of Care Patient Objectives (Form 107.2-O)

1. The Plan of Care (focused on attainable, measurable short term objectives) will be written in language and at a level that will be culturally sensitive and understood by the patient.

2. The Plan of Care will be focused on immediate objectives for the patient to achieve stabilization with projected target dates, safe self-management, progression, and/or discharge.

3. When the psychiatrist deems that a patient sufficiently meets his/her goals and objectives, he/she will write an order for discharge. The discharge order also means that the criteria for terminating involuntary status are deemed to have been met, unless any certification is transferred to the next provider of care.

4. A copy of the plan will be provided to the patient. 5. The objectives will be modified with the status noted as change occurs. The Plan

of Care may be modified at any time to reflect the patient’s needs not just during scheduled reviews. It should be updated to include additional efforts employed by the therapists to help the patient attain his/her identified objective for each group or intervention (e.g., if the patient refused to attend a group, the therapist can modify the approach to fits the patient’s needs. For instance, a 1:1 in lieu of a group that will assist the patient in attaining the objective). These changes should be noted in a progress note as well as on the patient’s POC. A Plan of Care Review must be completed for any major change in condition. (Refer to CMHIP policy 1.28, Active Treatment and General Activities.)

6. Form 107.2 contains a list of the recommended treatment services that are identified to help the patient achieve the identified objectives.

7. The names of assigned treatment team members are noted on the form. 8. The first Plan of Care Review shall be scheduled at the time of formulation and

shall occur no later than 30 days from the formulation (or sooner if a major change in condition occurs).

H. Plan of Care Interventions (Form 107.2-I)

1. A list of treatment interventions will include specific treatment services (or groups) identified to assist the patient in achieving identified treatment objectives.


2. The interventions will include the name and purpose of the intervention, name of staff person or discipline responsible, the frequency of the intervention, and, the planned duration of the intervention, which must include specific dates for expected achievement, per Centers for Medicare and Medicaid Services.

3. Several treatment interventions may be assigned to address a treatment objective. 4. A copy of the Plan of Care Intervention (Form 107.2-I) may be provided to the

patient. 5. Interventions will be modified and/or updated when the patient achieves the

objectives/goals. If the objective/goal is not achieved after a reasonable length of time (i.e., 3 months) or the intervention has proven to be unsuccessful, the objective(s) and/or intervention(s) will be modified.

6. “Ongoing” objectives and interventions may remain on the Plan of Care (especially, if removal of the objective(s) and/or intervention(s) might result in destabilization of the patient).

I. Plan of Care Review (Form 107.3)

1. The Plan of Care Review (Form 107.3) shall be completed at the time of the review.

2. A minimum of three disciplines (members) of the treatment team shall attend the Plan of Care Review. The Psychiatrist, Registered Nurse, and one other discipline must attend. Other team members are encouraged to attend and provide input.

3. During the first year of treatment, the treatment team shall meet monthly (no later than every 30 days) with the patient and family (as the patient requests) to: a. Review progress/response to interventions and achievement of objectives b. Modify current objective(s) and intervention(s) or develop additional

objective(s) and intervention(s) and place an updated form 107.2-O and 107.2-I in the Medical Record

c. Review new data (assessments/evaluations within the past 30 days) or order additional assessments or evaluations based on patient need

d. Review projected progression/anticipated discharge plans (living arrangements and follow-up care) and potential barriers to progression/discharge

e. Review current security stage (where appropriate) and Medicare recertification (medical necessity) for continued need for hospitalization.

4. After one year of continuous inpatient care, the Plan of Care may be reviewed every 90 days. A patient may request and participate in an additional Plan of Care Review outside of the required time frames. a. The Medicare recertification (medical necessity) for continued hospitalization

will be documented in the Plan of Care Review (Form 107.3). b. The psychiatrist shall review medication and treatment needs monthly and

document this review in the progress notes. c. A Plan of Care Review shall be conducted any time there is a major change in

the patient’s condition. d. Review anticipated plans for discharge follow-up care.


5. A Plan of Care Review occurs when a patient is admitted to or transferred to another treatment teams, within three working days of the move.

J. The use of seclusion and/or restraint requires the implementation of an Interim Plan

of Care – Seclusion and Restraint (Form 206sr-POC).

1. Whenever a patient is placed in locked door seclusion or seclusion and restraint, the Registered Nurse who completed the one-hour face-to-face evaluation must initiate a Plan of Care for the episode on Form 206sr-POC (Initial Interim Plan for Seclusion and Restraint) at the onset of the episode.

2. There must be a Plan of Care initiated for each individual episode of seclusion or seclusion and restraint regardless of how many may occur in a 24-hour period.

3. Form 206sr-POC must be completed based on the assessed needs of the patient at the time each new episode begins. It is not acceptable to make a copy of a previous Plan of Care (206sr-POC) for repetitive episodes that may occur over a brief time span.

4. When the seclusion or seclusion and restraint episode is terminated, the RN shall discontinue the Plan of Care specific to Seclusion and Restraint on form 206sr-POC. The discontinued care plans shall be maintained in the medical record in the designated Plan of Care section.

5. If there is not an active problem on the patient’s Plan of Care that addresses the behavior which precipitated the seclusion or seclusion and restraint episode, a formal Plan of Care Review should occur as soon as possible, but no later than three days after the episode, to modify the Plan of Care related to the behavior that precipitated use of external control.

______________________________________ _______________________ William J. May Date Superintendent

COLORADO MENTAL HEALTH INSTITUTE

AT PUEBLO

THE PLAN OF CARE

A COMPREHENSIVE MANUAL FOR TREATMENT PLANNING

Written and Edited by:

Tamara Bullard, RN

Irene Drewnicky, MS, MBA

Sharon Gilbert, RN, MS

Kelly Hoy, BA

Michele Manchester, MA

First Printing

April 30, 2010

Revised

July 11, 2011

Rev: 7/11

i

TABLE OF CONTENTS

INTRODUCTION .................................................................................................................................... 1 The Beginning ................................................................................................................................... 1

THE FUNDAMENTALS OF SERVICE ................................................................................................... 2 Required Staff in the Development of a Plan of Care ........................................................................ 2

Team Member Responsibilities ......................................................................................................... 2

Integrating Recovery Principles ......................................................................................................... 3

FORMS AND FORM NUMBERS ............................................................................................................ 4 Order of Use ..................................................................................................................................... 4

Order in the Chart ............................................................................................................................ 4

Filing of Forms .................................................................................................................................. 4

Form Structure and Format ............................................................................................................... 4

INITIAL AND INTERIM PLAN OF CARE (107.5) ................................................................................... 5 Process for the Initial and Interim Plan of Care ................................................................................. 5

Responsibilities Upon Admission ...................................................................................................... 6

Registered Nurse ........................................................................................................................ 6

Psychiatrist ................................................................................................................................. 6

Social Worker ............................................................................................................................. 6

PLAN OF CARE FORMULATION SUMMARY (107.4) .......................................................................... 7 Referring Agency .............................................................................................................................. 7

What Has to Happen for Patient to Progress or be Discharged (Discharge Criteria) ......................... 7

Progression and/or Discharge Plan (Including Barriers) .................................................................... 8

Additional/Further Evaluations or Assessments Required ................................................................. 8

Other Treatment Team Observations or Comments ......................................................................... 8

Page 2 of the Plan of Care Formulation Summary ............................................................................ 8

Patient Participation .......................................................................................................................... 9

Patient or Family Comments ............................................................................................................. 9

Patient Strengths That Can Be Used In Treatment ........................................................................... 9

Prompt Patient by Asking Following Questions ................................................................................. 9

Treatment Goals Patient Can Establish for Discharge from Hospital .............................................. 10

How Staff Can Help Patient Reach Their Goals .............................................................................. 10

Treatment Team Member Signatures ............................................................................................. 10

Rev: 7/11

ii

PLAN OF CARE PROBLEM LIST (107.1) ........................................................................................... 11 Problem List ................................................................................................................................... 11

Problem ..................................................................................................................................... 11

Problem Abbreviations .................................................................................................................... 11

Problem Summary and Description ................................................................................................ 11

Medical Problem(s) ......................................................................................................................... 14

Date Initiated and Status ................................................................................................................ 14

Status Definitions ............................................................................................................................ 14

Date Changed and New Status ...................................................................................................... 15

Cultural, Language or Learning Needs to Consider in Treatment ................................................... 15

PLAN OF CARE PATIENT OBJECTIVES (107.2 O) ........................................................................... 16 Guidelines for Completing the Plan of Care Patient Objectives ....................................................... 16

Problems and Objective(s).............................................................................................................. 16

Initiation Date/Status for Objectives ................................................................................................ 18

Other Examples of Objectives ........................................................................................................ 18

Dangerousness (D) .................................................................................................................. 18

Occupational/Social Deficits (O) ............................................................................................... 18

Behavioral/Mental Health (B) .................................................................................................... 19

Medical Problems (M) ............................................................................................................... 19

PLAN OF CARE INTERVENTIONS (107.2 I) ....................................................................................... 21 Problem Abbreviation and Objective Number ................................................................................. 21

Treatment Interventions .................................................................................................................. 21

Staff Action ............................................................................................................................... 21

Frequency/Duration (How Long and How Often) ...................................................................... 21

Individual Responsible and Discipline ....................................................................................... 22

Purpose of Intervention ............................................................................................................. 22

Initiation Date ................................................................................................................................. 22

Date/Intervention Status ................................................................................................................. 22

Intervention Status .......................................................................................................................... 22

Unit ................................................................................................................................................. 23

PLAN OF CARE REVIEW (107.3) ........................................................................................................ 24 Has Psychiatric Diagnosis Changed? ............................................................................................. 24

Physician Summary ................................................................................................................. 24

Recertification for Continued Stay................................................................................................... 25

Rev: 7/11

iii

Estimated Length of Stay in Hospital .............................................................................................. 25

Advance Directive Modified? .......................................................................................................... 25

Duty to Warn Reviewed? ................................................................................................................ 25

Date of Most Recent History and Physical ...................................................................................... 25

Date of Most Recent Psychiatric Assessment ................................................................................. 26

Risk Assessment ............................................................................................................................ 26

Plan of Care Review... .................................................................................................................... 26

Summary of Progress Towards Objectives ..................................................................................... 26

Summary of the Patient, Family Education Provided, Barriers to Learning ..................................... 26

Patient Participation/Attendance of Others ..................................................................................... 26

Treatment Team Member Signatures ............................................................................................. 27

GENERAL INFORMATION .................................................................................................................. 28

Transfers and Reviews ................................................................................................................... 28

What to Give the Patient ................................................................................................................. 28

When the Patient is Discharged ...................................................................................................... 28

Plan of Care Review Guidelines for Other Forms Associated with Review ..................................... 28

Updates to Problem List, Objectives, and Interventions during the POC Review ............................ 29

Plan of Care Progress Notes .......................................................................................................... 29

Frequency of POC Progress Notes per Policy No. 3.15 .................................................................. 29

Not Guilty by Reason of Insanity (NGRI) ......................................................................................... 30

Civil Commitments (to include Patients from Dept. of Corrections and Jails) .................................. 30

Court Ordered Evaluations ............................................................................................................. 30

Incompetent to Proceed (ITP) ......................................................................................................... 30

MEDICAL RECORD DOCUMENTATION SCHEDULE ........................................................................ 31 PLAN OF CARE FLOW CHART .......................................................................................................... 32

Rev: 7/11

1

INTRODUCTION The Plan of Care is an effective therapeutic tool that is helpful to staff as well as to the individual receiving services. It should serve as the “road map” for treatment. In following these guidelines, you have the freedom to use your clinical judgment in describing the patient and your treatment interventions. The main emphasis is that the plan be clear and describe an individual patient. It is essential that the plan be written in such a way that the patient and staff can clearly understand what problems are severe enough to warrant inpatient treatment. Choice and participation of the patient should be evident. The new Plan of Care has a basis in recovery principles using effective methods to building HOPE and ALLIANCE, which impact patient stability and progression. “LEAP INTO RECOVERY” – Treatment planning is a collaborative effort with our patients. The Beginning Patients are referred to the Colorado Mental Health Institute at Pueblo (CMHIP) from a variety of settings and for a variety of purposes. Our patients are sent to us through the courts, jails or from other mental health care providers. We provide excellent service for citizens of Colorado. Services may include psychiatric evaluations, assessments, rehabilitative care and mental health treatment. Our commitment to quality, efficiency, and effective treatment drives the process for the delivery of mental health care. We encourage the implementation of evidence-based practice that satisfies the expectations of the referring customers and our ultimate customers, our patients. The assessment of the patient’s need for intensive psychiatric care actually starts somewhere else other than CMHIP. Once a decision is made by a provider in the community or a judge to send a person to CMHIP for care and treatment, we begin the process of collecting critical collateral information, which impacts our services and the outcome of our soon-to-be patient. The treatment plan, or Plan of Care (POC), is the foundation for care for the patient and serves as an individualized road map for successful reintegration into the community. Success in writing such a plan requires the efforts and coordination of many professionals.

a. Pertinent records from the court, outside sources, other hospitals and mental health clinics

help to provide data to the medical and mental health professionals who perform evaluations, diagnostics and assessments of the patient.

b. Active participation by the patient, guardian, and/or significant other (as much as possible) in planning treatment is critical for positive and enduring treatment outcomes.

c. Regular evaluation of the effectiveness of the plan, modifying as there is success or editing when interventions are not working, is part of the dynamic process, including changes occurring in the psychiatric or medical condition of the patient, is required.

d. Active treatment at the right time is critical. e. Comprehensive discharge planning to include participation and agreement with follow-up

agencies, courts, providers, resources, family and, of course, the patient.

Rev: 7/11

2

THE FUNDAMENTALS OF SERVICE

Required Staff in the Development of a Plan of Care Members of the treatment team required to be present at the formulation are:

a. Psychiatrist b. Registered Nurse if the Lead Nurse is not present c. Social Worker

Other disciplines may be required to attend because of their contribution to the diagnostics, treatment planning and/or patient outcomes. A Plan of Care Liaison is not required to be present at the formulation, but is considered an asset when present. The attendees give evidence of their participation or review of the POC by their signature on the Formulation (107.4) or Review form (107.3). A Plan of Care Liaison will review all information that comes with the patient at the time of admission. This information may include the pre-admission screening, police reports, court reports and referring agency information. This information, in addition to the assessments, is completed by the hospital staff, as well as information directly acquired from the patient, will be considered and contribute to the diagnostic summary of the patient, draft problem list and treatment objectives. The patient will have several opportunities to provide input and assist in the development of his/her plan. If the Plan of Care Liaison is not present to assume the documentation responsibilities, scribe duties will be assigned to any one of the attending members. Team Member Responsibilities 1. The specific disciplines are responsible for assessing the patient as soon as possible and

complete documentation on the approved assessment form. Treatment recommendations to include goals and objectives are to be included in their assessment.

2. The Plan of Care Liaison/Scribe will collect, review and synthesize available clinical and medical information to develop an initial Plan of Care within the first five days after the patient is admitted. This activity includes talking to the patient and team members. The Plan of Care Liaison/Scribe will need to ensure the information is reflected on the formatted document in a concise and accurate fashion.

3. Members will attend meetings on time and give the meeting their full attention and cooperation.

4. Members will inform the Clinical Team Leader, or another formulation team member, of all pertinent information necessary prior to a scheduled absence from a Plan of Care formulation and summarize their findings and recommendations in a progress note.

5. Members will participate in creating relevant, concise discussions during the Plan of Care Formulation that meet required criteria for quality and completeness according to best practices at CMHIP.

6. Members will assist in keeping the team on task. It is important to keep the focus of the task for staff and patient alike, which is to define the problem(s) to be treated, the objectives to accomplish treatment and the responsibilities of staff to assist the patient in his/her recovery. Patient input will be regarded as important, viable and a place to begin the process. The formulation and/or review is not the time to do psychotherapy with the patient.

7. Members will complete all documentation related to the Plan of Care, including necessary signatures, providing a copy of the POC for the patient, placement of the POC in the medical record, recording of Plan of Care Reviews, and other necessary duties as assigned by the Clinical Team Leader.

Rev: 7/11

3

Integrating Recovery Principles A major aspect of CMHIP’s recovery philosophy is to discuss with the patient his/her perceived needs and treatment ideas before writing, rewriting, or reviewing the Plan of Care itself. Staff will make efforts to include family or loved ones into the Plan of Care process as authorized by the patient. The plan is to be based on assessments done by the various disciplines as documented on the Interdisciplinary Assessment (form 140), formal psychiatric assessment and other relevant documentation, to including information from the patient. Formulation of the Plan of Care is to be done in concise and succinct terminology. This process will be monitored as part of the hospital’s commitment to improvement of the provision of patient care services.

Rev: 7/11

4

FORMS AND FORM NUMBERS Identifying patient information is to be completed on the bottom of each form, as indicated. This includes patient’s name, date of admission, Avatar number, and the date the document is being completed. Make sure this is done on all pages where prompted or use the addressograph card.

Order of Use 1. Interdisciplinary Assessment (form 140 – filed appropriately by number): The attending

psychiatrist must dictate the psychiatric assessment and complete page 9 of form 140. This must be typed and available in the record within 24 hours for the Plan of Care Liaison to use for preparing the POC. (On-call physicians must complete form 140 if the admission occurred after hours.)

2. Initial and Interim Plan of Care (form 107.5 (suffix), eight to choose from, not including the Seclusion/Restraint Plan of Care)

3. Plan of Care Formulation Summary (form 107.4, two pages, and Addendum 140-EE) 4. Plan of Care Problem List (form 107.1) 5. Plan of Care Objectives (form 107.2 O) 6. Plan of Care Interventions (form 107.2 I) 7. Plan of Care Review (form 107.3, two pages plus optional addendum) Order in the Chart (filing from the bottom to the top) 1. Interdisciplinary Assessment (form 140) – CLOSEST TO THE BACK OF THE CHART and

filed in a different section of the chart “Assessments.” 2. Plan of Care documents to be filed behind tab “Plan of Care.” 3. Initial and Interim Plan of Care (form 107.5 (suffix), nine to choose from, with one blank for

unusual circumstances). 4. Plan of Care formulation Summary (form 107.4, four pages, and Addendum 140-EE). 5. Plan of Care Review (form 107.3, two pages plus optional addendum). 6. Plan of Care Patient Objectives (Form 107.2 O). 7. Plan of Care Interventions (form 107.2 I). 8. Plan of Care Problem List (form 107.1). THIS WOULD BE THE FIRST FORM YOU WOULD

SEE. Filing of Forms The above-noted forms are filed by: 1. Form number – Form 107.1 will be seen first, followed by form 107.2, form 107.3, etc. 2. With multiple same forms, the forms will be filed in chronological order, with the most recent

form on top. 3. Forms 107.5 are to be filed alphabetically by suffix (for example, 107.5D would be seen first

before 107.5M. Form Structure The form structure, format or design must not be altered when using the computer. This guide was written in the order of form use.

Rev: 7/11

5

INITIAL AND INTERIM PLAN OF CARE (107.5)

NAME OF FORM FORM NUMBER/IDENTIFICATION TIME FRAME INITIAL & INTERIM PLAN OF CARE (8 to choose from) INITIAL INTERVENTIONS

# FORM 107.5 (suffix specifies domain)

Within 8 hrs for RN 24 hrs for Physician Within 8 hrs for RN 24 hrs for Physician Within 72 hours by Social Worker

Process for the Initial and Interim Plan of Care Within the first 8 hours of the patient’s arrival on the unit, the RN will complete the nursing portion of the Interdisciplinary Assessment (form 140). The admitting nurse will have a conversation with the receiving nurse regarding findings. The nurse will analyze all the data completed and collected, including information from the Admission Summary (form 190); Health Assessment with findings noted in the progress note that will be reflected on the dictated form 178/179; Physician Orders (form 120); Progress Notes (form 206); and the information accompanying the patient from the referral source (form 139). On the last page of the nursing portion of the Interdisciplinary Assessment, the RN will determine what initial problem area(s), objective(s), and intervention(s) will be initiated to ensure the safety and well being of the patient. The problem areas are listed on the Interdisciplinary Assessment (IDA). The RN will choose from the eight Initial and Interim Plans of Care available or create a unique plan to treat the presenting initial problem. � DANGEROUSNESS (DAS) Patient is dangerous to self � DANGEROUSNESS (DAO) Patient is dangerous to others � BEHAVIORAL (B) Patient is gravely ill due to mental illness � LEGAL PROBLEMS ( ITP) Patient is admitted to be restored to competency � LEGAL PROBLEMS (EVALUATIONS) 2 pgs Court order evaluations for competency or

sanity/mental condition � MEDICAL PROBLEMS (MP) Physical/medical condition � FALL RISK (FALL) � SECLUSION & OR RESTRAINT (206sr) Patient demonstrate dangerous behavior and meets

criteria for the use of seclusion and or restraint � OTHER Other (if not adequately described by any of the

above)

Any of the Initial and Interim Plan of Care forms can be used on a temporary or short-term basis if there is a major change in the patient’s condition. The change in the patient’s condition would impact the effectiveness and validity of the current active treatment plan, thus a new plan usually focusing on safety is indicated. For example, perhaps “Dangerousness” has not been identified as a domain; thus, a Plan of Care has not be activated for any treatment along this category. However, perhaps the patient receives news from home that creates some feelings of anger resulting in threats to others. If the interdisciplinary team cannot be pulled together quickly to address this major change in condition, the RN in charge can activate form 107.5, Dangerousness to Others (DAO) until the team can be pulled together. The Interim Plan of Care can remain in effect for up to 30 days. If the identified problem continues after 30 days, it will be included on the formal Plan of Care (Form 107.2)

Rev: 7/11

6

Responsibilities upon Admission

The Registered Nurse will: 1. Select all applicable Initial Plan(s) of Care (form 107.5) based on those problem domains

checked on the IDA (form 140). 2. Initiate a short-term objective(s) and corresponding nursing intervention(s) by checking the

appropriate box(es) for each. 3. Enter the date initiated and status on each plan; sign and date in appropriate area on each

plan. 4. Assign the patient a treatment RN and Primary Nursing Contact. 5. Place the patient in assigned groups and activities based on his/her clinical assessment.

This does not include groups requiring discipline specific assessments prior to implementing treatment such as OT.

If the RN identifies more than one problem, there will be an Initial Plan of Care for each identified problems. The Psychiatrist will (within 24 hours of the patient’s admission): 1. Complete the psychiatric evaluation on the Interdisciplinary Assessment (form 140, page 9)

and dictate a psychiatric assessment on form 152. 2. Review and analyze the completed portions of the Interdisciplinary Assessment, all the data

completed and collected including information from the Admission (form 190); Health Assessment (form 178/179); Physician Orders (form 120 including medication, special procedures, lab work, clinic referrals, etc.); Progress Notes (form 206) and the information accompanying the patient from the mental health center or court.

3. Review the Initial Plans of Care, which were started by the admitting nurse. 4. Initiate psychiatric interventions by checking the appropriate box(es) for each plan. 5. Sign and date in the appropriate area for each plan. 6. Direct the care and treatment of the patient based on 1-5 above. The Social Worker will (within 72 hours): 1. Complete the assigned portion of the IDA. 2. Review the Initial/Interim Plan of Care and identify interventions to assist the patient with

achieving the identified objective. 3. Sign and date in the appropriate area for each plan.

This Initial Plan of Care is considered the active care plan until the formulation occurs. The Initial Plans of Care shall be reviewed, revised or cancelled by the treatment team at the time of the formulation within five days of admission, and this will be reflected in the Date/Status column.

Rev: 7/11

7

PLAN OF CARE FORMULATION SUMMARY (107.4)

NAME OF FORM FORM NUMBER/IDENTIFICATION TIME FRAME PLAN OF CARE FORMULATION SUMMARY

FORM 107.4 (2pages) Within 5 days from admission

Summarize risk factors, symptoms or specific behaviors that resulted in the patient’s admission to CMHIP and/or the need for continued hospitalization. State the reason for the patient’s admission to the hospital in behavioral terms (do not use jargon), including a reason for the behavior, if known. Use the patient’s name (i.e., Mr. Jones) to describe the presenting behavior or circumstances, which brought the patient to the hospital. There are many opportunities for your professional thinking to be reflected in the record, particularly the progress notes and assessments in which you have full opportunity to convey your diagnoses, dynamic formulations, interpretations, plans, strategies, treatment activities and results. Course of action is a very brief narrative of what you plan to provide (for example, medication, evaluation, treatment, etc.).

EXAMPLE – WRONG EXAMPLE – RIGHT

Psychosis, with delusions of grandeur. Mr. Jones states, “I am a king” and has hit others in the nursing home who would not follow his orders.

Patient is confused. Family reports that Mr. Jones “didn’t know who he was” and was found walking around the neighborhood without a destination or a reason.

Patient is delusional. Mr. Jones claims he has three children – Sister states he has none.

Referring Agency and Responsible MHC/Caseworker Indicate name of referring agency and the agency’s responsible mental health clinician or caseworker. What has to happen for the patient to Progress or be Discharged (Discharge Criteria)? Review and discuss the IDA, reason for admission and the patient’s attributes and barriers related to treatment and discharge. Then decide what amount of improvement in the behavior(s) that precipitated hospitalization is needed in order for the patient to be discharged. For instance, if the reason for admission states, “Mrs. Smith cries constantly, eats one meal a day, complains of waking at 3:00 a.m.,” the discharge criteria might be, “When Mrs. Smith talks coherently with others about her concerns without tearfulness, gains 10 pounds and sleeps 6 hours per night she may return to the group home.” The discharge criteria (or what has to happen) should emphasize what the patient will do, rather than what the patient will not do. These criteria need to be written from the patient’s point of view and in very specific, measurable terms so that anyone can tell when this patient is ready for discharge. The time frame will be reflected in the anticipated discharge date or length of stay estimate. IFP patients may require a statement to address court approval as one of the criteria for discharge.

Examples: x Mr. Jones will manage his anger by use of time outs or talking to others. x Mr. Jones will discuss concrete plans for finding employment after discharge and will refrain

from spontaneous references to a belief that he will become a movie star and make millions of dollars.

x Mr. Jones will no longer respond to voices by stalking females. He will voice and demonstrate management of his risk factors.

x Mr. Jones will meet the conditions of “Conditional Release” determined by the court.

Rev: 7/11

8

Progression and/or Discharge Plan (including barriers) The following section allows the treatment team to assess patient discharge needs from a perspective of presenting needs and information obtained. Review the formal psychosocial assessment addressing discharge planning and consider the following:

a. Recommend community follow-up services b. Problems/treatment issues deferred for community follow-up c. Level of support in living arrangement

If discharge is realistically two or more years away for a patient adjudicated NGRI, state the obvious. However, the discharge plan must be developed at the time of admission and reviewed every month for the first year, and every three months after the first full year of continuous hospitalization. In the event there is a change in the discharge plan, this will be reflected in the review documentation or annual updates by the psychiatrist and social worker. Identify the responsible mental health center to whom the patient will be referred at discharge, the name of the provider, and if possible, the location and name of the follow-up professional. Describe any other concerns regarding housing or placement. Additional/Further Evaluations or Assessments Required At the time of the formulation, the physician may order additional testing and evaluations to be completed to assist in the delivery of care. A physician order and progress note identifying the purpose of the additional testing and the initiation of the 405 will start the process. Other Treatment Team Observations or Comments This section allows for the team to note the behavior or patient’s response on the unit that would not normally be included in the development of the plan. For example: A patient who is here as Incompetent to Proceed (ITP) may speak in broken chaotic language with staff but is noted to speak clearly with peers, able to carry on a conversation and play chess with other patients. This discrepancy may have some value if noted. Page 2 of the Plan of Care Formulation Summary Page 2 of the Formulation Summary should be completed after the patient and family have been provided information regarding long-term treatment goals, short-term treatment objectives and the Plan of Care interventions. If the patient and family decline to contribute in writing or are unable, the social worker or designee will document the results of the efforts to include the patient’s family, loved one or friend (as approved by the patient) by checking the appropriate box. There may be clinical circumstances where a telephone conference is more appropriate than an in-person meeting. (Do not leave the space blank. Staff member should describe why the patient was not able to contribute.)

Rev: 7/11

9

Patient Participation The first box provides documentation regarding the level of patient, loved one and family participation in the development of the Plan of Care and Formulation Summary. There is a place to check the type of participation by the patient or family. In addition, the patient and family member(s) can be given the opportunity to document directly on the form, or the POC Liaison/Scribe can paraphrase comments for the patient and/or family.

Patient Participation (Patient can write below or tell the scribe what is to be written)

Aware of Plan Content

Family invited/unable to attend

Family on telephone Family attended N/A

Patient or Family Comments The social worker is expected to make contact with the patient’s significant other or family/friend, with appropriate authorization, to encourage participation in the treatment plan formulation. This box provides an opportunity for the patient to write or verbalize his/her perceptions about the information reviewed thus far and have input on the reason for the hospitalization and discharge criteria at least from his/her perspective. The patient or family may not want to write anything but should be encouraged to verbalize a response to the information. A staff member may write the thoughts down with permission. The patient may write in the box once the full POC has been discussed and should be offered the opportunity. Patient Strengths That Can be Used in Treatment EVERYONE has strengths. The strengths identified should be ones that will be utilized while the patient is here, not necessarily all strengths the patient has. The patient’s strengths or assets can then be used in the development or treatment interventions to meet his/her needs. Once a need or problem area has been identified, and the patient and staff establish a goal to work on in a specific area, the list of assets may be used by the patient and the staff to move toward the goal. Prompt Patient by Asking the Following Questions

1. What are your past and present interests? Be specific. 2. What people, relatives, employers, etc., are resources for you? 3. Are there things that you want to learn about? 4. What skills or knowledge do you want us to know about? 5. Have you found ways to help yourself when you begin to have intrusive thoughts or feelings? 6. What are the positive things about yourself that will help you while you are here?

It is important to discuss and recognize assets because they suggest ways that the team can work effectively with patients. Additionally, it is important for all team members to share this information with each other because a team that is working from a coherent approach is more likely to have patients show improvement. The more assets you identify that affect treatment, the greater the range of treatment possibilities you will have. The intent of the intervention is to utilize the identified strength to build a successful intervention. Strengths will continue to be assessed and utilized in the POC to achieve continued treatment alliance and successful progression. The social worker and psychiatrist formally and continually assess the patient’s strengths and formally in his/her annual assessments. If the patient is unable to write his/her strengths, the loved one or family member or a staff member may write (paraphrasing) patient’s strengths in the box.

Rev: 7/11

10

Treatment Goals Patient Can Establish for Discharge from Hospital This section provides the patient an opportunity to direct or at least partner with the team on his/her course of care. As part of the hospital’s recovery philosophy, staff are to engage in “LEAP” principles: to listen and empathize with the patient so as to develop agreement and mutual efforts to achieve eventual discharge and successful self-management of mental illness. How Staff Can Help Patient Reach Their Goals The patient, or staff if patient is unable, may fill in this box. The patient probably has some idea of what staff can do to achieve the goal(s) above. At first the patient may be too disorganized or angry that he/she is here but to engage the patient in the mutual problem solving starts the process for recovery and steps to build alliance. Staff should continue to ask the patient, “How can we help you?” Treatment Team Member Signatures The patient and members of the treatment team involved in the Formulation Summary must sign and date the document. At a minimum, the physician, registered nurse and social worker are required to attend the formulation. Other treatment team members unable to attend may sign the document as evidence that they reviewed it.

Present Review Signature Date Printed Name

Patient

Psychiatrist

Clinical Team Leader

Nurse

Social Worker

Psychologist

POC Liaison

Other

Rev: 7/11

11

PLAN OF CARE PROBLEM LIST (107.1)

NAME OF FORM FORM NUMBER/IDENTIFICATION

TIME FRAME PLAN OF CARE PROBLEM LIST FORM 107.1 Within 5 days of admission

Problem List A problem list is required for each patient. The form has five columns. Treatment will initiate from six major problem areas.

Problem Abbreviations

Problem Name (related to current hospitalization) Treatment Objective will address discharge barrier as written on the Plan of Care.

D Dangerous Behavior to Self or Others B Behavioral / Mental Health (e.g., acute psychiatric impairment; gravely disabled) S Substance Use / Abuse L Legal (e.g., Competency/Sanity Exam; ITP; Dual Commitment, other) M Medical Problem(s) O Occupational / Social

Problem This classification system serves to simplify problem identification and treatment planning by categorizing problems. In addition, a review of each category for each patient decreases the likelihood of the team overlooking an area of concern. The wide range of psychiatric/medical symptoms, syndromes, and issues are divided into six problem areas. Especially for long-term care patients such as those on the forensic division, the Problem List should note all domains in which the patient experiences problems. Problem Abbreviations The first column, titled “Problem Abbreviation,” is where problem(s) will be identified with the problem abbreviation. The abbreviation will be a constant identifier for this problem on subsequent pages. Problem Summary and Description The second column, titled “Problem Summary and Description,” should consist of a concise description that gives the reader an idea of what the problem is. It is possible that the patient could have several behaviors that you will treat under one problem abbreviation. The domain will maintain the same abbreviation. Examples of what you might find on a problem list are as follows. EXAMPLE:

Problem Abbreviation

Problem Summary &

Description Discharge

Barrier* Date Initiated

& Status** Date Changed

& New Status***

L Mr.Smith was admitted in 1990 as NGRI to charges of homicide. In the past, Mr. Smith has met with resistance from DA’s office when he has requested increases in his privilege levels. At present, Mr. Smith has off-grounds unsupervised privileges. He has not yet gained community placement.

Yes

No

Date Initiated: 4/12/2010

Date Changed:

Status: Active

New Status:

Rev: 7/11

12

D On the day of his instant offense, Mr. Smith thought he had to hurt the neighbor before the devil hurt someone else. Associated risk factors include relationship instability, substance use problems, and major mental illness. At present, Mr. Smith’s risk factors for dangerousness have been stable for years; however, he needs to demonstrate management of his risk factors in an unsupervised setting.

Yes

No

Date Initiated: 4/ 12/2010 Status: Active

Date Changed: New Status:

D Mr. Smith made a serious attempt on his life in 2005, resulting in medical attention. He voices risks associated with no hope, no reason to live, thought about the way he was going to take his life, has the means and the intent to hurt himself. He talks about killing himself after he “takes care” of his neighbor.

Yes

No

Date Initiated: 4/ 12/2010 Status: Active


S Mr. Smith has used many substances in the past including; cannabis, alcohol, cocaine, and amphetamine use these are all in remission in a supervised setting. Mr. Smith has not yet had the opportunity to demonstrate sobriety outside of the hospital. This is closely related to his dangerous behaviors, as he was possibly withdrawing from of drugs when he committed his instant offense.

Yes

No

Date Initiated: 4/12/2010 Status: Active


Below are examples of problems common to many of our patients. B Behavioral/Mental Health (formerly Psychological Impairment) ¾ B - Mr. Jones is so confused that he cannot

remember which is his room or which clothing is his, and gets hit by others who think he is stealing their clothes or trying to sleep in their bed.

¾ B or D - Mr. Jones thinks others are watching him or talking about him, resulting in his cursing and threatening them; he'll put his fist in others' faces and may pick up chairs to throw.

¾ B - Mrs. Smith stays in her room most of the time and refuses to attend any treatment activities.

¾ B - Mrs. Jones has daily bouts of screaming, usually triggered by "voices" she hears when sitting alone in her room.

¾ B - Mr. Jones sits mumbling to self then walks up to others cursing, shaking fist, and making threats.

¾ B or D – Several times a week Mr. Jones will jump up and down, shout, use profanities directed at his caregivers when requested to do something he doesn’t want to do, such as going to the dining room.

O Occupational / Social Problems ¾ O - Mr. Smith has not held a job in the last

two years, he will develop appropriate work habits and skills in order to find and maintain some sort of work after discharge.

¾ O - Mr. Smith's academic skills/life are such that he can read signs and directions, make change, etc.; however, he needs regular opportunities to practice and build upon these skills.

¾ O - Mr. Smith does not shower or shave and has offensive body odor.

¾ O - Mr. Jones has exhausted resources in the community as they refuse to further house or treat him.

¾ O - Inability to care for self without prompting or assistance of others

¾ O - Since Mr. Smith does not have work experience or job skills and he would like to work at a sheltered workshop upon discharge, it is important that he develop some basic job skills.

¾ O - Mr. Jones reports to have no friends, he complains that people make fun of him, call him names and he has no family involvement. He wants to stay in his room and not engage in any activity with others.

¾ O - In groups or on unit, Mr. Jones constantly bosses others around and interrupts their conversations; needs to learn to share

Rev: 7/11

13

attention and take turns with others.

D Dangerousness ¾ D - Mr. Jones has had three suicide

attempts in the past five years and now states, “I want to die,” relates a clear plan, and has accessible means to carry out self-harm.

¾ D - When environment is noisy or when she perceives others as threatening her, Mrs. Smith reacts by hitting or threatening others.

¾ D - Mrs. Smith reports hearing voices telling

her to do things. In response to them, she strikes out at others, strikes the air, grabs others' belongings, and verbally threatens others and hits on the walls.

¾ D - Mr. Jones expresses anger by throwing objects and hitting.

M Medical Problems ¾ M - Mrs. Smith is confused, does not

understand her diabetic diet, and grabs food from others in the dining room. This failure to control diet increases blood sugar levels and her confusion.

¾ M - Mr. Martinez has chronic constipation and was treated for a bowel obstruction within the last 12 months.

¾ M - Mr. Jones is at risk for metabolic syndrome. He is over weight, receiving treatment for high blood pressure, diabetes and high cholesterol, and he take psychiatric.

¾ M - Ms. Jones has chronic or acute pain a result of rheumatoid arthritis. She reports the pain level to be a 7 out of 10 on a constant basis. She requires adaptive devices to compensate for her disfigured and painful joints medication.

L Legal Problems ¾ L Mr. Smith has impending court hearing for

resolution of charges related to (insert specific charge and behaviors or mental status contributing to offense/charges.

¾ L - Mr. Smith has been adjudicated NGRI to charges of assault after fighting over a parking spot at the mall.

S Substance Abuse/Abuse ¾ S - During the last three home visits, parents

have reported that John drank beer from the time he walked in the door until they brought him back to the hospital. Parents repeatedly told John of the danger of mixing alcohol and his medication but did not stop his drinking.

¾ S - Mr. Jones states “That if you ever let me out of this hospital, I will go to the nearest bar and get drunk."

¾ S - Mr. Smith denies use of alcohol, however, on his last pass, he reportedly went to the nearest bar and socialized with old friends on a drinking spree. The past three hospitalizations Mr. Smith denied use of alcohol even though he comes in intoxicated upon admission.

When a specific problem behavior is resolved and resurfaces it would maintain the original domain abbreviation. Whether these problems can be listed as one problem or several depends on clinical judgment and the decision of the team. Sometimes, various behaviors can be listed as one problem. This would allow for several interventions to work within the scope of practice of the staff person to achieve the common objective. Other times, various behaviors are better listed as separate problems because the behaviors

Rev: 7/11

14

call for different interventions. The description of the problem (risk factors) will be the basis for objectives that relate to the problem description. In this context, staff members should not be looking at historical review of all the patient’s problems. Medical Problem(s) You may only place several active medical problems in one box if the problems are related to one disease; otherwise, medical problems must be indicated separately. For example, problems related to diabetes, such as wound care, circulation, vision problems and so on, may be included under the “Diabetes” problem. Unrelated medical problems, such as COPD and cancer, require separate problems. These problems would be those that require continued monitoring, treatment, clinic visits and evaluation. Some medical conditions are maintained and controlled with medication. Inactive medical problems can be listed in a box and noted as “inactive with treatment”. A treatment plan would be required only if the condition becomes out of control and requires more active medical attention or patient education. A third column, titled “Discharge Barrier,” identifies problems that must be addressed during hospitalization. This is indicated with a “Yes” or “No” response.

x Yes = Problem is a significant barrier to discharge. x No = Problem is not a significant barrier to discharge and may not solely necessitate inpatient care.

Date Initiated and Status ** The fourth column, titled “Date Initiated and Status,” indicates the date the problem was entered into the Individual Plan and the current status of the problem. Status Definitions

x Active: A problem that is thought to be actively present. The problem would require active assessment and ongoing treatment. An objective and intervention is required and progress must be documented on all active problems.

x Inactive: A problem that is “Inactive.” It should be noted it is likely that the problem may become

active or could have significant impact on treatment. Examples: history of homicidal attempt, history of suicide attempts, allergy to penicillin, only one functioning kidney. No objective or intervention is required.

x Inactive with Treatment: A problem that is resolved but continued to require treatment to maintain

or prevent the recurrence or exacerbation of the problem. For example, assaultiveness may be under control with lithium and present when lithium is withdrawn. Therefore, continued treatment would be indicated for this inactive problem. An “active problem” should not be changed to “inactive with treatment” until it is fairly certain that the change in status is real and not just a fairly temporary state. Once it has been determined that the patient has successfully resolved a problem behavior, yet interventions continue, it will be up to the treatment team to continue with a formal Plan of Care. Any changes in treatment would be documented in the same way that changes are documented for the active status for that problem.

x Deferred: A deferred problem may be: an “active problem” whose assessment and/or treatment

has been postponed until a later time, another place or indefinitely. A deferred problem could also be an active problem that for various reasons would probably never be treated or require further assessment. In the second instance, problems may be so clearly intertwined or require such similar treatment interventions that it simply makes more sense to treat the problems in a combined manner. For example, for NGRI’s (with the intense focus on risk reduction), the

Rev: 7/11

15

treatment team may choose to defer substance abuse treatment to treatment of dangerousness if the use has resulted in dangerous behavior.

Date Changed and New Status *** The fifth column, titled “Date Changed and New Status,” is fluid and based on the assessment and status of the problem(s) identified. For example a “Resolved Problem” can become active once again. A new or changed status is defined as:

x Resolved: Used when an “Active Problem” has reached a state where it is felt to be of little or no clinical significance.

x Active: A problem that was once resolved or inactive and becomes active again. This will require

active assessment and ongoing treatment. An objective and intervention is required and progress must be documented on all active problems (forms 107.2 I and 107.2 O).

x Inactive Problem: A problem that is no longer active. An objective and intervention is NOT

required and progress must be documented on all active problems. x Inactive with Treatment: Continued treatment is required to prevent the recurrence or

exacerbation of the problem. x Revised: Used when a change is made in the “Problem Summary and Description.” This is

intended to clarify any confusion or misunderstanding with the present problem description. Revisions in the “Problem Description” should improve clarity or reflect change in the nature of the problem itself. For example: “Allergy to thorazine,” could be revised to “Severe EPS on thorazine,” after it was determined that rather than an allergy, the patient has severe EPS in response to thorazine.

x Cancelled Problem: Used to remove a problem that may have been incorrectly identified as a

problem for the patient.

Cultural, Language or Learning Needs to Consider in Treatment A patient’s cultural background, ethnicity, primary language and cognitive functioning is reviewed and considered when writing a treatment plan. The impact of these variables is completed by the nurse and social worker when completing the interdisciplinary assessments. For monolingual patients, the plan is written in the language that is understood by the patient. Interpreters are available to assist with the exchange of pertinent medical and clinical process with the patient and staff members. Cultural, language, or learning needs to consider in treatment:

Rev: 7/11

16

PLAN OF CARE PATIENT OBJECTIVES (107.2 O)

NAME OF FORM FORM NUMBER/IDENTIFICATION TIME FRAME PLAN OF CARE OBJECTIVES FORM 107.2 O Within 5 days of admission and

updated PRN Guidelines for Completing the Plan of Care Patient Objectives Form This is a change for us as the PLAN OF CARE is a prescription for change in the patient; therefore, we want the POC to reflect first person singular “I”. The plan is for the person making the change: our patient, thus using the proper noun and language may facilitate motivation to change. The language on the plan will reflect what the patient will do. Long-Term Goal: What is the goal for the hospitalization in the language of the patient? The long-term goal indicates a reasonable expectation of what the patient is thought to be capable of achieving either, (1) at discharge; or (2) what is expected to be accomplished within a particular security stage. The long-term goal must be obtainable and reasonable. While regulatory standards do not require the long-term goal to be measurable, sound clinical practice directs long-term goals to contain some elements of measurability, though not with the level of detail required by short-term objectives. An outcome measure would allow the clinician to ascertain, at any point in time, whether the long-term goal has been obtained. When the long-term goal is attained, the patient’s progression is clearly closer to community transition. In some cases this would translate into sequential long-term goals, which would work toward showing clear steps for progression. Life Goal (in patient’s own words): Can the patient articulate what he or she would like to accomplish? The intent is to reach for hopefulness and a better future. “What do you want to be doing in the next year, or next 5 years or so?” Most Significant Barrier to Achieve Goal (in patient’s own words): Ask the patient, “What would get in the way of you achieving the your life goal or long-term goal?” This is the beginning of recovery and engaging the patient in their own self care and management. Problems and Objectives Each problem is identified with a single character abbreviation given the problem on the problem list (form 107.1). If the problem is resolved and reappears during hospitalization, start it again. Each objective is a statement in first person, singular “I”. This is what the patient will do to resolve the problem. There are treatment objectives under the “Problem” and the objectives are numbered. The short-term objectives must be written terms of what the patient will do. A target date for accomplishing the objective will be established. Do not just enter the date the team will next meet to review treatment progress. If the patient has not made progress towards this objective, the objective or intervention should be changed after a reasonable amount of time. If the objective and target date remain unchanged at the Plan of Care Review, leave it as it is. Remember, a short-term objective should be a small step towards elimination of or managing the problem. The target date is related to the patient’s ability to achieve the objective, not the date the staff will review the Plan of Care. For example: (1) I will sleep at least four hours per night, four out of seven nights. The “Target Date” would give Mrs. Smith two weeks to achieve this goal. It is permissible to use “Ongoing” as a target date for an objective that has been attained but it must be maintained in order to work towards a long-term goal of stability and management of risk.

Rev: 7/11

17

Problem: Behavioral/Mental Health

INITIATION DATE 12/1/10

Objective #1: Target Date – November 25, 2010 I will be willing to take medications as a step to self-care and to begin feeling better. Objective #2: Target Date – November 25, 2010 - I will ask for assistance with my personal hygiene and methods to manage my beliefs about water. Objective #3: Target Date - December 6, 2010 - I will eat food, as evidenced by maintaining a weight of 170 pounds to maintain my health. I will drink 64 ounces of water with only one reminder during the day. Objective #4: Target Date – January 5, 2011 - Within one month, I will feel different about the benefits of water. I will bathe by myself with no prompting and drink fluids as evidence that I am managing my mental illness symptoms.

STATUS Active

The objective is clinically sound when it meets the CAMP criteria:

x C – controllable, or under the patient’s control and not under the control of an outside agency or individual

x A – attainable, or realistically something the patient can achieve given the patient’s strengths and limitations

x M – measurable, or described in a manner that can be counted or observed x P – described in positive terms, emphasizing what the patient will do rather than just what the

patient will refrain from doing This means that most of the objectives should be connected to reduction of risk factors for future dangerous behavior. The explicit connection can be made in the wording of each short-term objective in the description of the “Problem Behavior” example. Obviously, there are problems that require treatment that are not related to risk of future danger. For example, medical problem objectives will seldom be connected to risk to the community. It is not acceptable to make a patient objective that documents, “I will achieve platinum level,” which is basically a certain level on the Contingency Management System. However, the target behavior that is desired can be used as an objective. Ask, “What behavior must the patient demonstrate to achieve the platinum level?” That behavior is what can be described in the objective and using “I” will (write the desired behavior) and it helps to put under what circumstances the desired behavior, (e.g., when experiencing frustration…). The use of the CMS program is what the staff do to help the patient achieve the stated desired behavior, thus the CMS program is an intervention and must be explained in the intervention section of the plan. Indicate what the patient will be doing when the problem is reduced or eliminated. It would be helpful to include the reinforcement schedule for rewarding the patient’s target behavior. Objectives should reflect desired patient behaviors. Think of small steps toward long-term goals and reflect on the patient’s criteria for discharge. As the patient attains these goals, the team may consider increasing the duration of the step(s) until the problem is resolved. For example: “I will remain assault free for 1 day,” could be changed to, “I will remain assault free for 7 days.” Remember, you can have more than one objective for each problem, especially if there are several behavioral elements to the problem. There can be a sequential order of short-term objectives with successive target dates developed. An initial active objective can lead to another similar objective with longer periods of consistency or successful accomplishment, yet it will not become active until the previous objective has been accomplished. Thus, you may build a hierarchy of progressive objectives with various implementation dates and subsequent target dates. This would prevent the need to have a Plan of Care Review while allowing staff to continue to work on progress made by the patient toward the long-term goal. All the

Rev: 7/11

18

progress will be formally reviewed at the specified Plan of Care Review. All progress and patient response will be recorded in the medical record. Initiation Date/Status for Objectives Each objective requires an entry regarding its continuing status at each Plan of Care Review. The objective(s) may be attained, revised, deferred or cancelled, active, inactive, inactive with treatment, and rewritten depending on the patient’s response to treatment and/or additional information obtained. The date and status are entered in the box titled “Date/Status.” With this method, printing an updated POC is simple once the status of the old is completed.

x Active: A new objective, or an objective that was once resolved and becomes a focus of treatment again.

x Attained: Attained indicates that the patient has demonstrated the identified behavioral change.

There may be more than one discipline providing treatment to the patient focused on one specific objective. The patient may attain the purpose and focus of the objective by completing a certain group, but may not have generalized the skill to another intervention service provided by another staff person. Thus, the intervention will remain active and the goal will not be completely attained. The staff person that assesses the patient’s achievement of the objective within their group will no longer have to document in the progress notes after the final assessment of the progress. They may want to establish a new intervention for a new target objective or simply identify a new objective within the same intervention and must communicate this to the POC Liaison/Scribe.

x Deferred: An objective that is still considered valid but is postponed until a later time. x Revised: Indicates that a change has been made in the objective. x Cancelled: Indicates that an objective is no longer applicable. x Active: A new objective, or an objective that was once resolved and becomes a focus of

treatment again. x Rewritten: When objectives and interventions become longer than one page or the changes have

become such that legibility is poor, the problem description and long-range goal or objective should be rewritten.

Other Examples of Objectives

Dangerousness (D) x D 1 – I will talk to others one time per day using words and language that are respectful and non-

offensive. x D 2 – I will accept staff assistance with showering and change of clothes at least twice a week for

four weeks without kicking, biting, or scratching staff. x D 3 – I will interact with others, practice listening to another’s opinion, allow the other person to

voice his/her option while remaining calm and respectful when I disagree. Occupational / Social Deficits (O) x O 1 – I will attend work skills training five days a week and earn performance ratings of 4 or

above (1-5 scale) each day for the next 90 days.

Rev: 7/11

19

x O 2 – I will be able to plan my weekly meals, shop for my meals and cook my meals as demonstrated on my ability to live and care for myself.

Behavioral / Mental Health (B) x B 1 – I will participate in an on-unit activity 30 minutes per shift for 5 out of 7 days a week without

pacing. x B 2 – I will be able to identify my symptoms and interfering thoughts / ideas and talk to staff about

them 1 time a day with the nursing staff. x B 3 – When I am having disturbing thoughts, I will ask staff for some assistance with medication

or activities to help manage my feelings.

Medical Problems (M) x M 1 – I will follow the diet prescribed to me to manage by blood sugar. I will choose other awards

in the CMS system that will not create a diabetic problem for me.

It is acceptable to work on only some of the objectives at one time. They should be realistic and attainable by the patient. Use common sense when deciding if a group of problem behaviors has one major objective or several small objectives. For example, when hearing the voice of the devil, the patient always runs up and down the halls, yells, screams, and threatens to kill others, it is recommended to keep the behaviors together in one goal statement. However, with a specific problem such as depression, you can differentiate the behaviors so that you would have separate objectives reading:

x B 1 – I will remain out of bed for 8 hours a day. x B 2 – I will make an effort to talk to others at least one time per day when in cooking group.

In this way the interdisciplinary team could focus on their discipline specialty group. To further explain, B 1 would be very appropriate for the nursing staff to work on, while B 2 would be more appropriate for the OT staff to address during less formal activities. Each discipline could then write progress notes that are specific to their intervention, which supports a common objective for the patient. The patient may also have short-term objectives that a variety of staff design different interventions for. For short-term hospitalizations, there are very few instances where maintenance objectives are appropriate. We are not here to just maintain behavior but to increase positive behaviors or to decrease ineffective behaviors. An example of a maintenance intervention to insure psychiatric stability would be for those patients who receive intermittent maintenance ECT, and some other long-term treatment, patients who may not be acutely ill but without continued intervention and support, would decompensate. It is acceptable to increase the length of time the patient will be free of a specific behavior or maintain a positive behavior. In other words, by increasing the time, you have a new positive objective. This is particularly applicable for those patients that need to demonstrate for the court, Disposition Committee, and/or community placement staff that he/she is not exhibiting specific problem behaviors prevalent in the past. At these times remember that since you can have more than one objective for the problem, you can have objectives specific to the court or for Disposition Committee. Note: Compliance is not to be used as a method for manifesting our desire to control. For example, “comply with unit rules and regulations” is not an acceptable objective. The skill that is required is to be able to manage personnel needs in a community living setting by negotiating the use of the phone with

Rev: 7/11

20

others by limiting the number and length of phone calls. EXAMPLE: “I will be able to work and live with others safely by sharing the use of the telephone by limiting the amount of time I am one the phone.” The recommended groups and the names of the primary treatment staff will be on the POC. The groups and treatment services will be reflected on form 107.2 I. The recommended groups will be simplified and written for easy reference for the patient on the 107.2 O form in the appropriate section. A copy of the weekly treatment schedule with the groups highlighted or circled will be helpful for the patient and shall be given to the patient at the time a copy of the POC is provided to the patient.

Rev: 7/11

21

PLAN OF CARE INTERVENTIONS (107.2 I)

NAME OF FORM FORM NUMBER/IDENTIFICATION TIME FRAME PLAN OF CARE INTERVENTIONS FORM 107.2 I Within 5 days of admission and

updated PRN SAMPLE OF FORM:

Problem Abbreviation &

Objective #

Treatment Interventions (Staff Action, Frequency/Duration, Individual Responsible, Discipline, and Purpose of the Intervention must be included)

Initiation Date

Status (Active, Attained, Cancelled,

Revised)

Problem Abbreviation and Objective # This column will indicate the short-term objective(s) by the letter abbreviation. “B” for Behavioral/Mental Health. This letter and objective number will be the focus of the intervention. It is possible to have one intervention for more than one objective. Treatment Interventions Interventions will be listed in the second column. Interventions are actions performed by staff that will assist the patient to increase, decrease or change behaviors. Effective and sound treatment starts with effective and sound evaluations and assessments. Evaluating or monitoring is expected of ongoing assessment and treatment, not necessarily an identified staff intervention. In other words, say what you are going to do to help the patient change a specific behavior, not that you are going to evaluate it. Also, use the word “encourage” less frequently. Encouragement to patients receiving services is an expected behavior of all staff. Several interventions could work on one objective. Each intervention does not require a separate objective.

Staff Action List specifically each intervention that will be made by various disciplines to help the patient achieve the objective. State exactly what kind of treatment you are going to provide so that anyone can understand what you are doing and why (i.e., toward what objectives). The intervention is written from the staff point of view. Frequency / Duration (How Long and How Often) State the frequency of the intervention. If you see a patient in therapy five days a week, this doesn’t indicate five hours, just five contacts, each of which might only be five minutes. So, say what you are going to provide – how long and how often. The frequency should be appropriate to achieving the objective and realistic in terms of the patient’s level of functioning. The duration of the activity depends on the target date (this might include the patient’s willingness to work on the objective, the severity of the problem, cognitive abilities, etc.). The duration of the activity might also depend upon the patient’s response and cycle of intervention services. The continuation of an intervention will be reviewed at the Plan of Care Review. Treatment consists of definite, ongoing actions by which you attempt to change, alter or prevent undesirable behavior or symptoms while increasing desirable, adaptive behaviors. An intervention should not focus simply on controlling a negative behavior when it occurs (e.g., PRN). Rather, it

Rev: 7/11

22

should be an ongoing effort to help the patient expand positive, responsible behaviors. It is not always possible to predict when a behavior might occur, but your knowledge of the patient and his/her behavior will help you decide how often your intervention will be needed. In a few cases, you may use “as needed” or “daily.” Individual Responsible and Discipline Enter the name and discipline of the person who is primarily responsible for facilitating the intervention. More than one person may be providing the intervention and can be listed as responsible staff. Documentation is provided by any of those listed as “responsible staff.” Purpose of Intervention The purpose of the group demonstrates a relationship with the short-term objective(s). The group protocols on the unit would serve as a reference for the description of the intention, purpose and objectives of the group. EXAMPLE: “K. Henderson will team Mr. Jones about the hazards of drugs and alcohol abuse. She will teach methods to refrain from using during the Substance Abuse Education Group that meets one hour on Monday afternoons at 3:00 p.m. Purpose: To learn skills to maintain his sobriety and manage his cravings.”

Initiation Date This date reflects the date the intervention will begin to be implemented. This method will allow for sequential steps to be included on the plan while reflecting a plan for the patient’s progression onto the next short-term objective and subsequent intervention without a formal Plan of Care Review. It is acceptable to enter “Deferred” until the previous sequential intervention is achieved. Date / Intervention Status When an intervention(s) is active, completed, cancelled or revised, it will be reflected on the form. This change in status would also be indicated on the 107.3, “Summary of Progress” section, of the Plan of Care Review. Intervention Status

x Active: Indicates that an active intervention that is currently being performed by staff to assist the patient to increase, decrease or change behaviors

x Completed: The intervention is finished. Example: Patient went through all of the DBT modules. x Cancelled: Indicates that an intervention is no longer applicable. x Deferred: An intervention that is still considered valid but is postponed until a later time. x Revised: When interventions become longer than one page or the changes have become such

that legibility is problematic, the description and long-range goal or objective should be rewritten. EXAMPLES: (Note: All interventions should include the responsible individual’s name and credentials and the purpose of the intervention related to the objective.)

Rev: 7/11

23

x Nutrition Services will provide foods patient likes to increase food intake to 50% at all three meals. Joan Smith, Registered Dietitian, will insure the Nutrition Services Department provides patient with food she likes and will review on a weekly basis. Purpose: Increase patient’s weight to the lower normal range.

x R.T. will provide a group recreational activity scheduled 2 hours a day, 4 days a week.

Samuel Clemons, Certified Recreation Therapist will provide the group activity. Purpose: To teach, reinforce and demonstrate role-modeling and pro-social interactions with others in a highly interactive activity.

x Nursing will direct Mrs. Smith’s attention to the radio or other tasks she enjoys. This will

occur in the milieu with hourly positive reinforcement during Shifts I and II. Sally Jones, RN, will reinforce the behavior on a continuous basis. Purpose: To decrease frequency of patient’s yelling and cursing behaviors.

x Community Integration Group to occur 2 times a week for 45 minutes. George Strait,

Social Worker, will provide Mr. Jones sessions to increase his understanding of and cooperation with treatment once in the community. Purpose: To provide education and motivation for the patient to follow the discharge plan to remain clinically stable in the community.

x Individual Shaping Class with Alfred Skinner, Psychologist, to teach Mrs. Smith

appropriate verbal responses when she is denied her demands. Purpose: To teach new response skills. Two times a week for 30 minutes each.

x Nursing staff will intervene during cursing and threatening behaviors by giving firm

instructions for Mr. Jones to stop, then refocus attention. This reinforcement schedule will occur as the opportunity presents itself. Mr. Jones will be given positive reinforcement for calm controlled behavior on a schedule of every 30 minutes by nursing staff. The assigned case manager, John Smith, will assist Mr. Jones by charting and monitoring his behavior on a daily chart. Purpose: To modify dysfunctional and ineffective expressions of fear or anger.

Unit The unit refers to the ward or name of the patient’s current treatment team.

Rev: 7/11

24

PLAN OF CARE REVIEW (107.3)

NAME OF FORM FORM NUMBER / IDENTIFICATION

TIME FRAME PLAN OF CARE REVIEW FORM 107.3

2 pages unless addendum is used

MAJOR CHANGE IN CONDITION – E.G. AN ASSAULT (see instruction on page for the use of Initial & Interim Plan of Care) At least every 30 days after hospitalization for one year; at least every 90 days thereafter. Within three working days following transfer from ward to ward. The next review would be scheduled not more than 30 days from the transfer POCR. Seclusion/Restraint Review (206 SR POC): Is used every time the use of Seclusion and or Restraint is ordered.

The process for interim Plans of Care was already reviewed; however, to repeat, when there is a major change in the patient’s condition and the interdisciplinary team is not available quickly any of the Initial and Interim Plan of Care forms should be used on a temporary or short-term basis. Every time seclusion and/or restraint is used to provide safety the Interim 206 SR must be initiated. The change in the patient’s condition would usually impact the effectiveness and validity of the current active treatment plan. For example, perhaps “Dangerousness” has not been identified as a domain, thus a Plan of Care has not been activated for any treatment along this domain. Perhaps the patient receives news from home that creates some feelings of sadness resulting in threats of self-destruction. If the interdisciplinary team cannot be pulled together quickly to address this major change in condition, the RN in charge can activate form 107.5 – Dangerous to Self (DAS) until the team can be pulled together. This temporary or interim plan will require the review and support of the physician or social worker as quickly as possible. The interim plan must be cancelled when the problem is resolved or when the issue is addressed on the 107.2 POC, whichever comes first. Has Psychiatric Condition Changed? Check the appropriate box and make whatever changes are required on the Multi-axial Diagnosis form (form 107). In the space provided for rationale, the psychiatrist will document the clinical reasoning for the change in the diagnosis.

Physician Summary Patient’s clinical progress, to include medication response and rationale, and when pertinent, medical concerns, physical status and risk assessment. Any good cause restrictions of rights based upon safety and security must be noted and reviewed at least every 30 days. (IFP – include review criteria/goal for movement to less secure area.) The rights restrictions include, but are not limited to, non-DOC patients sleeping in rooms with locked doors at night for over 60 calendar days unless an individualized assessment is made and the treatment team determines that the patient is imminently dangerous to him/herself or others. The assessment must be documented and reviewed at least every 30 days.

Rev: 7/11

25

The physician addresses the summary of patient progress and reviews the patient’s response to interventions in this section. It includes the patient’s medication response and rationale for any change. The medication will be formally reviewed and evidence of medication education will be summarized very briefly with further needs assessed as well. The narrative will include action taken on requested treatment and therapeutic consults. For IFP, this section must address the clinical rationale for patient movement to include gains and losses of privileges. Non-forensic or civil units must address medical necessity of continued hospitalization and treatment. The physician assesses the benefit of individual psychotherapy by completing the box.

Assessed the current need and benefits for individual psychotherapy. Individual Psychotherapy Ordered No Yes (405 started)

If yes, describe purpose: Reflected on the POC? Discontinue Postpone Objective Attained (Though the physician must author this section, it may be typed on the Plan of Care by other persons.) If more space is needed; or if dictated, check here and continue on Form 107.3 Addendum.

Recertification for Continued Stay The psychiatrist determines the appropriate criteria. IFP must review the security stage of the patient at each POC Review to assess what the patient must achieve to progress to a lower security stage. Estimated Length of Stay in Hospital Consider the current level of functioning of the patient and consider the goals and severity of the problems in estimating the length of stay. The psychiatrist must give some definite statement regarding the patient’s clinical status that supports continued hospitalization. Advance Directive Modified Any Advance Directive will be reviewed at this time. It would also be appropriate based on the age and medical status of the patient to review the present status of any DNR (Do Not Resuscitate) requests and orders at this time. Any modifications of the Advance Directive will be documented in the progress notes and a new form 665a. Duty to Warn Reviewed Check the appropriate box. Date of Most Recent History and Physical Must be completed annually.

Rev: 7/11

26

Date of Most Recent Psychiatric Assessment Must be completed annually Risk Assessment Risk assessment findings will be considered. The physician will evaluate factors, which drive the POC modifications and should be entered into the summary box. The physician’s signature will be evidence of this consideration. IFP completes formal risk assessments on patients who are NGRI. For Maximum Security patients, the physician should indicate the privilege level in the narrative summary above. Plan of Care Review Fill in the projected POC Review date. Summary of Progress Towards Objectives The physician, POC Liaison/Scribe, or designee must summarize the patient’s progress towards the active goals and response to interventions. The Plan of Care form should reflect all changes to problems, goals, objectives or interventions. Summary of Patient / Family Education Provided and Barriers to Learning Education provided to the patient or family since the last review should be listed in this section. New barriers and learning needs will be identified and documented as well. Form #204 can be used to review and summarize education offered. The patient’s best way to learn should be evaluated and documented as he/she stabilizes and cognitions improve. Patient Participation / Attendance of Others When the Plan of Care is reviewed, guardians, family members or loved ones should be encouraged to attend (if the patient desires and authorizes). Document the effort to include family by checking applicable boxes as well as the level of the guardian or significant other’s participation. It is necessary for the patient and guardian or significant other to sign the Plan of Care Review form. If the patient refuses to sign, note the reason in the patient comment section. There is a place to check the type of participation of the patient or family. In addition, the patient and family member can be given the document to write directly on or the POC Liaison/Scribe can paraphrase comments for the family.

Written Patient or Family Comments: The patient or family will be encouraged to write comments in this section, but do not leave blank if patient refused or is unable. Staff should make an entry such as “refused” in the space provided.

If more space is needed in any of the three sections calling for narrative, there is an addendum. (Addendum Form 107.3 is available for noting additional information.)

Rev: 7/11

27

SAMPLE OF FORM:

Aware of Plan content Was offered copy of Plan Patient declined family attendance Family invited/unable to attend Family on telephone Family Attended N/A

Written Patient input and/or family comments:

Treatment Team Member Signatures

Present Review Signatures Date Print Name

PATIENT

Psychiatrist

Nurse

Social Worker

Team members required to attend the Plan of Care Review include the psychiatrist, a nurse and social worker as well as those disciplines that are necessary to meet the patient’s needs as determined by the Clinical Team Leader or physician (at least one of those disciplines must attend). The POC Liaison may be present to document modifications to the original Plan of Care but does not count as the RN. Other participant’s titles and signatures can be added to the list. All disciplines must be checked as present or sign that they have reviewed the plan. The clinical disciplines – O.T., R.T., P.T., Voc Rehab, and Speech Therapist – are required to base patient treatment objectives and interventions on assessments ordered by a physician.

Assigned RN: Primary Nursing Contact: Identify the assigned RN even if the nurse remains the same from review to review. Also, as other nursing classifications may have primary contact with the patient, that person must also be identified at this time and at every review.

Rev: 7/11

28

GENERAL INFORMATION Transfers and Reviews The receiving team must review the objectives, assign new treatment groups and complete an updated intervention form. It goes without saying that you have a different treatment team and the patient must have the current treatment team members’ names. The treatment interventions will change and staff responsible will be modified. It is critical for the receiving team to review the most current assessments and meet with the patient to re-evaluate the patient’s objectives to begin the therapeutic relationship. If changes on the Plan of Care are made outside the regular review, a progress note must be written. Staff on the interventions sheet must assure that the POC Liaison/Scribe has the most current information reflected on the POC. When completing the “Basis for Continued Hospitalization” section, it is often difficult to decide when to use current behaviors versus pre-admission behaviors, or a combination of both. In this situation, thinking about the criteria for discharge should help give you the answer as these sections must be consistent with each other and make sense together. In other words, you must have a criterion for all major behaviors listed in “reason for stay.” Ask yourself the question, “What would the patient have to act like in order to leave?” This should tell you what he is doing that convinces you he needs to stay. What to Give the Patient The patient will be given copies of the Plan of Care Objectives. The Interventions sheet may be given, but it seems to confuse the patient as the POC has the recommended groups on the form. Copies of other parts of the medical record would require review and authorization from the physician. When Patient is Discharged When the patient is discharged, the Plan of Care must be cancelled. Plan of Care Review Guidelines for Other Forms Associated with the Review

1. The problem list is updated. 2. The review date is listed as well as interventions. 3. The target dates are updated. Remember that target dates are independent of the projected

POC review dates. 4. The diagnoses are updated and diagnosis update forms are sent to Medical Records

Department. 5. The primary nursing contact or POC Liaison/Scribe has reviewed as appropriate the progress

notes and assessment prior to Plan of Care Review, and also has checked to see that referrals and consultations have been followed up on.

6. Required signatures are obtained. 7. The Plan of Care Review will be filed in the chart as soon as possible. 8. The staff present is listed; the patient receiving services, family, guardian participation is

indicated; and written input from absent staff members is noted. 9. It is an expectation that the patient receiving services and/or guardian will be given every

opportunity to meet with the team during the review and to participate fully to the extent allowed by his/her legal status and physical/mental condition.

Rev: 7/11

29

Updates to the Problem List, Objectives and Interventions during the POC Review

1. The patient’s progress or lack of progress for each objective is discussed. Changes in the Plan of Care made between POC Reviews as well as changes made at the time of the POC Review will be reflected in all of the appropriate forms.

2. The effectiveness of interventions, treatment activities, and medications related to goals are summarized.

3. Discharge plans will be reviewed and updated. 4. Projected length of stay in the hospital will be reviewed once again. 5. Summarize the patient and family education that has been provided, including any barriers to

learning (emotional, physical, cognitive, language) and their understanding of the information they have received.

6. In the summary, indicate reasons for continued stay, what the treatment focus will be over the next review period, and progress and action towards each objective and discharge.

7. The risk assessment must be reviewed and updated per signature of the psychiatrist. 8. All handwriting must be legible. Progress notes are to reflect objective and a complete picture of

the patient using SAPO, DAP, SOAP or FAIR methodology. 9. Changes must be retained in the medical record or patient supplemental file.

Plan of Care Progress Notes A progress note can be documented by any of the listed individuals in the intervention statement on the POC. In the left hand column, enter: the date of entry, time (non-military), and cross-index to the short-term objective. In the body of the progress note document:

1. Labeled per intervention – EXAMPLE: “Anger Management”* 2. Attendance – “Mr. Jones attended the entire Anger Management groups on 11/5, 11/6 and 11/9.” 3. Indicate provision of and a patient’s response to a specific modality using one of the following

guides (SOAP, SAPO, DAP, FAIR). Do not use derogatory statements, such as “patient acting immature or having a tantrum.” Describe the behavior. Also generalized statements such as “patient had a good day” are not descriptive. Note behaviors that suggest the patient had a good day.

4. Write what progress the patient has made towards short-term objective. 5. Plan to continue/change POC and rationale for continuation/change. 6. Legibly sign and note staff credentials. *Items are strongly suggested.

Frequency of POC Progress Notes per Policy No. 3.15 The therapist providing the services as designated in the Plan of Care shall document progress notes at least weekly. If an intervention occurs less than once a week, (i.e., a group that meets every other week) the progress note shall be documented at the same frequency. A final entry shall be made when the outcome criteria are met and at the time of discharge and/or completion of the intervention. Progress notes shall be documented more frequently should the condition and needs of the patient warrant more frequent entries. This schedule does not preclude the necessity for ALL DISCIPLINES to document relevant information governed by the condition and needs of individual patients (medical necessity) so that ongoing care and treatment are provided without interruption.

Rev: 7/11

30

Not Guilty by Reason of Insanity (NGRI) For patients adjudicated NGRI, the primary focus of treatment must be on reduction of risk of violent and criminal behavior. Therefore, problem behaviors related to the patient’s risk of future dangerous behavior must be explicitly identified as related to risk. This explicit connection to risk orients both the patient and treatment staff to the importance of making change in these problem behaviors. Because the treatment of NGRI patients must be very risk-focused, and because risk factors are often interrelated, it is acceptable to defer treatment of one-problem behaviors to another problem behavior. For example, substance abuse is commonly quite closely correlated to a patient’s assaultive behavior. It is expected that the assaultive behaviors will be described under the Dangerousness domain (D), and that the substance abuse behaviors will be described under the Substance Abuse (S) domain. Furthermore, it is expected that both problem descriptions will explicitly note the connection with risk of future dangerous behavior. The treatment team may choose to treat each problem separately or defer the substance abuse problem to the dangerousness for treatment purposes. Static risk factors are stated elsewhere and has little purpose in the reinstatement as those risk factors or problems will not be remedied. Civil Commitments (to include Patients from Department of Corrections and Jails) For individuals who are committed as civil patients, the focus will be the medical necessity which may include a reduction in violence to self, others, and resolutions of unmanageable symptoms of mental illness. Court Ordered Evaluations An evaluation case is simply to evaluate the patient and this evaluation is completed by an assigned professional not within the treatment team. However, there are occasions when the patient presents with clear symptoms of mental illness so the evaluation case may become a treatment case as well. Certain courts are using a new form of court order for competency evaluation cases. The orders direct that treatment should begin (or continue) at the time that CMHIP recommends to the court that the patient/defendant be found ITP. For cases with this specific type of court order, we are ordered NOT to return the patient to jail at the conclusion of the evaluation. A formulation and Plan of Care will be expected within 72 hours of the court order or when treatment begins. The evaluations will have already occurred. Incompetent to Proceed (ITP) For individuals determined as ITP, the focus of treatment is the patient’s restoration so he/she can assist in his/her own defense. This means providing the necessary psychiatric treatment to stabilize interfering symptoms. Once an individual is admitted for competency regulated by statute, treatment will be provided as ordered by the physician and not the evaluator. Once the team feels the person is stable, an evaluation will be completed and a letter sent to the court with the recommendation. This usually results in the patient’s discharge back to jail for the legal process to continue.

Rev: 7/11

31

MEDICAL RECORD DOCUMENTATION SCHEDULE

DISCIPLINE

ADMISSION–2 MONTHS 2 MTHS–12 MTHS 12 MTHS &EREAFTER

Psychiatry Weekly progress note Monthly progress note Continue monthly progress note

Nursing

Admission Nursing Pathway (Form 309) for first 2 weeks Daily shift note for first 2 weeks (RN must write on days 2,3 and 7), then Weekly discipline progress note Weekly Group Therapy note

Monthly discipline progress note Weekly Group Therapy note

Continue monthly discipline progress note Monthly Group Therapy note

Social Work

Weekly discipline progress note Weekly Group Therapy notes Individual Psychotherapy note weekly or after each contact if more frequent

Monthly discipline progress note Weekly Group therapy notes Individual Psychotherapy note weekly

Continue monthly progress note Monthly Group Therapy note Individual Psychotherapy note weekly

Occupation. Therapy

Progress note every10 calendar days



Voc Rehab Progress note every 10 calendar days

Progress note every 10 calendar days


Recreational Therapy



Progress note every 10 calendar days If patient is in Activity only, Document monthly

Education Weekly progress note Monthly progress note Continue monthly progress note

Psychology

Weekly Group Therapy Notes Individual psychotherapy note weekly or after each contact if more frequent

Weekly Group Therapy notes Individual psychotherapy note weekly

Monthly Group Therapy notes Individual Psychotherapy note weekly

Non-RN nursing staff

supervised by RN

(Includes Pharmacy Medication Education)

Weekly Group Therapy note Weekly Group Therapy note Monthly Group Therapy note

Speech Therapy

Progress note after each contact, but at least every 10 days



Physical Therapy




Rev: 7/11

32

Plan of Care Process

Patient referred to CMHIP

Pre-Admission / Admission Information (Form #100) Initiated

Coordinate w/receiving unit date for admission

Patient Arrives at CMHIP

Admissions Process a) DPS Search, Form #190 b) H&P, Forms #178/179 c) Admissions Form #100 d) Nursing Assessment and

Psychiatrist sections of Form #190

e) Form #139, Pre-Assessment for Behavior Management

f) Physician Orders #120, #120.B, #120.C

g) Progress notes #206 h) Advance Directives #665

Patient taken to unit

Nursing assessment (Form #140) completed w/in 8 hrs

RN starts an initial Plan of Care

Psychiatrist completes “Initial Psychiatric Assessment,” (#140,

pg 9)

Social Worker completes “Psychosocial Assessment,”

(#140, pages 11-15)

Is Pt to be discharged w/in 7 days?

Patient discharged

Yes

No POC Liaison reviews forms #100, #139, #140, #190

POC Liaison interviews Patient to obtain perspective re: POC

treatment

POC Liaison drafts treatment formulation (#107.4)

POC Liaison completes first draft of Tx Plan Problem List (#107.1)

POC Liaison completes draft of Plan of Care Objectives and

Interventions (#107.2)

Clinical staff document patient’s progress on #107 per policy

Interdisciplinary team & patient meet to finalize POC objectives and

interventions (#107.2)

TPR occurs every 30 days or if change in pt’s condition for first

year of treatment

TPR completed reflecting treatment status on #107.3

New POC reflects change in patient’s goals & interventions

(#107.2)

Is Pt’s LOS >12 months?

TPR (#107.3) occurs every 90 days or if change in patient’s

condition

Risk/Problems resolved; patient stable

Is patient ready for discharge?

Patient discharged

Yes

No

No

Yes


SECTION – PATIENT CARE POLICY NO. 1.10


TITLE: RELAXATION ROOMS

This is a new policy in the CMHIP Policy and Procedure Manual.

I. PURPOSE/DEFINITION

It is the policy of CMHIP is to provide safe and effective utilization of the equipment and space named the Relaxation Room. The purpose of this policy is to outline issues of safety, infection control, and appropriate use and maintenance of equipment and space. The Relaxation Room is a multidisciplinary space that facilitates effective sensory modulation. Sensory modulation refers to a person’s ability to regulate responses following exposure to sensory input. It also encompasses the ability to adapt to the environment increasing safety and performance with daily activities. The Relaxation Room is a patient-centered, multimodal area utilized to promote self-soothing and awareness, which translates to adaptive, healthy behavioral responses.

II. ACCOUNTABILITY

All clinical staff are responsible for implementing and adhering to this policy. III. PROCEDURE

A. General Guidelines

1. The Relaxation Room is available for individual patient’s treatment.

2. The Relaxation Room may be used 24 hours per day, 7 days per week as indicated.

3. Staff will perform an environmental scan of the space prior to and at the conclusion of each patient’s use.

B. Supervision Responsibilities of Staff

1. Any clinical staff person who has completed the sensory modulation trainings may supervise patient use of the Relaxation Room.

2. Patients on Assault Precautions II will be provided, at a minimum, line of sight supervision.

3. Patients on Suicide Precautions II will be provided arms length supervision, adhering to CMHIP policy 6.56, Clinical Precautions/Alerts.

RELAXATION ROOMS POLICY 1.10 PAGE 2

4. Staff must be aware of patients that may have the following precautions: a. Allergies b. Seizure history c. Diagnostic considerations d. Respiratory precautions e. Cardiac precautions f. Medication changes or side effects

5. In order to track patient use of the space and allow for equity of use, staff must complete a sign-in sheet that includes the patient’s name and the time a patient begins and ends his/her use of the Relaxation Room. The sign-in sheet will also be used to document items checked out to the patient and verify that the item(s) were returned at the end of the session.

C. Equipment

1. Stationary Equipment stored in the Relaxation Room is limited to: a. Massage chair and/or rocking chair b. Water fountain

2. All other equipment must be stored in the Nurses’ Station when not in use and is available from staff at the patient’s request: a. Reading materials- self-help, crosswords b. Aromatherapy c. Music- classical, drumming, calming Celtic d. Fidgets e. Weighted items f. Personal Stress Reliever (PSR) devices

D. Care of Equipment

1. Staff must adhere to the established cleaning protocol for equipment, which includes using CMHIP-approved disinfectant. The protocol will be posted in the Nurses’ Station in the vicinity of where Relaxation Room items are stored.

2. Only intact and well-maintained equipment will be used for patient care. If any small or movable equipment becomes damaged, it should be removed from the space immediately and reported to the Clinical Team Leader/Coordinator and Lead Nurse. A malfunction of stationary equipment should be reported to the Clinical Team Leader/Coordinator and Lead Nurse and appropriate safety precautions should be implemented.

____________________________________________ _________________________ William J. May Date Superintendent


SECTION - CARE OF PATIENTS POLICY NO. 1.25


TITLE: PATIENT AND FAMILY EDUCATION This policy replaces CMHIP Policy 1.25, dated 11/19/03. I. PURPOSE/DEFINITION

It is the policy of CMHIP to provide patients and their families with education that can: 1) promote their active participation in the treatment process, 2) foster and support emotional/physical health, 3) facilitate a successful return to the home and the community while providing the education and safeguarding the patient’s Protected Health Information. (See CMHIP Policy 14.51, Disclosing PHI to Non-Healthcare Providers.) The purpose of this policy is to describe the patient education process and documentation thereof.

II. ACCOUNTABILITY

Individuals responsible for implementing this policy include all clinical staff providing patient and family education.

III. PROCEDURE

The patient and family education process will include assessment, planning, implementation, evaluation, and revision.

1. Education needs will be assessed; specifically, the patient's and family’s learning needs, skills, attitudes, and readiness to learn, while giving consideration to barriers and limitations (ability/readiness, acute psychosis, mood/thought disorder), obvious uncorrected physical disability (hearing, vision), language, resistive/hostile, cultural/religious. The clinical staff member who provides the education shall document in the medical record on the Interdisciplinary Patient Education Record (form 204) or in a progress note.

2. Patients and family members shall have the opportunity to participate in the patient’s treatment and disposition planning.

3. Education shall be provided in a manner that will encourage: a. An understanding of the patient's health status. b. Participation in decision-making about healthcare options. c. Increased potential to follow the therapeutic healthcare options. d. Maximizing care skills. e. Coping with the patient's mental health status.

f. Understanding the roles of the patient and family in continuing care and promoting a healthy lifestyle.

PATIENT AND FAMILY EDUCATION POLICY NO. 1.25 PAGE 2

g. Understanding complex health care and legal issues related to psychiatric care including voluntary and involuntary medication.

4. Community resources will be identified to assist the patient and family with the

education process following discharge. ______________________________________ _________________________ Teresa Bernal, RN, C, BS Date Interim Superintendent


SECTION - PATIENT CARE DOCUMENTATION POLICY NO. 1.27


TITLE: DISCIPLINE AUDITING OF ASSESSMENTS, PROGRESS NOTES AND

PLAN OF CARE INTERVENTIONS This replaces policy 1.27 dated 6/13/12. I. DEFINITION/PURPOSE

It is the policy of CMHIP to complete discipline audits of individual interventions and group progress notes, discipline notes, plan of care interventions, and assessments for that discipline. The purpose of this policy is to define the timeliness for completing audits, number of audits to be completed and the mandatory reporting schedule of audit findings to the Assistant Superintendent of Clinical Services.

II. ACCOUNTABILITY Individuals responsible for implementing this policy include the Assistant Superintendent for Clinical Services, Discipline Chiefs, Department Heads and assigned designees.

III. PROCEDURE A. Audit Sample Size

Discipline Chiefs or Department Heads or their designee are responsible for completing audits of progress notes for a 15% sample or at minimum three medical records, whichever is greater, for each employee in their department. Of that sample size the current plan of care and a minimum of three individual intervention/group notes per medical record shall be audited.

B. Audit Completion/Reporting Frequency

1. Audits of 15% or at minimum three medical records, whichever is greater, shall be completed quarterly. Notes will be reviewed in reverse chronological order, starting with the most recent note. The Discipline Chief or Department Head will immediately address the deficiencies with the therapist noted on the Plan of Care (POC) and the therapist is expected to correct these deficiencies (if applicable) within five business days, and appropriate follow-up will occur for non-correctable deficiencies. If the audit shows less than 90% efficiency for any therapist, the audit frequency will increase from a quarterly to a monthly audit by the department head or designee. Once the therapist demonstrates 90% efficiency, the audit frequency will be quarterly again. (Deficient = a minimum of 9 medical record audits per quarter per deficient employee; Efficient = a minimum of 3 medical record audits per quarter per employee).

DISCIPLINE AUDITING OF ASSESSMENTS, PROGRESS NOTES AND PLAN OF CARE INTERVENTIONS POLICY NO. 1.27 PAGE 2

2. Deficiencies identified in the Plan of Care section will be reported to the Clinical

Team Leader/Coordinator and the Assistant Superintendent for Clinical Services on a quarterly basis. The Clinical Team Leader/Coordinator will immediately address the identified deficiencies with the Plan of Care Liaison who is expected to correct these deficiencies within five business days. If the audit shows less than 90% efficiency for any Plan of Care Liaison, the supervising Clinical Team Leader/Coordinator will conduct a monthly audit until a 90% efficiency is demonstrated.

3. A quarterly report outlining audit findings, including noted deficiencies and immediate corrective actions, shall be developed by the Discipline Chiefs, Department Heads or Clinical Team Leaders/Coordinators and submitted to the Assistant Superintendent for Clinical Services by the 10th of the month following the end of each quarter. The findings will be separated by Plan of Care related deficiencies and progress note specific deficiencies.

4. The Assistant Superintendent for Clinical Services shall convey findings of the

audits to the Executive Committee quarterly.

C. Auditing Criteria

1. Information that must be included in a discipline group/intervention progress note includes, but is not limited to, the following:

a. The name of the group

b. The frequency and duration of patient attendance

c. Evaluation of patient progress or lack of progress related to the identified objective

d. Recommendations for changes to the POC related to the group

e. If patient refused to attend the group, the therapist’s persistent encouragement for the patient to attend is documented.

f. The POC is updated to include additional efforts employed by the therapist to help the patient attain his/her identified objective noted on the POC for that group (e.g., if the patient refuses to attend a group, the therapist can modify the approach to fit the patient’s needs—for instance a 1:1 in lieu of the group will assist the patient in attaining the objective). This shall be noted in a progress note and on the POC. (Refer to CMHIP policies 1.05 Plan of Care, 1.28 Active Treatment and General Activities and 3.15, Patient Progress Notations on Psychiatric Units.)

2. POC interventions must be written and audited to include goals that are focused

on attainable, measurable short-term objectives that are written in language and at a level that will be culturally sensitive and understood by the patient. (Refer to CMHIP policy 1.05, Plan of Care.)

DISCIPLINE AUDITING OF ASSESSMENTS, PROGRESS NOTES AND PLAN OF CARE INTERVENTIONS POLICY NO. 1.27 PAGE 3

3. The POC should be focused on immediate objectives for the patient to achieve stabilization with projected target dates, safe self-management, progression and/or discharge. (Refer to CMHIP policy1.05, Plan of Care.)

4. Assessments for each discipline should be present and completed within specified

time frames for new patients and annual updates (within the 30-day grace period after one year) and qualitatively meet the discipline guidelines for content. (Refer to CMHIP policy 3.08, Assessment for Psychiatric Patients.)

______________________________________ ___________________________ William J. May Date Superintendent




TITLE: ACTIVE TREATMENT AND GENERAL ACTIVITIES This policy replaces policy 1.28, dated 10/9/13. . I. DEFINITION/PURPOSE

It is the policy of CMHIP that daily patient care, active treatment and rehabilitation, and general activity programs are available and provided through scheduled interdisciplinary clinical services and staff-monitored activities.

The purpose of this policy is to define active treatment, interventions and activities while setting standards for schedules and activity expectations. DEFINITIONS PROGRAM SCHEDULE: Program schedules are a list of the daily active treatment offered by the unit, which shall relate to patient’s Plans of Care and general activities that contribute to improving or maintaining patient functioning. ACTIVE TREATMENT: A clinical process involving ongoing individualized assessment and reassessments of diagnosis and interventions, patient response to treatment, evaluation of care and treatment, and planning for discharge that develop, restore, rehabilitate or maintain the patient’s bio-psychosocial functioning, and address the reasons for the patient’s hospitalization. Active treatment interventions relate to the problem list on the Plan of Care, and interdisciplinary staff interventions are designed to assist the patient to achieve his/her short-term objectives on the Plan of Care. Active treatment may include individual, group psychotherapy and psycho-education groups. Active treatment interventions are individualized, based upon assessments of the patient’s strengths and deficits, are included on the patient’s Plan of Care, and are documented in the Progress Notes. PSYCHOTHERAPY: Psychotherapy includes treatment, assessment or counseling in a professional relationship to assist individuals or groups to alleviate mental disorders, understand unconscious or conscious motivation, resolve emotional relationship or attitudinal conflicts, or modify behaviors which interfere with effective emotional, social, or intellectual functioning. Psychotherapy follows a planned procedure of intervention, which takes place on a regular basis and over a period of time, or it can be a one-time intervention.

GENERAL ACTIVITIES: General activities are organized services or activities planned by staff to provide the patient with opportunities to acquire knowledge, skills, or attitudes that are relevant and meaningful for general well-being, but are not directly

ACTIVE TREATMENT AND GENERAL ACTIVITIES - POLICY NO. 1.28 PAGE 2

related to the patients’ specific clinical condition and reason for hospitalization. These activities may provide enjoyable diversion, motivation, social opportunity, or helpful information, and offer staff an opportunity to assess interpersonal skills/function. If an activity contributes to improving or maintaining patient functioning it is considered therapy and must be identified as such on the Plan of Care.

II. ACCOUNTABILITY Individuals responsible for implementing this policy include clinical staff, clinical leadership and administrative staff.

III. PROCEDURE A. Care, treatment and rehabilitation (Active Treatment) are appropriate to the patient’s

needs and are provided in a safe, supportive and therapeutic environment. B. Sufficient active treatment shall be reflected on the individualized Plan of Care to

meet those identified needs of the patient that must be addressed before the patient can be discharged.

C. The treatment listed on the Plan of Care is matched with the individual’s needs and

capabilities and balanced with structured and unstructured personal time. D. Progress notes will reflect patient progress in meeting short-term objectives from the

Plan of Care. (See CMHIP policy 3.15, Patient Progress Notations on Psychiatric Units for required frequency of progress note documentation.)

E. Program schedules shall reflect the active treatment (which relate to the patients’ Plan

of Care) and those general activities that contribute to improving or maintaining patient functioning. There must be at least six hours of active treatment offered daily during weekdays with one of the hours scheduled after dinner. There must be at least four hours of active treatment offered on each weekend day.

The program schedules shall: 1. Reflect treatment, activities, and other clinical functions of the unit. 2. Include the days and times for treatment and activities. General activities and

active treatment will be scheduled concurrently so that patients may go to one or the other.

3. Be posted in easy view of patients and staff and written in an easily readable font. 4. Be provided for patients so that they are aware of the treatment and activities for

which they are scheduled as well as those available that may not be on their POC. 5. If a scheduled group engages only a portion of the unit patients, then additional

discipline specific groups/therapeutic services or alternative activities must be available for the remaining patients. These groups and services must be recorded on the program schedule and on the individual plan of care with associated progress note documentation.

F. Each patient shall have a monthly activity log (form 206A, Record of General

Activities) filed in the medical record. The logs will be maintained in a notebook during the month of use, and must be filed in the medical record at the end of the


month. The notebook will be located in the nurses’ station by the patients’ charts and is not to be removed from this area. The activity log will reflect the general activities the patient participates in that are not directly related to the patient’s specific clinical condition and reason for hospitalization. The activity contributes to the patient’s functioning and wellness, and demonstrates the level of initiative on the part of the patient.

Significant clinical information observed during an activity will be documented in the medical record progress note on form 206. On the day of the activity, staff facilitating the activity will complete form 206A, which includes: 1. The supervised activity 2. Staff initial who supervised the activity 3. The date of the activity 4. The duration of the activity (in units of service, i.e., 15 minutes = 1 unit) 5. Noted patient response or behavior in the activity

G. Personal time, leisure time, meal time and time to complete activities of daily living

shall be part of daily scheduled activities. H. Alternative activities shall be planned and available. The purpose of these activities is

to provide additional resources for patients in the event a scheduled group is cancelled.

I. When movies are shown as an activity (or at any other time), there will be no “R”,

“NC-17,” “Unrated,” or “Not-Rated” movies shown. If it is rated PG-13, it needs to be assessed for appropriate content and must be approved by the Lead Nurse or Clinical Team Leader/Coordinator.

J. An alternative activity resource book must be available on each unit. The resource

book shall provide instructions for conducting activities and identify the location of materials for staff to use in the course conducting those activities.

K. A group protocol shall be written for group treatment. The purpose of the protocol is

to: 1. Organize therapist/teacher actions to insure a smooth and coordinated experience 2. Define the purpose of the service by listing outcomes or objectives sought for

patients 3. Set a theoretical/conceptual framework for the therapist/teacher, set a course of

treatment for the patients by mapping a direction for staff and patients 4. Specify facilitator competency associated with the service 5. Provide a format for measuring competence, and, 6. Provide direction for staff that might be called upon to provide the service in lieu

of the primary therapist.

L. The group protocol shall address: 1. Name of service 2. Maximum attendance


3. Focus of the service 4. Inclusion criteria for the service (e.g., patient symptoms or deficits that will be

addressed as well as prerequisite skills, behaviors, privilege expectations) 5. Name of primary therapist(s), co- therapist(s), including their discipline 6. The plan to use alternate therapists or a different service in the event that the

primary therapists cannot provide the service 7. Patient goals or outcome (e.g., patient will be able to…) 8. Therapists’ procedures and materials

M. The group protocols shall be accessible on the unit and on the LAN, and are to be

kept current. N. Clinical Team Leaders/Coordinators are responsible to assess patient involvement in

assigned treatment activities in order to identify and address lack of patient involvement. Clinical Team Leaders/Coordinators must ask, during morning report and team meetings, if there are patients refusing most or all of their interventions. If a patient has not been involved or attending for a period of two weeks, the Clinical Team Leader/Coordinator will schedule a special interim Plan of Care review meeting to address the patient’s needs and to update the Plan of Care.

O. Staff are required to practice within their scope of professional training and license,

experience and competence when providing patient care. Competence is documented in individual Educational Profiles.

P. Patient accountability procedures continue during implementation of program

schedules. Q. Documentation of the patient’s participation in group therapies or activities should

address the following:

1. The name of the group

2. The frequency and duration of patient attendance

3. Evaluation of patient progress or lack of progress related to the identified objective

4. Recommendations for changes to the POC related to the group

5. If patient refused to attend the group, the therapist’s persistent encouragement for the patient to attend is documented.

6. The POC is updated to include additional efforts employed by the therapist to help the patient attain his/her identified objective noted on the POC for that group (e.g., if the patient refuses to attend a group the therapist can modify the approach to fit the patient’s needs—for instance a 1:1 in lieu of the group will assist the patient in attaining the objective.) This shall be noted in a progress note and on the POC. (Refer to CMHIP policies 1.05, Plan of Care and 1.27 Discipline Auditing of Assessments, Progress Notes and Plan of Care Interventions).

_____________________________________ _______________________ William J. May Date Superintendent


SECTION – CARE OF PATIENTS MEDICATION/TREATMENT POLICY NO. 1.29


TITLE: UNIT-BASED CONTINGENCY MANAGEMENT SYSTEMS This replaces policy 1.29 dated 7/26/06. I. DEFINITION/PURPOSE

It is the policy of CMHIP to motivate patients to participate in treatment programming and to teach and reinforce prosocial behavior and adaptive life skills through unit-based Contingency Management Systems (CMS). The purpose of this policy is to describe the framework of unit-based contingency management systems around which CMHIP divisions may design specific systems for their units. While CMHIP divisions (GAAPS and IFP) have standardized some features of the CMS across units, each respective unit makes adaptations to suit its clinical population patient factors.

DEFINITIONS: Implemented consistently, the CMS provides the framework within which other treatment interventions can occur optimally. Specifically, CMS programs are based on operant learning principles and social learning theory. As such, they generate in-patient environments that increase the frequency of self-care skills, improve social interactions decrease interpersonal aggression, and facilitate development of independent living skills. Thus, the CMS enhances unit security, unit stability and encourages prosocial communal living. Contingency Management System - A CMS is a unit-based motivational system in which target behaviors are linked with points or tokens, which are then exchanged for social and tangible reinforcers. Progressive Steps (IFP) or Levels (GAAPS and LAU) within the unit-based CMS, may also be used to shape targeted behavior, to foster intrinsic motivation, and to provide for increasing amounts of freedom and responsibility.

x All CMS procedures target one or more of the components of the “three-term contingency” or the “ABC’s” of behavior (Antecedent, Behavior, Consequence)

x Effective CMS procedures reinforce occurrences of the desired behavior immediately, often, and with a valuable (from the patient perspective) reinforcer.

x Effective behavior should be generalized across settings, behaviors, and time. Response Cost – Withdrawing something of benefit immediately following an undesirable behavior, which serves to weaken the behavior.

POLICY 1.29 UNIT-BASED CONTINGENCY MANAGEMENT SYSTEMS PAGE 2

II. ACCOUNTABILITY Individuals responsible for implementing this policy include the treatment team and unit staff.

III. PROCEDURE

A. Program Participation Requirements 1. Participation in the CMS is not in itself a privilege or a right. Patients may

refuse to participate in the CMS but retain the ability to earn points regardless of their expressed intent not to participate in the CMS.

2. Depending on the specific CMHIP division and/or unit, patients may earn daily

point totals and/or weekly averages. A patient’s Step (IFP) or Level (GAAPS and LAU) may in turn be determined by calculating his/her average from the previous day/week, resulting in possible regression in, maintenance of, or progression in Step/Level.

* It should be noted that security stage progression on IFP units is not contingent upon advancing to the highest CMS Step. Rather, progression to less secure units is contingent upon the individual’s level of risk and psychiatric stability.

B. Orientation to CMS

Shortly after patients are admitted to the unit, providing they are sufficiently stable

and oriented, staff provide information about the unit’s CMS program. Specifically, staff inform new patients of the their beginning CMS Step (IFP) or Level (GAAPS and LAU), describe the point sheet and associated target behaviors, and direct the patients to additional sources of information, including the unit psychologist, nursing staff, peers.

C. Point Sheets

1. Patients are given a Point Sheet on which their earned points and Response

Costs are accumulated. In general, Point Sheets are initialed by staff. 2. Points and other reinforcers/rewards should always be paired with social

reinforcement to facilitate skills generalization across environments. 3. In general, all patients will be offered a Point Sheet, regardless of whether they

state they are participating, or functionally able to participate in the CMS program.

4. Patients and staff are both responsible for ensuring that points are awarded

accurately and reviewed regularly throughout the day. Patients shall receive frequent supportive and behaviorally-specific feedback from staff on their CMS status.

5. Staff inform patients of points earned or response costs earned for specific

activities/behaviors during or at the conclusion of those activities/behaviors. Furthermore, staff provide behavioral anchors for the points earned as well as concrete suggestions for earning more points in the future, as needed.

POLICY 1.29 UNIT-BASED CONTINGENCY MANAGEMENT SYSTEMS PAGE 3

D. Suicide, Escape, and Assault Precautions

1. Patients on suicide, escape, or assault precautions or restrictions are encouraged

to continue to participate in the CMS. 2. The ordering of precautions may limit privileges associated with the CMS, and

limit the ability of the patient to earn points if the group/activity takes place off the unit.

E. Reinforcers

The menu of Reinforcers may vary by unit and division, is based in part on patient

input, and may include the following: ¾ point store ¾ phone cards ¾ vending machines ¾ Canteen ¾ “ordering out” ¾ headphones ¾ access to computer games ¾ Play Station ¾ Industrial Therapy jobs ¾ eligibility to use on-grounds or off-grounds privileges, depending on the

privilege status and the current functioning of the patient. F. Plan of Care

Participation in CMS is generally included in the patient plan of care only if

participation is targeting specific behaviors as specified in the Individual Behavioral Plan (IBP).

G. Individual Behavioral Plans (IBP)

Since it is not likely that every patient will respond to or agree to a unit-based

CMS, Individual Behavioral Plans using unique reinforcers and response costs may be written using CMHIP form 117, Individual Behavioral Plan.

An Individual Behavior Plan (IBP) is designed for patients whose behavioral needs cannot be adequately addressed through the unit-based CMS; for example, patients who are unable to follow through with the unit-based CMS for a variety of reasons such as extreme behavioral problems, dementia or severe psychosis. For these patients, the treatment team may develop an IBP that either substitutes for or augments the regular unit-based CMS. [The IBP referenced above should not be confused with the IIBP described in Policy 6.05, Intractable Injurious Behavior Plan.]


2/22/06

Considerations when working with visually impaired and blind individuals

1. Don’t use a louder tone of voice, unless the individual is hearing impaired. 2. Don’t hand the visually impaired/blind person something until you verbalize to

them that you are going to do so. Then place the item in or near their extended hand.

3. Prepare the individual by telling them about all routines and procedures prior to

performing them (medications, diagnostic procedures etc…).

4. Offer your elbow or shoulder to guide the visually impaired/ blind person if they are not skilled in use of a cane or if they are in a new environment. Eliminate tendencies to grab the person by the arm or shirtsleeve to pull them along with you.

5. Set the meal tray up the same at every meal. Verbalize what food items are on the plate and their location (e.g., Potatoes are located at the 3 o’clock position on the plate).

6. Maintain the arrangement of furniture on the unit. If a change occurs, do extra

and ongoing training with the visually impaired/blind individual until they are used to the new setup.

7. Don’t enable the individual by performing tasks that they are skilled in. 8. Use physical/tactile landmarks when orienting the individual to the unit to assist

individual with locating their room, the nurse’s station, bathrooms, patient telephone, and the front door.

This is not a comprehensive list of considerations when working with visually impaired and blind individuals. Remember that the onset of visual impairment or blindness and the training and coping strategies they’ve developed prior to admission to CMHIP must be taken into consideration when deciding how to approach the individual and incorporate interventions on the Plan of Care. Initial assessment and ongoing reassessment of interventions and interactions are recommended and will be based on individual needs.


SECTION – MEDICATION/TREATMENT POLICY NO. 1.36


TITLE: SERVICES FOR THE VISUALLY IMPAIRED PATIENT This replaces policy 1.36 dated 2/23/11. I. DEFINITION/PURPOSE

It is the policy of CMHIP to identify the physical and psychosocial needs of visually impaired patients and to provide those resources and aids that will help assure their safety, understanding of and participation in treatment, patients’ rights, and all other aspects of patient care.

Visual impairment is defined as lack of vision or loss of vision that cannot be corrected with glasses or contact lenses. Blindness can be partial, with loss of only part of the vision, or it can be complete with no perception of light. Persons with vision worse than 20/200, or a field of vision less than 20 degrees in the better eye are considered legally blind. The purpose of this policy is to outline safety and independence recommendations that may be utilized by the patient while here and upon discharge to the community.

II. ACCOUNTABILITY Individuals responsible for implementing this policy include all clinical staff.

III. PROCEDURE A. Admission Procedure

1. Upon information or assessment that the patient is visually impaired, the admitting physician shall determine the degree to which the impairment exists and what, if any, aids the patient utilizes or needs to assist with ambulation or mobility (glasses, contact lenses, cane etc.). The admitting physician will initiate a plan for follow-up assessment if indicated.

2. Upon admission to the psychiatric unit, the nursing assessment portion of form

140 shall further ascertain the degree of impediment the patient’s visual impairment represents, particularly in the context of safe and dignified ambulation, and ability to complete basic ADLs with assistance or independently on the assigned unit. An appropriate care plan addressing goals and interventions related to visual impairment will be initiated.

3. The initial psychiatric assessment shall identify urgent needs related to visual

impairment on the psychiatric unit and the psychiatrist will order any necessary accommodations to help maintain the patient’s safety.

SERVICES FOR THE VISUALLY IMPAIRED PATIENT POLICY NO. 1.36 PAGE 2

4. The social work assessment shall identify urgent needs related to visual impairment on the psychiatric unit. Additionally, the social worker will promptly initiate discharge planning to include any necessary accommodations that will be required upon the patient’s discharge to the community. This may include but not be limited to things such as assisting the patient to procure modified/supervised housing or adaptive equipment to assist with independent living and travel. The social worker may collaborate with other clinical staff or departments, such as Occupational Therapy, to procure necessary adaptive equipment based on assessment.

5. Additional discipline specific assessments will be completed upon the order of the attending psychiatrist (i.e., Occupational, Physical or Recreational Therapy).

B. Post Admission Procedures

1. Upon completion of all assessment screens, the treatment team will formulate a Plan of Care that outlines recommendations for immediate attention to the patient’s needs related to the visual impairment with emphasis on safety and promotion of independence.

2. A sticker indicating that the patient is visually impaired will be attached to front of the medical record.

3. Guidelines for assisting the visually impaired patient will be prominently posted on the unit for easy staff reference.

4. Education will be provided related to attaining and maintaining independence for the patient, patient’s family, patient’s peers and all staff. The treatment team will explore education options as the need arises and utilize advice, information and referral services of organizations established to meet the needs of the visually impaired. Individual treatment teams shall decide the best approach for contacting such organizations based on the needs of the patient and the staff working with the patient.

5. Adaptive equipment and assistive devices will be the responsibility of therapy services including Occupational Therapy, Physical Therapy and Speech Therapy based on the therapeutic assessment. Therapies will be responsible for monitoring this equipment, modifying if necessary and providing education to patients and families regarding safe and appropriate use.

C. When possible, CMHIP shall provide the following for visually impaired patients:

1. Tactile door knob grip 2. White cane 3. Audio recordings 4. Large print and/or Braille reading materials

___________________________ __________________ William J. May Date Superintendent


SECTION - PATIENT CARE POLICY NO. 1.46


TITLE: MEDICARE PART A, 2-DAY NOTICE OF DISCHARGE RULE This replaces policy 1.46, dated 11/1/10. I. DEFINITION/PURPOSE

It is the policy of CMHIP to provide inpatient Medicare Part A beneficiaries with information about their hospital discharge appeal rights using the statutorily-required notice known as the Important Message from Medicare.

This policy applies to all Medicare Part A recipients with current benefits who are inpatients of the hospital. This policy does not apply to Medicare Part A recipients who have exhausted their Medicare Part A benefits, nor to Medicaid patients.

Medicare Part A beneficiaries with current benefits have the right to appeal discharge decisions to the Quality Review Organization (QIO), which represents the Centers for Medicare and Medicaid Services (CMS) in Colorado, known as the Colorado Foundation for Medical Care (CFMC). The purpose of this policy is to describe the process for providing Medicare Part A patients with the Important Message, and what steps to take when patients exercise their right to appeal their discharge.

DEFINITIONS

Important Message - is a standardized form provided by the Centers for Medicare and Medicaid Services (CMS) (form 626, Important Message from Medicare). (Hospitals may not deviate from the content of the form except where indicated.)

Detailed Notice of Discharge: the standardized notice required by CMS (form 626a), that addresses the following:

x A detailed explanation why services are no longer covered. x Any information required by CMS or CFMC.

Patients must receive a second Important Message (form 626a, Detailed Notice of Discharge) for discharges to a lower level of care (for example, a nursing home, a boarding home, jail or independent living) no more than two calendar days before discharge. The following discharges DO NOT require a second Important Message be provided to the patient:

x Patients transferred or discharged from one psychiatric unit to another

MEDICARE 2-DAY NOTICE OF DISCHARGE RULE POLICY NO. 1.46 PAGE 2

x Patients transferred to another acute care inpatient hospital such as Parkview or St. Mary Corwin

x Patients admitted for competency or sanity evaluations x Department of Corrections (DOC) patients

II. ACCOUNTABILITY

Individuals responsible for implementing this policy include Admissions staff, social workers, and Southern District Patients’ Accounts staff.

III. PROCEDURE A. Provide a copy of the Important Message from Medicare (form 626) to a new patient at

the time of Admission

1. Whenever possible, CMHIP must deliver to Medicare Part A recipients an original copy of the Important Message from Medicare (form 626) at the time of admission, but no later than two (2) calendar days following the date of the Medicare Part A patient’s admission to the hospital.

2. Admissions staff will have all Medicare Part A patients, except for those from DOC, sign the Important Message from Medicare at the time of admission, and give them the original. If the patient refuses to sign the form, the Admissions staff person will write “refused” in the signature line and sign his/her own name.

3. Admissions staff will place the copy of the form on the patient’s medical record.

4. ECT patients must be given the first Important Message before their procedure. Admissions staff will be responsible for including the Important Message in the ECT patient’s packet. Since ECT patients are discharged within two (2) days of admission, a second notice is not required (see Exception, B.6, below).

B. Delivering a Second Copy of the Important Message from Medicare to a Patient at Discharge 1. Patients Accounts Department will maintain a list of Medicare Part A patients with

open Medicare Part A billing. The list is accessible via the Current Patient database.

2. The assigned social worker on the patient’s unit will provide a second (canary) copy of the Important Message from Medicare no more than two (2) calendar days before the planned date of discharge, so that the beneficiary has a meaningful opportunity to act on it.

3. Social workers must obtain the patient’s signature on the canary copy at the time the second Important Message from Medicare is provided. The patient then gets the canary copy for his/her records. The pink copy of the Important Message from Medicare remains in the medical record.

4. When a discharge cannot be predicted in advance, the follow-up copy may be provided the day of discharge. If the follow-up copy of the notice must be provided


on the day of discharge, CMHIP must give the patient at least four (4) hours to act on his/her right to request a Quality Improvement Organization (QIO) review.

5. If the discharge is delayed beyond the 2-day timeframe, the social worker must deliver another copy of the signed notice again within two (2) calendar days of the new planned discharge date. The social worker will ask the patient to initial and date the pink copy, which is returned to the chart. Social workers will make a copy of the initialed pink copy and give the copy to the patient. If subsequent discharges are delayed, the above procedure will be followed.

6. Exception to Delivery of the Follow-Up Copy. If delivery of the original Important Message is within two (2) calendar days of the date of discharge, no follow-up notice is required.

7. Social workers may not routinely deliver the follow-up copy on the day of discharge; delivering the notice on the day of discharge is for unforeseen discharges only.

C. Completing Detailed Notice of Discharge (form 626a) in the Event a Patient Exercises

the Right to Request a Review

1. Upon receipt of the second Important Message from Medicare from the social worker, the patient has the option of contacting CFMC and requesting a review of the discharge decision.

2. The patient must call CFMC at the number listed on the Important Message from Medicare (form 626), requesting an appeal.

3. When a Medicare Part A patient, whose benefits have not been exhausted, requests a review of the decision to discharge from CMHIP, CFMC will contact the Director of Social, who will contact the unit social worker to request a Detailed Notice of Discharge (form 626a) be submitted to CFMC by the social worker.

a. In the event the social worker is unavailable, the Director of Social Work will contact the Social Worker’s supervisor.

b. If a patient appeals his/her discharge on a holiday or weekend, the unit staff will contact the unit social worker who will be responsible for completing the Detailed Notice of Discharge form (form 626a).

4. If CFMC contacts the social worker during regular business hours, the social worker must deliver a Detailed Notice of Discharge to the patient and fax the requested documents to CFMC as soon as possible but no later than noon of the following day.

a. The social worker will fax a copy of the following documents to the CFMC staff person who contacted the social worker:

� The Important Message from Medicare signed by the patient at admission and initialed at discharge.(canary copy)

� the completed Detailed Notice of Discharge

� pertinent portions of the patient’s medical record:


� Admission H&P (form 178/179)

� Interdisciplinary Assessment (form 140) or annual update

� Last Plan of Care Review (or formulation if the patient is discharged within 30 days of admission)

� Progress notes from last two weeks including the physician’s discharge note

� Any other information deemed pertinent to the discharge decision or requested by the CFMC reviewer

b. If the patient requests copies of the documents that were sent to CFMC, the unit social worker or designee will provide the copies.

D. Delivery of Notices to the Patient’s Representative

1. CMS requires that notification be made to the patient’s representative such as a

guardian or Durable Power of Attorney.

2. In the event the patient has a representative, the representative should sign the notices as described in this procedure.

3. If the representative is unable to personally sign the notices, the social worker will document this information and note the date and time the patient’s representative was notified on the Important Message from Medicare.

E. CFMC Determination CFMC will notify the patient and CMHIP of its determination within two (2) calendar days of the receipt of information pertinent to the patient’s appeal.

1. The patient will not be discharged from CMHIP until CFMC has made a determination regarding the patient’s appeal of the plan to discharge.

2. In the event that CFMC notifies CMHIP and the patient that it agrees with the hospital’s decision to discharge, the patient may be discharged. The patient may remain in the hospital until noon of the day following CFMC’s verbal notification of its decision.

3. The patient does have further appeal rights under CMS rules but does not have a right to remain in the hospital while further appeals are pursued.

_______________________________ _________________________ Birgit M. Fisher, PhD Date Interim Superintendent




TITLE: DISCHARGES, FINAL SUMMARIES and SPECIAL LEAVES This replaces policy 1.47 dated 2/8/12. I. DEFINITION/PURPOSE

It is the policy of CMHIP that information related to the care and services provided is exchanged when a patient is discharged or placed on special leave, and that discharge instructions and recommendations for aftercare are given to the patient and those responsible for providing continuity of care. The purpose of this policy is to describe the procedures, information, forms and final summaries to be used when discharging patients or placing them on special leave. Release of discharge documents is described in Colorado’s Statewide Continuity of Care policy and CMHIP policy 1.50, Continuity of Care/Discharge Planning. Special Leave is defined as a patient’s necessary absence from CMHIP for a period of time before official discharge. The following are examples of when a patient would be placed on special leave in lieu of an official discharge: 1. Patients being assessed or treated at other medical facilities or physician offices in the

community in which an overnight stay is not involved

2. Patients on escape status (AWA, AWAU) who have legal charges and who may not be discharged in the absence of a court order or a death certificate

3. Patients who are sent to court who generally have a known return date (to CMHIP) indicated

4. Patients with dual legal statuses who may be in another facility but who cannot be discharged without an order from the court.

Final Summaries must be completed in their entirety prior to or at the time of discharge and prior to providing copies to receiving agencies. Final Summaries shall be completed in the following instances:

1. Discharges (exclude criminal evaluations)

2. Escapes or AWAU’s of 20 days of more

3. Temporary Physical Removals/Community Placements (OPTX, OPMH, OPHI, CRMH, CRTX)

4. Conditional Releases

5. Unconditional Releases Discharge occurs when the patient has reached maximum benefit from treatment provided at CMHIP and is deemed no longer a danger to self and/or others, is gravely

DISCHARGES, FINAL SUMMARIES, AND SPECIAL LEAVES POLICY NO. 1.47 PAGE 2

disabled, OR a court order remands the patient to the custody of the court, the Department of Corrections, or to Forensic Community Based Services (FCBS).

II. ACCOUNTABILITY Individuals responsible for implementing this policy include psychiatrists, nursing staff, social workers, treatment teams, Medical Records Department staff, Program Directors, the Disposition Committee, and the Superintendent.

III. PROCEDURE A. A patient is considered discharged when terminated from CMHIP enrollment and

CMHIP no longer has jurisdiction nor is providing treatment.

1. All discharges shall have: a. Physician’s Discharge Orders (form 120ds [106ds, page 5]) b. Taper Resistant Discharge Prescriptions to be Filled in the Community (form

120ds-RX c. Physician’s Orders for Transport to another Hospital (form 120-T) d. Interdisciplinary Discharge Summary-Psychiatric (form 106ds, page 1) e. Interdisciplinary Discharge Summary-Nursing (form 106ds, page 2) f. Interdisciplinary Discharge Summary–Social Work (form106ds, pages 3, 4a

and 4b) 2. The patient shall NOT be discharged from CMHIP until all of the forms listed

above are completed in their entirety by the assigned disciplines. 3. In the absence of the attending psychiatrist, it is the responsibility of the

psychiatrist providing coverage to complete the Physician Discharge Order (form 120ds[106ds, page 5]) and Psychiatric Interdisciplinary Discharge Summary (form 106ds, page 1).

4. Psychiatrists, at their own discretion and highly suggested, may also dictate a detailed Final Summary on form 106 that augments information provided in the Interdisciplinary Discharge Summary (form 106ds, page 1). Under no circumstances shall a dictated Final Summary take the place of the Psychiatric Interdisciplinary Discharge Summary completed prior to discharge.

5. Each discipline may provide additional information on the Interdisciplinary Discharge Summary-Addendum (form 106ds Addendum). Information may be added to this form until the medical record is taken from the unit to the Medical Records Department. Forensic reports, including IFP Disposition Reports, may be forwarded to the receiving agency and Mental Health Center as addenda, when the Court has authorized release of the report.

6. An assigned administrative assistant or designee, prior to or at the time of discharge, shall assemble a discharge packet containing, at least:

a. The Admission Psychiatric Summary (form 152)


b. The Admission Health Assessment (form 178/179)

c. The Interdisciplinary Discharge Summary (form 106ds, pages 1-5)

d. The 106ds Addendum page, if applicable

e. The Tamper Resistant Discharge Prescription to be filled in the Community (form 120ds-Rx)

f. Other relevant information to be decided upon on a case-by-case basis and upon agreement from the treatment team and receiving facility

g. If the patient has been hospitalized for more than one year, the most recent Annual Psychiatric Assessment Update (form 153) and the most recent Annual Health Assessment (form 178/179).

h. Form 682, Agency Transfer, is no longer in use. All the information is on form 106ds.

7. The completed packet shall be faxed, mailed or handed to a representative of the receiving facility. It shall not be given to the patient at the time of discharge.

8. In the event of a patient death, the physician portion of the Interdisciplinary Discharge Summary (form 106ds, page 1) shall be immediately completed. Additionally, because of the need for more detailed information in such cases, the psychiatrist shall dictate a comprehensive Final Summary within 30 days of the patient’s death. When an autopsy is performed, the provisional anatomic diagnoses shall be recorded in the medical record within 72 hours and the complete protocol filed in the record within 60 days of the completion of the autopsy. Refer to CMHIP policy 8.68, Death Notification and Autopsies.

B. A patient is placed on “Special Leave” status when temporarily on leave from

inpatient treatment at CMHIP. During the period of Special Leave, the hospital no longer has physical custody of the patient, nor is providing active treatment; however, by definition, the patient is not discharged from inpatient treatment. 1. Patient to return from Special Leave on a known, specific date

a. If the patient is scheduled to return on a specific date, the psychiatrist shall write an order on the Physician’s Order (form 120), placing the patient on Special Leave, ordering medications that are to be sent with the patient, and indicating the return date.

b. Nursing staff shall transcribe the order and write an “out the door” progress note when the patient leaves the unit.

c. Before the patient leaves, the psychiatric and nursing portions of the Interdisciplinary Discharge Summary, pages 1 and 2 (form 106ds) shall be completed.

d. The patient’s medical record may be left on the treatment unit while the patient is on Special Leave.


2. Patient to return from Special Leave on an unknown date

a. If the patient’s return date (to CMHIP) is not known, the psychiatrist shall write an order on form 106ds, page 5 placing the patient on Special Leave, and ordering medications that are to be sent with the patient.

b. Before being placed on Special Leave status, the team shall complete the following:

Interdisciplinary Discharge Summary, pages 1-5 (form 106ds). The psychiatrist must check the box on page 1 indicating that the patient is on Special Leave.

c. If the patient returns, the psychiatrist will write an order returning the patient to inpatient status; and he/she will complete the Psychiatric Discharge Summary (form 106ds, page 1), by indicating on the line provided that the patient has returned on that specific date. No psychiatric admission assessment (form 140, page 9) is required. However, if the patient is gone for greater than 30 days, the Interdisciplinary Assessment (form 140) shall be updated to reflect any changes. The physician and social worker shall update information in the appropriate sections of form 140. Nursing shall complete the Nursing Assessment Update (form 140U). If the patient is gone for greater than one year, all disciplines must complete annual reassessments (within 8 hours for nursing, 24 hours for psychiatry and 72 hours for social work).

d. When the patient is discharged from the hospital, a new Interdisciplinary Discharge Summary shall be completed in its entirety (see section A, 1-7 above) by the treatment team.

e. If the patient does not return, the psychiatrist will write an order that the patient is discharged from Special Leave status. The date that notification is received indicating the patient can be discharged is the date that must appear on the discharge order (not the date the patient was placed on Special Leave). At this time, the psychiatrist will complete the Psychiatric Discharge Summary (form 106ds page 1), by indicating on the line provided that the patient will not be returning from Special Leave and the date of the discharge order.

f. The ONLY exceptions to section III, B, #2 above (in which case the Interdisciplinary Discharge Assessment, pages 1-5 (form 106ds) need NOT be completed), are patients whose return date is not known but who will absolutely be returned to CMHIP as noted below:

1. IFP patients on Special Leave to have a court determination made on request for special privileges.

2. A patient arrested for assault while in the hospital that must be taken to Pueblo County Jail for arraignment on such charges.

3. The discharge assessment (form 106ds, pages 1-5) shall be completed for patients discharged to Forensic Community Based Services (FCBS).


C. Unit staff or Medical Records Department staff shall enter the leave code into the Avatar system (see CMHIP policy 3.45, Patient Roster, for Avatar codes), indicating the patient is on Special Leave.

D. The current medical record and any supplemental charts for patients on Special Leave

(return date unknown) will be maintained in the Medical Records Department. The charts shall be sent to the Medical Records Department within eight (8) days of the patient’s departure (15 days on Circle).

E. Reports required for patient discharges are as follows:

1. Clinical division staff shall compete the Notice of Disposition (form M-3.1) prior to discharge when a patient has been admitted as the result of one of the following: a. Emergency Mental Illness Report and Application (form M-1), if a transport

order accompanied the patient on admission. b. Affidavit, Motion, and Order for Evaluation and Treatment (form M-3). c. Motion and Order for Evaluation and Treatment (form M-7).

2. For certifications (short-term, long-term, or extensions), the following shall apply:

a. A Notice of Transfer (form M-9) shall be completed if the patient is being transferred to another designated facility and the certification is to continue. Copies of the current certification, any pending petitions, and the Notice of Appointment of Attorney, a copy of the court order for involuntary medications, if applicable, shall be sent to the receiving agency.

b. A Notice of Termination of Involuntary Treatment (form M-10) shall be completed if the patient is to be discharged from his/her certification. The court of jurisdiction shall receive the notice within five (5) days of termination.

c. All mental health certifications can be terminated by action of the court of jurisdiction via court order. If a copy of the court order is not available at the time of discharge, CMHIP shall request one.

3. For Executive Transfer Orders, the following shall apply:

a. Department of Human Services: An Executive Transfer Order (ETO) shall be completed at the time of transfer. (If the patient was admitted to CMHIP as the result of an M-9, a new M-9 shall be completed at the time of transfer.)

b. Department of Corrections: An Executive Transfer Order (ETO) shall be completed for patients who have received treatment at CMHIP for over 30 days and are returning to the Department of Corrections. (A new ETO is not required for temporary transfers up to 30 days.)


4. For criminal statuses, the following shall apply: a. Evaluations (pre-sentencing, sanity, competency, etc.): The following shall be

addressed in sequence. (1) An Evaluation Report (form 150) shall be completed and sent to the

Superintendent’s Office for submission to the court. (2) If a recommendation of competent or sane is noted in the evaluation

report, the Court Services Department will enter the opinion in the Anticipate database that generates automatic email notification to the Medical Records Legal Department. The Legal Department staff will notify the respective sheriff’s department for patient transport to the jail. Legal staff will enter the transport call date, and the Anticipate database will generate an email message to the treatment team staff indicating transport is arranged. If the treatment team recommend discharge be delayed or canceled, the psychiatrist must notify the Office of the Superintendent for permission to keep the patient longer. Upon approval from the Superintendent or designee, Legal Records will cancel the discharge until notified of discharge readiness.

b. Commitments: Not Guilty by Reason of Insanity (NGRI); Not Guilty by Reason of Impaired Mental Condition (NGRIMC); and Incompetent to Proceed (ITP) (1) NGRI and NGRIMC

(a) The Institute for Forensic Psychiatry Disposition Committee shall review the case and make recommendations, which are submitted to the Superintendent’s Office.

(b) CMHIP subsequently provides recommendation for conditional release or unconditional discharge, which is submitted to the court of jurisdiction.

(c) Prior to releasing/discharging the patient, the team shall have a court order that grants release or discharge.

(2) ITP (a) A letter of recommendation shall be sent to the Superintendent’s

Office for submission to the court, the patient’s attorney and mental health center as appropriate.

(b) If a recommendation of competent is noted in the restoration report, the respective sheriff’s department shall be notified to initiate transport as described above for evaluation patients. The Anticipate Database will generate an email message to the treatment team staff indicating transport is arranged. If the treatment team recommend discharge be delayed or canceled, the psychiatrist must notify the Office of the Superintendent asking for permission to keep the patient longer. Upon approval from the Superintendent or designee, Legal Records will cancel the discharge until notified of discharge readiness.


(c) The patient is discharged back to jail. (d) Await a court order of restoration. NOTE: For those patients with an ITP status, the Medical Records

Department shall obtain a computation of the maximum allowable confinement and inform the patient’s treatment team of that date. If the patient is still in the hospital 30 days prior to that date, the team shall advise the committing court of the forthcoming date and request a termination of the commitment or the commencement of civil proceedings required by Section 16-8-114.5, C.R.S.

In no case shall a discharge or change of legal status be initiated without court direction.

(3) ADAD Commitment: CMHIP shall have recommendations to the court for discharge.

5. Discharge Against Medical Advice (AMA)

a. Voluntary: If a voluntary patient insists on leaving before the physician considers him/her sufficiently improved, but the physician feels there is no legal basis on which to hold the patient involuntarily, the patient may be discharged AMA. (Alternative to discharge Against Medical Advice - If a voluntary patient insists on leaving and is considered dangerous to self or others or who is gravely disabled, the treatment team shall initiate proceedings to complete an M-1.)

b. Involuntary (Mental Health and Juveniles): Occasionally the court orders a patient released contrary to CMHIP staff recommendations, and CMHIP shall discharge AMA.

6. Notification of Discharge a. The responsible treatment team shall ensure that the appropriate parties are

notified at the time of the patient’s discharge, i.e., relatives, conservators, guardians, social services, mental health centers, court of legal jurisdiction and individuals named on “Duty to Warn” affidavits when applicable.

b. If the patient to be discharged receives Social Security benefits, a Physician’s Statement (Social Security Administration Form SSA-786), shall be prepared and forwarded to the Division of Patients’ Accounts.

7. Discharges to Jail or Correctional Facility

The discharge assessment (form 106ds, pages 1-5) shall be completed for any patient discharged to jail or a correctional facility.





TITLE: OUTSIDE MEDICAL SERVICES This replaces the policy dated 2/23/11. I. DEFINITION/PURPOSE

It is the policy of CMHIP to refer patients for non-emergent medical care outside the hospital only after review by designees of the Chief of Medical Staff. In the event that the patient’s condition constitutes an emergency, refer to CMHIP Policy 8.60, Code 0. Staff do not need prior approval to initiate emergency care. The purpose of this policy is to define a standardized process for review of and accountability for outside medical/surgical care for CMHIP patients. DEFINITIONS Attending Physician is the psychiatrist assigned to the patient and is the primary physician directing care and treatment. The care and treatment may be in consultation with other providers such as the medical physicians. Clinics refer to the full range of medical clinics, laboratory, radiology and other medical/health diagnostic services provided at CMHIP for the psychiatric patients. Outside Medical Services (OMS) - refers to the program and services discussed in this policy. Outside Medical Services Coordinator - manages all aspects of the OMS for inpatients hospital-wide to include management of the OM database and official OMS purchase orders under the guidelines and processes established by the Medical Review Committee. Central Transport Unit (CTU) – refers to a centralized resource for arranging scheduled appointments for outside medical care as directed by the attending physician, medical physician and Medical Review Committee. The CTU staff provide safe and secure transportation of a patient to the appointment. Medical Review Committee (MRC) – is comprised of at least one licensed medical physician and one psychiatrist who review non-emergency physician orders for outside medical professional services, diagnostics, and retrospective review emergency medical services. The MRC verifies that the condition of the patient meets the appropriate criteria for outside medical services, clarifies whether the services are duplicative, and whether the necessity of further diagnostics and/or inpatient medical care are beyond the scope of services available at CMHIP. “Service” Database (405) – is an electronic system that is accessible by the originator of the order, other medical staff and administrative staff. The system tracks the order from its initiation to completion. The information is stored electronically and perpetually available for printing and review of historical treatment.

OUTSIDE MEDICAL SERVICES POLICY NO1.48 PAGE 2

II. ACCOUNTABILITY Individuals responsible for implementing this policy include the Superintendent, Chief of Medical Staff, Executive Committee of the Medical Staff, physicians, Department of Nursing staff, Clinical Team Leaders, Central Transport Unit (CTU), Clinic staff, Southern District General Accounting and Medical Records Department (MRD).

III. PROCEDURE

A. MRC Review of Non-emergency Outpatient Services

1. All medical services provided by medical staff at CMHIP must be ordered by the attending physician and recorded in the Service database on the electronic form 405.

The physician will document the rationale for the ordered outside medical procedure on Form 120, Physician’s Orders. Unit staff will enter the data on form 120 into the Service database and initiate Form 405, Medical Services Request.

2. Clinic services provided by Department of Medicine physicians and CMHIP clinics

do not require approval by the MRC. 3. All non-emergency outside medical service (OMS) provided by the OMS providers

or members of the Board of Medical Consultants must be reviewed by the MRC. Review is required for all patients including patients with private insurance, Medicare, Medicaid or DYC coverage, DOC coverage and those with no coverage.

4. The MRC will meet regularly, but not less than three times a week to review the

Service database for requests for outside and provider network medical services. The MRC provides retrospective review of emergency services provided to patients such as Emergency Department services.

5. If outside medical inpatient care is determined to be medically necessary by the

MRC, a “physician-to-physician” review between the CMHIP physician who ordered the service and the outside provider physician will take place prior to transport of the patient to an outside medical facility and will be documented in the patient’s medical record on the progress note, form 206, by the CMHIP physician.

B. Tracking of and Transport to Outside Medical Care Appointments

1. All arrangements for approved outside ambulatory care services such as laboratory,

medical, surgical and other diagnostic services will be arranged through CMHIP’s Clinic Office and CTU.

2. The OMS Coordinator will coordinate with CTU to schedule appointments and the

outside ambulatory clinic to ensure tracking and documentation of service are completed and available through the electronic 405 Service database for the CMHIP providers.


3. Tracking of patients during their absence from CMHIP will be initiated by CTU and

verified by the MRD. MRD verifies the accuracy and appropriateness of the data entries of the Avatar codes (refer to CMHIP Policy: 3.45, Patient Roster) for the patient’s absence and amends incorrect and/or enters missed data entries.

4. CTU transports the patient to his/her appointment. If the appointment or clinical

service is expected to last more than 2.5 hours, nursing staff from the unit or pool staff, as assigned by the Staffing Office, will accompany the patient as directed in the nursing guidelines, Guidelines for Observing Patients at Outside Medical Facilities.

5. In the case of non-emergent outpatient care, the outside provider completes form

405 and returns the form to staff who accompanied the patient. If the outside provider does not document on the 405 form, copies of the medical documents will be obtained by CTU, or unit staff accompanying the patient or by the OMS Coordinator the next working day. Staff provides a copy of the 405 form and/or medical documents to CTU or the OMS Coordinator following the appointment. The information will be electronically attached to the originating 405.

6. The OMS Coordinator and General Accounting implement measures to reconcile

bills, reports and other data from the providers. MRD staff reconcile patient census by reviewing the Service database and Avatar entries.

C. Outside Inpatient Medical Hospital Services (Non-emergency)

1. Attending Physician Responsibility: When a CMHIP physician determines that a

patient is to be transported to an outside hospital for an emergency (OTHER THAN CODE 0), observation, or inpatient services, the physician will contact:

a. For Parkview Medical Center – the Admission Coordinator (“877-PMC-Admit” or “877-762-2368”)

b. For St. Mary Corwin and all other hospitals – the admitting physician or Emergency Department physician who will be seeing the patient.

While discussion with the Chief of the Department of Medicine or the Chief of Medical Staff before ordering the transport of the patient is desirable, the attending physician is responsible for the patient’s care and treatment and therefore has the authority to write the necessary orders. Approval by the MRC in advance is not required. The CMHIP physician will complete the “Physician’s Order for Transport to Another Hospital” (Physician Order Form 120-T) and Form 106ds, Page 1 (Interdisciplinary Discharge Summary-Psychiatric), checking the Type of Discharge as “SPLV.” If it is likely that the patient will return to CMHIP in the near future, the physician may complete the 106-I form instead of Form 106ds.

2. Unit RN Responsibility: The nurse on the patient’s home unit will collect the

information necessary (listed on form 120-T) and complete the “CMHIP Emergency Outside Medical Services Checklist” (Form 4050), including a nurse-to-nurse


discussion with the receiving facility to ensure continuity of care. The nurse will also arrange for appropriate transportation to the outside hospital. The checklist specifies what information is to be sent to the outside hospital.

3. The OMS Coordinator Responsibility:

a. Provides information to the MRC at its next meeting of patients sent to an outside hospital.

b. Obtains the patient’s benefits information from Patient Accounts, contacts the outside hospital’s patient finance department to verify the level of services and provides billing instructions. MRD will be advised of the admission. The OMS Coordinator coordinates information with CTU for date/time of the patient arrival and notifies General Accounting of the admission to an outside hospital.

c. Contacts the hospital and clarifies, as soon as possible, whether the patient is being admitted to the hospital. If the patient is admitted, the OMS Coordinator will notify the patient’s treating psychiatrist who will then order the patient discharged from CMHIP and enter the discharge date on form 106ds, Page 1. Nursing staff will complete the 106ds and document a discharge progress note on form 206. If the patient remains at the outside hospital for observation, no further order is needed until the patient is admitted there or returns to CMHIP.

4. MRC Responsibility: Reviews the (1) indications and process, (2) ensures

monitoring by a CMHIP physician of the patient’s condition and his/her medical care at the outside facility, and (3) collaborates with and assist the physician at the outside hospital in planning for the return of the patient to CMHIP or other appropriate disposition.

5. CTU Responsibility: Transports the patient unless an ambulance is needed. When

necessary, the OMS Coordinator contacts the ambulance company and provides billing instructions.

6. MRD Responsibility: Verifies the patient’s leave status by reviewing the Service

database and enters the appropriate AVATAR code. 7. The transfer of the patient’s care back to CMHIP will be approved by and

coordinated with the Admissions Department, OMS Coordinator, receiving CMHIP physician, Division Director, receiving treatment team, Medical Records Department and CTU. When the patient returns to the psychiatric unit, a unit staff enters the appropriate Avatar entry. MRD verifies the code the next business day. An Avatar entry is required that indicates the patient has returned from leave/discharge.

D. Emergency Outside Services – Refer to 8.60, Code Zero

In the event that the patient’s condition constitutes an emergency, refer to Code Zero, CMHP policy 8.60. Staff do not need prior approval or review to initiate emergency care.


1. The Unit RN on the patient’s psychiatric unit collects as much of the material ordered by the physician and/or listed on Form 4050 as possible and sends it with the ambulance personnel accompanying the patient in the white envelope addressed “Deliver to Emergency Department Physician.” All information not available before the patient leaves for the outside hospital will be collected as soon as possible (i.e., within minutes) and faxed to the receiving outside hospital.

2. The white envelope addressed: “Deliver to Emergency Department Physician”

containing billing information, a copy of the MAR, and copies of pertinent medical information listed by the attending physician in the Transport order (Form 120-T) will be given to the ambulance Emergency Medical Technician for the Emergency Department staff.

3. The staff on the unit initiates an electronic 405 that notifies the MRC of the

patient’s emergency medical status immediately.

4 The OMS Coordinator places a call to the outside medical facility the following business day if the admission is after 5:00 p.m. to verify patient admission status, determine location and obtain physician contact information. The OMS Coordinator gives this information to the MRC the next working day to foster the physician-to-physician contact.

5. The OMS Coordinator coordinates tracking and documentation for patients

admitted for outside inpatient care.


Colorado Mental Health Institute at Pueblo POLICY MANUAL SECTION - PATIENT CARE POLICY NO. 1.50 Effective Date: 6/13/12

TITLE: CONTINUITY OF CARE/DISCHARGE PLANNING This policy replaces 1.50, Continuity of Care, dated 7/28/04. I. PURPOSE/DEFINITION

It is the policy of CMHIP to assure that continuity of care is achieved through the discharge planning process, and that relevant statutory and State mental health system requirements are met. The purpose of this policy is to describe the discharge planning and continuity of care processes.

II. ACCOUNTABILITY Persons responsible for implementing this policy include attending physicians, nurses, social workers and division support staff.

III. PROCEDURES

A. Continuity of Care Referrals

1. A referral to the appropriate mental health center prior to discharge is made by the assigned social worker. When indicated, additional information may be forwarded to the mental health center.

2. Patient's request for referral for treatment in another psychiatric unit of CMHIP or any other appropriate external agency shall include:

a. A written request by the patient to the attending physician stating the reason

for the request. b. Review of the request by the attending physician. If consistent with Colorado

statutes, the physician forwards the request to the appropriate division or external agency for approval or denial.

B. Discharge Planning

1. Discharge planning begins at the time of admission with implementation of a preliminary discharge plan identified on the Pre-Admission/Admisson Information, form 100, and formalizing a viable discharge plan with the initial inter-disciplinary Plan of Care Formulation, Form 107.4.

2. The documented anticipated discharge setting and level of care should be the least restrictive and most clinically appropriate for the patient. The discharge plan is continually modified with any significant change in the patient’s condition and/or needs throughout the patient’s hospital stay by the assigned social worker.

CONTINUITY OF CARE/DISCHARGE PLANNING POLICY NO. 1.50 PAGE 2

Conditions necessitating a lengthy hospital stay or preventing a discharge to a less restrictive setting are also documented in the Kardex system.

3. The patient and his/her support person, if there is one, are directly involved in the discharge planning process as soon as the patient arrives on the unit and continues until the patient is able to understand the needs and options, can understand any education provided, can exercise appropriate choice, and assent with or discuss the discharge plan and change of level of care as appropriate.

4. Upon authorization (consent) from the patient, family and other significant persons in the patient’s support system are involved and kept informed of discharge plans.

5. Providers of post-hospital care are involved in the discharge planning process as soon as the patient arrives on the unit and as the treatment team continually identifies the appropriate level of care. In the case of a 27-65, Notice of Transfer, form M-9 (involuntary), this release is not required, but the patient is still fully informed of the plan (see Transfers below and refer to CMHIP policy 1.47, Discharges, Final Summaries and Special Leaves).

6. The discharge planning process involves case management services for a successful discharge, e.g., referral for community services and placement, application for benefits, etc.

B. Discharge Summaries

The disciplines of psychiatry, social work and nursing complete discharge summaries and instructions, utilizing forms 106ds, pages 1 through 5, Interdisciplinary Discharge Summary, and 120ds (Page 5 of 5, Physician’s Discharge Orders (refer to CMHIP policy 1.47, Discharges, Final Summaries and Special Leaves). The patient’s course of treatment, response to treatment, treatment recommendations, civil status, medications, appointments and other follow-up plans are addressed as called for in the forms.

C. Transfers to Other 27-65 Designated Facilities (Refer to CMHIP policy 1.47,

Discharges, Final Summaries and Special Leaves)

Transfers of involuntary patients to other 27-65 facilities must follow the Division of Behavioral Health’s Care and Treatment of Persons with Mental Illness rules and regulations. 1. At least one discharge planning conference with participants from CMHIP and the

receiving facility shall occur, with the patient being immediately informed of it. 2. The patient on certified status shall be given 24-hour notice of the transfer, unless

waived in writing by the patient or an emergency condition exists and must be documented in a progress note.

3. Upon patient discharge, the psychiatrist initiates a M-9 form, Notice of Transfer, and the administrative assistant provides this information to the court of jurisdiction, the patient’s attorney and the receiving facility (i.e., mental health center). The social worker will notify the patient’s family or other support person within 24 hours if a release is signed.

CONTINUITY OF CARE/DISCHARGE PLANNING POLICY NO. 1.50 PAGE 3

D. Transfers to Other Hospitals (Medical or Psychiatric)

Such transfers must comply with the Congressional Omnibus Budget Reconciliation Act, applicable to CMHIP with completion of the Interdisciplinary Discharge Summary, form 106ds, pages 1-5 and Interdisciplinary Discharge Summary Addendum, when applicable.

E. Discharges to Homeless Shelters

In general, it is the policy of the Colorado Mental Health Institute at Pueblo not to discharge persons from CMHIP to homeless shelters. Such discharges may jeopardize continuity of care and result in psychiatric decompensation. If a discharge to a homeless shelter occurs according to either of the exceptions outlined below, every possible attempt to coordinate community services will be made.

1) Planned exceptions: if the CMHIs and responsible community provider agree that

discharge to a homeless shelter is the best available plan for the individual, the assigned social worker or the social work supervisor will contact the Director of Social Work, who will notify the Superintendent. The Superintendent may request an administrative review by the Office Director of the Office of Behavioral Health or his/her designate. Such a review will include but not be limited to information about the reason(s) for the consideration of placement to a homeless shelter, the community mental health continuity of care plan, and the ultimate community placement plan following discharge to a homeless shelter. Upon approval by the Office Director or his/her designate, the discharge to a homeless shelter may occur.

2) Unplanned exceptions: In the event that a discharge to the community results in a homeless shelter placement due to unforeseen circumstances, the assigned social worker or the social work supervisor will contact the Director of Social Work, who will notify the Superintendent. The Superintendent shall immediately notify the Office Director of the Office of Behavioral Health or his/her designate of the circumstances following the homeless shelter placement and efforts underway to facilitate continuity of care.

IV. Statewide Continuity of Care System

CMHIP is a participant in the quarterly meetings of the Colorado Statewide Continuity of Care system. These quarterly meetings are attended by the mental health institute and the community mental health centers. All continuity of care activity at CMHIP involving admissions and discharges is conducted in accordance with regulatory requirements.



SECTION - CLINICAL RISK MANAGEMENT POLICY NO. 1.53 Effective Date: 3/13/13

TITLE: PATIENT PRIVILEGE LEVELS This replaces policy 1.53, dated /219/13. I. DEFINITION/PURPOSE

It is the policy of CMHIP to treat patients in the most appropriate and least restrictive environment, considering the patient’s clinical needs and progress, the physical capacity of the units, and the safety of the public.

The purpose of this policy is to assure patient, staff, and community safety while

promoting patient independence and self-reliance. The following are associated definitions in future policies, procedures, clinical manuals

or guidelines.

Level: refers to an acquired privilege level or status within the unit or stage based on increasing integration into a less structured environment. Patients at certain levels may have increased responsibility and privileges based on acquiring more steps or demonstrating increased stability. Step: refers to the patient’s status or step in the contingency management system. The step is the treatment status designation for the patient on units that have contingency management systems. The steps focus on reaching target behaviors paired with increased responsibilities and benefits at the different steps. Stage of Movement: refers to the security status associated with the patient assigned to a particular unit. For example: a patient may be assigned to the Maximum Security Stage rather than the Medium Security Stage due to clinical risk assessment findings of probability, imminence or severity of a negative outcome if moved to a lower secure setting. *Success in the step may lead to an increased level of privileges or benefits but not necessarily a reduction in security stage. Success in one may lead to success in another thus they are interdependent but also autonomous of each other.

II. ACCOUNTABILITY Individuals responsible for implementing this policy include the psychiatrist or physician extender, treating staff and clinical administrative staff. Any privilege level will be designated by a doctor’s order preceded by input and review by the treatment team, patient and/or significant other as appropriate. When the team fails to reach consensus regarding the privilege level for a patient, the Chief of Psychiatry or Program Director will review the case and make the final determination.

PATIENT PRIVILEGE LEVELS POLICY NO. 1.53 PAGE 2

III. PROCEDURE

A. The privileges granted depend on balancing the individual rights of the patient,

individual patient safety and public safety as well as patient legal status, clinical progress and the intention of the granted privilege or leave.

B. Each program will determine levels or types of privilege appropriate for the mission

and focus of the program, the population served and potential risk to the patient and public. The program will use consistent terms for privileges within the program. Considerations of program specific patient privilege may include: 1. Population specific privileges. 2. Degree of staff supervision on the unit or needed off-unit activity. 3. The amount of time associated with levels of given privileges. 4. The method to explain and insure understanding of the privileges by patients. 5. Sites, destination or locations for specific privilege levels. 6. Legal status of the patient.

C. The review or assessment of the above information will be documented in the

medical record on the appropriate program-specific privilege assessment form. D. The privilege level will be re-evaluated in the Plan of Care Reviews based on the risk

assessments. The privilege orders are good for 30 days unless superseded by a new order indicating a change in the privilege level. Privilege orders must be renewed at least monthly to include a current risk assessment.

E. Patients with a major change in their clinical condition warrant a treatment plan

review in which privileges are reassessed. F. Patients undergoing Electroconvulsive Therapy (ECT) need close monitoring for 24

hours following the procedure. Unsupervised privileges for patients recovering from ECT therefore should be restricted for 24 hours following the procedure.

G. Nursing staff, with consultation from the patient’s physician (when possible) may

restrict a privilege for up to 24 hours if any factor in sections III. B or III. C is assessed as a risk to the patient’s current status. A physician’s order is required to restrict (pull) a patient’s privileges and the reasons for the decision will be documented in the medical record.

H. When a patient’s privileges are completely restricted (pulled), and the patient must

stay on the treatment unit, the unit psychiatrist will complete sticker 206PP, Post Privilege Loss (Brief Assessment [after privileges are pulled or other perceived disappointment by the patient]) within 12 hours. If the psychiatrist is not available, the unit psychologist shall complete the Brief Assessment. If neither the psychiatrist nor the unit psychologist is available, the physician will give an RN, who is familiar with the patient, a telephone order for the privileges to be pulled along with an order to complete the Brief Assessment within 12 hours of the privileges being pulled. The sticker shall be placed on a progress note (form 206) in the medical record.

PATIENT PRIVILEGE LEVELS POLICY NO. 1.53 PAGE 3

1. If the Brief Assessment indicates increased risk factors for self-harm or assaultive behavior related to loss of privileges, the patient shall be placed on Suicide or Assault Precautions accordingly.

2. When a patient’s privileges are pulled, he/she will be automatically placed on a sharps restriction, which will remain in effect until some level of privileges is resumed.

3. If a patient who self-administers medication(s) has his/her privileges pulled, staff will administer the patients medication(s) for the duration of the restriction or until some level of privileges are resumed. (Refer to Policy 3.01, Medication Practices.)



SECTION: CLINICAL RISK MANAGEMENT POLICY NO. 1.54 Effective Date: 3/12/14

TITLE: GLOBAL POSITIONING SATELLITE (GPS) PATIENT MONITORING

This replaces policy 1.54 dated 9/1/11. I. PURPOSE

It is the policy of CMHIP to provide patients the opportunity for therapeutic privileges while maintaining public safety. The purpose of this policy is to describe the accepted practices of using the Global Positioning Satellite (GPS) ankle monitoring at CMHIP/FCBS, and the accountability for these practices.

II. ACCOUNTABILITY

Individuals responsible for implementing this policy include the treating psychiatrist, the Clinical Team Leader/Coordinator or designee, and the Hospital Operations Department.

III. PROCEDURE A. The attending psychiatrist will write an order for ankle monitoring system. If

a Court Order is issued for the GPS, this information must be sent with the request for the GPS. Nursing staff will initiate Form 405.

B. The need for the GPS ankle monitoring system must be communicated to the

Hospital Operations Department via the 405 referral system prior to implementation to insure that the ankle monitoring hardware is available, and that a referral form is submitted to the vendor.

C. The team will arrange to have the necessary hardware placed on the patient by

the Clinical Team Leader/Coordinator or designee. This hardware consists of an ankle monitor, a charging cord and a beacon. The Clinical Team Leader/Coordinator or designee from the clinical team will educate the patient on the proper use of all hardware, including the associated costs of the hardware. This teaching will be documented on Form 204, Interdisciplinary Patient Education Record.

D. The clinical team will determine the level of oversight for each patient. It is

the responsibility of the Clinical Team Leader/Coordinator or designee to individualize the software to meet the clinical and security needs of the patient. This consists of setting the parameters of the violation alarms and the

POLICY 1.54 GPS PATIENT MONITORING Page 2

violation notifications. Violation notifications can be communicated through e-mail, through alphanumeric pagers, or they can be disabled.

E. It is the responsibility of the Clinical Team Leader/Coordinator or designee to

review and respond to the “Daily Violation Summary Reports" issued via e-mail by the vendor. The Clinical Team Leader/Coordinator or designee will also review the patient's movements and activities to verify consistency between patient's self report, treatment expectations and daily violations. If a designee reviews the report, the Clinical Team Leader/Coordinator will also initial it indicating he/she has checked it to assure that the report has been reviewed.

F. A summary report of daily violations is available from the vendor upon request. G. The use of the GPS will be addressed on the patient's Plan of Care, and

patient's response will be noted in corresponding progress notes. H. When an order is written to remove the GPS, the Clinical Team

Leader/Coordinator will notify Hospital Operations by e-mail and return the equipment to the Hospital Operations Department for restocking/reordering. Any damaged items will be billed to the unit.

_______________________________ _______________________ William J. May Date Superintendent




TITLE: PATIENT WELLNESS This replaces policy 1.56, Patient Accountability dated 3/12/14. I. DEFINITION/PURPOSE

It is the policy of CMHIP that the safety of all patients is continually monitored by staff who are aware of the behavior, location and well being of patients at all times. Information collected during patient wellness checks must be documented and verified. Clinical information of note will also be documented in a progress note in the patient’s medical record. The purpose of this policy is to assure the patient’s safety and well being are monitored by providing patient wellness checks on a routine basis.

II. ACCOUNTABILITY

All clinical staff on inpatient-care units and their supervisors are responsible for conducting and verifying patient wellness checks. Staff making entries on the Patient Wellness Form (form 5604) are responsible for the accuracy of the entries.

III. PROCEDURE

A. Patient Wellness Checks 1. Patient wellness checks will occur at the frequency appropriate to the level of risk

of the patient population on the unit. Patient wellness checks may be no less frequent than hourly except on the Advanced Cottage. The checks on Advanced Cottage will be done at the following times: 7:00pm, 11:00 pm, 3:00 am, and 7:00 am, unless there is a clinical, medical, or safety need to monitor more frequently.

2. The Charge Nurse will assign responsibility for patient wellness checks at the

beginning of each shift. Staff will not be assigned to more than two consecutive hours of patient wellness checks to increase likelihood of accurate checks and subsequent documentation, excluding the Advanced Cottage. It is expected that the Charge RN conduct at least one wellness check per shift in addition to a 2nd level check.

3. When staff are assigned to Wellness Checks they MUST:

a. Carry the Patient Wellness Form and the Patient Pictorial Census with them while making checks so that accurate entries are made immediately upon observation of the patient. The door tool for the Hawkins Building, excluding E1 and E2, must be carried with the Wellness Board.

PATIENT WELLNESS POLICY NO. 1.56 PAGE 2

b. Directly observe each patient’s physical condition (e.g., including presence of respirations, color, see patient’s face, movement, and absence of acute injury, illness, or death).

c. Always enter the patient’s room at all times to observe the patient and to “listen.” The ONLY exception is if the patient has a window in his/her bedroom door, AND staff member is able to observe all of the four items listed below:

1. The patient MUST be observed from head-to-toe

2. The patient’s entire face MUST be seen

3. The patient MUST be awake, AND

4. The patient MUST be walking around his/her bedroom with no signs of distress or physical injury

d. Enter the patient’s bedroom during each and every wellness check if the patient is asleep to observe both items listed below:

1. “Listen” for noises (gurgling, breathing, wheezing, choking, etc.)

2. See the patient’s face (i.e., no covers over head)

e. Check the patient as directed above if a patient is in Locked Door Seclusion or Open Door Restraint.

f. Use additional illumination such as a flashlight if necessary for proper visualization. If the patient’s face needs to be illuminated, the red/blue lens flashlights should be used.

g. Directly observe patients who are attending on-unit groups or activities following direction above, but will do so as unobtrusively as possible.

h. Take note of any emotion/behavior of concern and take action accordingly (i.e., interact and intervene with the patient as indicated, alert Charge Nurse, contact physician, and document in the progress notes).

i. Take note of any physical distress/medical issue/concern (e.g., cannot observe respirations, a change is seen in general appearance, or bleeding/injury/illness is detected) and take action immediately (i.e., call for help, interact and intervene with the patient as indicated, alert Charge Nurse, contact physician, and document in the progress notes).

j. Always perform an environmental scan of the patient’s room and all areas of the unit that are open to patients and check for the fabric laundry bags during each wellness check (see B 7 and 8 below).

k. Provide his/her initials on the Patient Wellness Check form indicating that the staff member has followed directives above and has directly verified the patient’s behavior, physical condition, and location (excluding patients who are off the unit for any reason).

4. If the staff member assigned to patient wellness checks needs to leave the unit for any reason, or takes a break, he/she will hand off the patient wellness board to another staff member and alert the Charge Nurse prior to leaving.


5. Units completing patient wellness checks every 15 minutes requires unit staff to carry the wellness board with them at all times.

6. Staff will use both a behavior code and a location code for each check. During times staff are unable to use a behavior code (i.e., patient is in the shower or utilizing unsupervised privileges), the staff member will use a location code only. If a patient is displaying several behaviors, choose the one that is most apparent and document. The staff member assigned to wellness checks will carry the wellness board with him/her at all times and document in real time.

7. If a patient has a significant negative event, (e.g., Disposition Committee, divorce,

death in family, an upsetting visit or phone call), staff must assess the patient’s response and notify the physician, to discuss if a change in level of monitoring is needed.

8. Staff will enter the behavior and location codes to identify the patient’s behavior

and location at the time of the patient wellness check. a. Location codes may be individualized to meet specific unit needs with

Nursing Executive Committee’s (NEC) approval. b. Units/programs will attempt to maintain consistency of behavior/location

codes across the hospital and with the suicide precaution flow sheet, form 305 (Suicide Precautions/1:1 Observation/72-Hr Post SP) whenever possible to maintain continuity for staff who work throughout the facility.

9. When a patient cannot be located during a patient wellness check, staff will search

for the patient in the immediate area. If the patient cannot be located immediately, AWA, AWAU or escape procedures will be immediately initiated. See CMHIP policies 12.45(Medical Records Requirements for Non-Inpatient Patients), 24.05, (Department of Public Safety), and 32.10, (Escapes/AWA/AWAU – Reporting Unauthorized Absences).

10. When escorting a patient/group of patients off of the unit, the following steps will

be followed to document patient wellness:

a. A list will be made of those patients being escorted from the unit. 1) The NCR form used to track groups of patients escorted from the unit

must be used and filled out by the group leader. The form lists: ¾ date ¾ destination ¾ signature of nursing staff ¾ therapist in charge ¾ phone/pager/Nextel # ¾ patients attending ¾ time of departure ¾ check in and check out times ¾ staff initials ¾ patient privilege level ¾ additional check out destination/initials


2) The original will be attached to the Patient Wellness Form (form 5604). The staff member conducting the group and responsible for escorting the patients from the unit will retain the duplicate copy.

3) If it is necessary to excuse a patient from the group prior to return to the unit, it will be documented on the copy of the list kept by the staff member in charge of the group.

b. In the event the majority of the patients are taken off the unit and only a few patients are left on the unit (e.g., dining room/Recreation Center), the Patient Wellness Form will be taken with the majority of the patients off the unit. The few patients left on the unit will continue to be checked per unit guidelines (e.g., every 15 minutes, 30 minutes, 1 hour noting location and behavior). The NCR form will be used to ensure each of these patients remaining on the unit are checked per unit guidelines. The nursing staff member will fill out: ¾ date ¾ destination (on unit) ¾ signature of nursing staff in charge of checking the patients ¾ phone/pager/Nextel # of staff off unit ¾ time of initiation of these checks ¾ check in and check out times (time initiation/time ending) ¾ staff initials ¾ patient precaution levels

After these checks are complete and the wellness board/patients are returned to the unit, the original NCR form will be attached to the Patient Wellness Form.

c. With Charge Nurse’s approval, the staff member taking a single patient off the unit may document on the Patient Wellness Form by drawing a diagonal line through the box, entering the location code on one side and his/her initials on the other side of the diagonal line in the box.

11. At any given time, a registered nurse must remain on the unit if one or more

patients are present on the unit. 12. When a patient is transferred or admitted to another unit, or an adjacent unit is

providing temporary oversight of a patient, the receiving unit will immediately add the patient’s name to its Patient Wellness Form and assume responsibility for checking the patient for the duration of the patient’s stay on the receiving unit.

13. When a patient or group of patients uses unsupervised privileges, staff will note

location code for each time increment the patient is actually off the unit at the time of the patient wellness check.

14. During change of shift, two checks will take place. During the first, the charge

RN transferring responsibility for the unit/patients will conduct a patient wellness check with the charge RN assuming responsibility for the unit/patients in order to verify the behavior, location and condition of all patients before accepting the unit. Any two staff members on the unit can perform the second check. During this check, staff will ensure locked trash can is locked, egress doors are closed and locked, laundry room door is closed and locked, fabric laundry bag is accounted


for, and the environment scan is completed and documented on the Patient Wellness Form. Exceptions are detailed in CMHIP policy 18.35 (Laundry Rooms in Patient Care Areas).

15. Patient wellness checks will be conducted during fire drills, disaster drills, bona

fide emergencies, or if there has been a security breach such as an unlocked door. 16. The Clinical Team Leader/Coordinator keeps the Patient Wellness Forms in a

confidential file for a period of six months and then discards them in the designated bin for the destruction of documentation containing patient Protected Health Information (PHI).

B. Patient Wellness Form (form 5604)

1. Patient Wellness Forms are official CMHIP documents. A Patient Wellness Form

upon which entries have already been made may not be destroyed or discarded by staff for a period of six months. All employees making entries on the Patient Wellness Form are responsible for accuracy of entries. If an error occurs, the author places an asterisk (*) by the error and a corresponding asterisk (*) in the lower portion or back of the sheet explaining the error. The error should not be erased, painted out with correction fluid, or written over. See CMHIP policy 12.02 (Medical Record Information).

2. In the event of an incident involving patient wellness checks, patient deaths or

sentinel events, the Charge Nurse of the unit will immediately collect the form and hold it until the Department of Public Safety staff can take custody of the form. The Department of Public Safety will keep the original form, and make a copy of the form for the Charge Nurse. The staff assigned the responsibility for patient wellness checks will continue the checks, documenting on the copy for all subsequent checks.

3. Only forms approved by NEC may be used as Patient Wellness Forms. Any

recommended changes to the form must be made through the NEC approval process.

a. A standardized form is preferred but accommodations can be made by NEC

for population-specific needs. b. Behavior/location codes utilized may be individualized by unit/program with

NEC approval. 4. Shift III staff or program staff (e.g., Treatment Mall) are responsible for preparing

the Patient Wellness Forms for the current day as outlined in the instructions for wellness forms (INS-5604)

5. It is not necessary to enter the actual times that the checks were completed unless

a patient’s condition warrants more frequent checks; otherwise, the following time frames apply: a. Hourly checks are conducted within the time period of 15 minutes before to 15

minutes after the stated time.


b. 30-minute checks are conducted within the time period of 10 minutes before to 10 minutes after the stated time.

c. 15-minute checks are conducted within the time period of 5 minutes before to 5 minutes after the stated time.

d. Depending on unit population and frequency of patient wellness checks, random checks are required on units specified by NEC as outlined in the instructions for wellness forms (INS-5604).

e. On the Advanced Cottage, wellness checks will be conducted at designated times, within the time period of 15 minutes before to 15 minutes after the stated time.

f. ***When performing wellness checks, the staff member must adhere to the time frames, but need to try to perform the check in a random fashion such as:

1. If you began the last check in the male hall or Wing A for this check, begin in female hall or Wing B.

2. If you began the last check on one side of the hall, begin this check on the other side of the hall.

3. If you normally begin the check four minutes after stated time (remaining within the time frames), begin the check at the stated time.

6. The Patient Wellness Form is also used to document that egress doors have been checked as well as documentation of an environment scan for immediate safety concerns. (See procedure #7 below.)

7. The unit staff will ensure the fabric laundry bags in the laundry room are

accounted for. a. After each fabric laundry bag check, a check mark is placed in the appropriate

box, noting that the appropriate bag is present. b. If during a fabric laundry bag check, the staff member(s) discovers a fabric

laundry bag is missing, he/she must immediately contact the supervisor and perform a unit search. The unit search should include asking all patients to gather in the day hall. One by one, each patient will be asked to go with staff to witness staff searching his/her room. If at the end of the full-unit search, the missing fabric laundry bag is not found, an Incident Reporting Form (form 1300) must be completed and filed. This information needs to be communicated to all oncoming shifts through the cross shift report. Patient wellness checks will be increased to 15-minute checks until assessed by the team.

8. The unit staff will perform an environment scan. This scan must be completed

coinciding with wellness checks and documented on the Patient Wellness Form using a check mark(s). The environment scan includes looking for safety concerns/issues or things out of place (e.g., looking at the outside of the doors in the hallways for any material at the top of door frame to include knotted material, torn bed sheets, extra linen, extra towels, S/R mattress in place, contraband, water on the floor, fire exit blocked, exit sign not lit, doors unlocked that should be locked, and trash can is unlocked, but it should be locked). The environment scan


also includes looking at each patient bedroom at least once a shift. Staff should have heightened awareness at all times. a. After each egress door/environment scan check, a check mark (�) is placed in

the appropriate box for egress/laundry doors and environment scan denoting the egress/laundry doors are shut and locked and that the environment scan was performed and there were no safety concerns.

b. If an egress/laundry door was found unlocked/open or there was a safety concern, staff are to place an asterisk (*) in the appropriate box and a corresponding asterisk (*) in the lower portion or back of the form explaining what was found and what was done to correct the issue.

9. Staff shall ensure that vacant bedrooms are unoccupied and locked for the safety

and security of the unit. Patients are never locked in their assigned bedrooms unless a patient is being treated and monitored per an IIBP. (Refer to CMHIP policy 6.05, Intractable Injurious Behavior Protocol).

10. During each cross shift, staff will use the Patient Wellness Form to document that

they have checked to ensure that the locked trash can remains locked. Staff’s initials note the locked trash can is locked.

11. In the event there is a Code 0 or death, documentation will reflect the patient’s

status. a. “Code 0” will be entered onto the Patient Wellness Form in the time column

corresponding to the time of the event. b. If the patient is pronounced dead, “expired” is entered in the time column

corresponding to the time the patient was pronounced dead. 12. In the event that staff are unable to ascertain a patient’s location, documentation

will reflect this. If the patient cannot be located, the staff will immediately initiate AWAU, AWA, and escape procedures, and document the status in the time column corresponding to the event.

13. When a patient is admitted to another unit or discharged, “transferred” or

“discharged” is entered in the time column corresponding to the time the patient left the unit.

14. If staff are uncertain how to code special circumstances such as improper coding

or checks done at the wrong time, an asterisk (*) will be placed in the column and a corresponding explanation written on the back or at the bottom of the Patient Wellness Form.

C. Patient Pictorial Census

1. In order to provide a visual reference for staff conducting patient wellness checks,

a patient pictorial census must be attached to each Patient Wellness Form. 2. The pictorial census consists of a template containing photographs of each patient

on the unit.


3. Staff in Admissions will take a digital photograph of each patient (except for patients admitted for out-patient clinical services and out-patient evaluations) at the time of admission and will upload and save the photo by Avatar number on the LAN. Admissions staff will print two copies of the patient’s photograph and place them on the chart to be taken to the receiving unit.

4. Designated unit staff will access the shared database and retrieve the picture and

copy the picture in the template for the Patient Wellness Forms. 5. Designated staff will print out the updated Patient Pictorial Census Sheet and

immediately deliver to the unit. 6. Staff will replace the outdated Patient Pictorial Census with the updated Patient

Pictorial Census and discard the previous Patient Pictorial Census in the Protected Health Information (PHI) bin.

7. If a patient is admitted to another unit, designated staff will access the shared

database and retrieve the patient’s picture. If the patient needs an updated picture taken, staff will contact the designated person on the division and have the updated photo placed in the shared database.

8. During the Plan of Care Review, the clinical team should assess whether the

patient needs an updated picture for the Patient Pictorial Census and the medication sheets. If needed, the clinical team will contact the photographer who will take the new picture and place it on the shared database. This person will notify the designated staff of the updated picture being placed in the database so that the Patient Pictorial Census can be updated.

D. Supervisory Second, Third, and Fourth Level Patient Wellness Checks

1. The Charge Nurse will be responsible for completion or delegation of second

level patient wellness checks. Supervisors or designees will observe the completion of the patient wellness checks at least once each shift by accompanying the staff member responsible for the check in order to observe his/her interactions with patients, the accuracy of the notations entered onto the Patient Wellness Form, and proper execution of the wellness check process. The RN will note the second level check in the space provided on the form. The second level check does not apply on the Advanced Cottage.

2. Any errors or omissions detected by the supervisor or designee will be marked

with an asterisk (*) and a brief description of the mistake will be written on the bottom or back of the form.

3. The original form will be given to the Lead Nurse, who will also review it for

discrepancies, accuracy and completeness and note the third level check in the space provided on the form. The Lead Nurse or designee will review and discuss any relevant patient findings in the multidisciplinary meeting the next morning.

4. The Clinical Team Leader/Coordinator provides a 4th Level Check and will also

review it for discrepancies, accuracy and completeness by non-nursing staff and note the 4th Level Check in the space provided on the Patient Wellness Form.


The Clinical Team Leader/Coordinator will also note any clinical changes of the patient.

E. Orientation and Training

1. Staff conducting patient wellness checks must be assessed for competency to

perform this duty biannually (twice a year). 2. New employees will be thoroughly trained in the application of this policy and the

unit procedure for performing patient wellness checks during unit orientation and biannual competency reviews. Particular attention will be paid to the Patient Pictorial Census to identify unfamiliar patients.

3. Before conducting patient wellness checks independently, pool staff and staff pulled

to a unit from another area will be oriented to the unit procedure for conducting patient wellness checks, complete at least two patient wellness checks with a regular staff member, and be able to demonstrate the ability to accurately identify all the patients.

______________________________________ ___________________________ Birgit M. Fisher, PhD Date Interim Superintendent


SECTION – CARE OF PATIENTS POLICY NO. 1.60 Effective Date: 8/8/12

TITLE: CLINICAL CONSULTATION COMMITTEE (CCC) This replaces CMHIP policy, Clinical Consultation Committee dated 11/1/08.

I. DEFINITION/PURPOSE

It is the policy of CMHIP to provide clinical consultation to treatment teams for difficult-to-treat patients and/or when the patient’s treatment may not be proceeding as effectively as expected. The purpose of this policy is to establish a Clinical Consultation Committee (CCC) that can provide consultation regarding patient care to treatment teams, and to describe the process and procedures by which it functions.

1. As cited in the CMHIP Plan for the Provision of Patient Care, “…We prize excellence in

our clinical practice; we are committed to continuous improvement in all that we do; and we see change as a challenge and opportunity. …”

2. Patients receiving clinical services at CMHIP are among the most difficult to evaluate and

treat. They often have a combination of severe and complex psychiatric illnesses and characterological problems, further complicated by unique social, cultural, and environmental factors.

3. Work with these patients is further complicated by clinical phenomena that often interfere

with evaluation and treatment. While these phenomena are described using many different terms, they are often subtle, unconscious, and difficult to recognize.

a. In patients, these may be described as resistance, negative transference, inability or

unwillingness to participate in therapy, and inability or unwillingness to engage in a therapeutic alliance.

b. In staff, these may be described as therapy interfering behaviors, negative counter-

transference, and a lack of understanding of the patient’s clinical or cultural background.

c. These phenomena may prevent establishing and/or maintaining an alliance between patients and clinicians, lead to a lack of cohesion in therapeutic efforts, undercut empathy, and result in a lack of goal consensus and collaboration within a treatment team.

4. Consultation is often needed to help clarify what may be interfering with or minimizing the effectiveness of treatment. Consultation only means that an outside perspective from experienced clinicians who have not been involved in the day-to-day treatment and care may be helpful in (1) identifying factors that are interfering in therapy, and (2) raising therapeutic variations or alternatives that may not have been considered.

CLINICAL CONSULTATION COMMITTEE (CCC) POLICY NO. 1.60 PAGE 2

5. The CCC process differs from that of the Clinical Progression Committee (CPC, see Policy

1.61), in that CCC recommendations related to privilege level or placement are not binding.

II. ACCOUNTABILITY

Individuals responsible for implementing this policy include treatment teams, clinicians involved in treatment planning and decision-making; and members of the Administration who oversee treatment processes and environment.

III. PROCEDURE

A. Committee Composition

1. The CCC consists of four senior clinicians: a social worker, a psychologist, a nurse, and

a psychiatrist. The clinician from each discipline identifies an alternate to serve on the Committee when that discipline’s clinician is unavailable.

2. The Assistant Superintendent for Clinical Services of CMHIP appoints the CCC

members and their alternates on a case-to-case basis. 3. The Assistant Superintendent will designate an administrative support person to

maintain a Master Record of the consultations and information received that annotates progress and/or completion information and dates.

B. Requesting Consultation from CCC

Consultations may be considered when: 1. A patient no longer meets criteria for medical necessity. 2. A treatment team is requesting that a patient be placed on Intractable Injurious Behavior

Protocol (IIBP) status. (Consultation required by IIBP procedure, policy 6.05 and form 107.3 IIBP.)

3. A treatment team is requesting that a patient be allowed to self-administer medication.

(Consultation required by Self-Administered Medication procedure and form 308.) 4. Newly admitted Not Guilty by Reason of Insanity (NGRI) patients whose LOS on the

Maximum Security admission unit to which they have been admitted exceeds 35 days. 5. Patients with a LOS on the same security stage exceeding one year. 6. Treatment teams would like fresh perspectives, discussion, and/or treatment

recommendations for patients who do not appear to be progressing in treatment. 7. Patients may ask for consultation if they feel they are not progressing as fast as they

think they should. CCC members will review the patient’s questions and concerns, discuss them with the treatment team, and if appropriate, will schedule the patient for consultation.


8. Patients whose progress is impeded by factors beyond the treatment team’s control. 9. Other potential problem areas in treatment.

C. Requesting Consultation

1. Treatment teams, Administration, the patient, and/or the CMHIP Patient Representative (i.e., CMHIP’s patient advocate) may request a consultation.

2. The process of consultation will vary from case to case depending on the nature of the

problems or concerns. 3. In providing consultation, CCC will review the treatment, problems that may have

arisen, and possible ways in which the treatment may progress. 4. The CCC will meet with the treatment team. When appropriate, the patient may

participate in the meeting. Others may be present if the CCC feels his/her input and involvement would be helpful.

D. Scheduling the Consultation

1. Anyone wishing to request CCC consultation will contact the designated administrative support staff person.

2. The CCC members will designate times that will be available for consultations each

week. In the event that time period would not allow for the active participation of key members of the treatment team, alternate times will be identified.

3. In general, the CCC will schedule the consultation to occur within thirty (30) days of the

referral being received. For IIBP referrals, the consultation will occur within five (5) working days.

E. Case Review and Presentation

1. In the CCC meeting with the treatment team, team members will present the reason for

the patient’s admission and the reason(s) consultation has been requested. As appropriate, the treating physician and the treatment team will summarize the patient's current clinical care and response to treatment, overall risk, specific risk factors, treatment interventions, and perceived problems implementing an effective treatment plan.

2. Additional information should be provided to the CCC in advance of the meeting that

will facilitate the CCC members’ understanding of the patient, treatment, etc., which may include, but need not be limited to, behavioral functional analyses, medication reviews, and behavior plans.

3. Any specific concerns, e.g., safety or patient’s rights, will be addressed during the

meeting. 4. The patient will usually be invited to join the CCC meeting with the treatment team.

One or more CCC members will interview the patient regarding his/her concerns and


perspectives on treatment goals and effectiveness, as well as his/her goals for the future and commitment to treatment. CCC may waive the patient’s attendance if it is contraindicated for clinical reasons.

F. Documentation of Findings and Recommendations

1. A CCC member will write a brief progress note in the patient’s chart summarizing the

CCC findings and recommendations. 2. The CCC may recommend that current care be modified or continued, and why the

recommendation is being made (e.g., suggestions for additional treatment services or activities so the patient is more likely to respond to treatment and progress to a lower security stage or discharge).

3. A CCC member will write a report of the principal CCC findings and recommendations.

The CCC administrative support person will distribute copies of the report to:

a. The patient;

b. The Clinical Team Leader for transmission to all other treatment team members;

c. The CCC master file

4. The CCC will inform the Assistant Superintendent for Clinical Services if there are external impediments to clinical progress (i.e., beyond the control of the treatment team).

G. Feedback and Evaluation of the Consultation

1. The Clinical Team Leader will review the CCC reports with the treatment team for

discussion, implementation, and progress updates. 2. If the treatment team believes that any of the CCC recommendations are contraindicated

for safety or clinical reasons, the psychiatrist will document the rationale for not following them in the patient’s chart If deemed appropriate, the CCC will meet again with the treatment team to discuss the outcome of the consultation.

3. The Clinical Team Leader will provide CCC with feedback on the appropriateness,

usefulness, effectiveness, and impact on both the patient and the treatment team of the consultation. The CCC administrative support person will maintain a master record of that feedback, including annotation of progress, completion information, and dates.

4. The CCC will use the information to improve the consultation process.

________________________________ ___________________________ William J. May Date Superintendent


SECTION – CARE OF PATIENTS POLICY NO. 1.61

Effective Date 2/13/13

TITLE: PATIENT PROGRESSIVE MOVEMENT This replaces policy 1.61 dated 9/15/11. I. DEFINITION/PURPOSE

It is the policy of CMHIP to provide treatment services to patients on the least restrictive unit with appropriate treatment interventions and to progress patients through the CMHIP patient units both safely and efficiently. The purpose of this policy is to outline the responsibilities of the clinical treatment staff and the steps to facilitate patient progression.

II. ACCOUNTABILITY Individuals responsible for implementing this policy include psychiatrists, psychologists, social workers, program directors, clinical team leaders/coordinators, members of the Disposition Committee, members of the Clinical Progression Committee, and the hospital Superintendent.

III. PROCEDURE A. Review of Patient Cases by the Clinical Progression Committee (CPC)

1. The Clinical Progression Committee (CPC) will be composed at the minimum of three clinical staff, including one psychiatrist and one psychologist skilled in risk assessment. A nurse and social work representative may attend. The CPC will meet on the patient’s unit.

2. The CPC will review all NGRI and ITP patients remaining on the same unit for

more than one year or patients who are deemed ready to progress by the treatment team whose progression is being delayed for non-clinical reasons, such as legal status. Civil commitment patients may be referred for review by the treating psychiatrist. CMHIP patients residing at the Department of Corrections deemed too dangerous to be cared for at the hospital will be reviewed at least annually.

3. The patient’s treating team will prepare a report and packet for the CPC

committee. The accompanying packet of information will include a copy of the most recent risk assessment, psychiatric assessment, and substance abuse assessment, sex offender assessment, and Disposition Committee report if applicable. A Microsft Word version of the report will be sent via email to the CPC Program Assistant, along with the accompanying information in the packet, by the close of business the Friday of the week prior to the scheduled review. The Program Assistant will distribute this information to the committee members for

POLICY NO. 1.61 PATIENT PROGRESSIVE MOVEMENT PAGE 2

their review before the review date. Cases are presented by the attending physician or, or in the physician's excused absence, by any professional member of the treating team (e.g., psychologist, social worker, clinical team leader/coordinator, nurse). The medical record, which includes the most recent psychiatric assessment and current Plan of Care, is reviewed. The report and presentation should include the following:

a. Patient's name b. Hospital number c. Admission date d. Date of Birth e. Committing County f. Instant Offense or Index Crime g. Legal Status h. Legal History i. Diagnoses j. Brief Psychiatric History k. Summary of Hospital Course

i. Briefly list resolved primary problems with successful interventions ii. List unresolved problems, current interventions and progress to date iii. Current medications, side effects, compliance iv. History of seclusion/restraint episodes, elopements or other risk behaviors v. Substance abuse and treatment received or other risk behaviors

l. Family Involvement/Other Supports m. Barriers to transfer to a lower security stage or discharge n. Current risk factors and prognostic risk factors, which may impact patient

progression

4. The treating psychiatrist and other treatment team members will attend the CPC review meeting and present their report. The CPC and the treating team will discuss the case. Steps to facilitate progression will be identified and interventions and a timeline agreed upon. If the CPC affirms the patient is ready for placement on a less restrictive unit or in the community, the patient will be transferred within seven days of the bed or placement availability. In the rare instance the CPC and the treatment team do not agree, and the CPC believes the patient should move, the CPC will become responsible for the transfer.

If the CPC determines that increased privileges involving TPR are warranted for

an NGRI or ITP patient, and the clinical treatment team does not agree, the Program Director of the unit the patient resides or a delegee will prepare the disposition report.

5. If the Disposition Committee agrees and the court grants the request, and the

clinical treatment team is not in agreement, the CPC will become responsible for the order.


6. CPC will determine when the next review will occur to follow-up on patient progress.

7. Program Directors will receive a copy of the final report prepared by CPC and

work with Clinical Team Leaders/Coordinators and the clinical treatment team to respond to barriers of movement and develop a behavioral plan in response to identified barriers for movement or implement interventions identified during the CPC.

B. Progressive Patient Movement between Units within CMHIP

1. Program Directors and Clinical Team Leaders/Coordinators will be responsible to coordinate with the unit psychiatrist, lead nurse, psychologist, and social work staff to maintain an ongoing list of patients considered stable enough for movement to less secure/restrictive units. These lists will be reviewed and discussed at weekly intervals to ensure readiness for patient movement.

2. The physician on the sending unit and the physician on the receiving unit in

consultation with their respective clinical team members will determine individual patient movement between units within CMHIP. Once a transfer date is set, the physicians will notify their respective Clinical Team Leaders/Coordinators who will then coordinate any accompanying administrative details. Prior to transfer, physician-to-physician transfer (Psychiatric Transfer Summary, form 103) and nurse-to-nurse transfer form (Patient Hand-Off Communication, 140-I) will be completed as well as required physician-to-physician and nurse-to-nurse direct communication.

3. Clinical Team Leaders/Coordinators will anticipate discharges and notify other

Clinical Team Leaders/Coordinators on more secure/restrictive units when their unit will be vacating a bed. The Clinical Team Leaders/Coordinators, in collaboration with Clinical Program Directors, will assess the list of patients ready to move who are appropriate to the receiving treatment program. The receiving unit will confirm transfer of one of the patients within a 3-day timeframe. If the receiving unit does not notify the sending unit of the patient they wish to receive, the sending unit will transfer the most appropriate patient to the receiving unit on the 4th day after the bed is vacated. Psychiatrists, nursing staff and social workers are responsible for physician-to-physician, nurse-to-nurse, and social worker-to-social worker contact and documentation prior to a patient move.

C. Regressive Patient Movement between Units at CMHIP

1. Patient regressive movement between units will be referred on an individual case

basis and coordinated by the clinical team leaders. Psychiatrists, nursing staff and social workers are responsible for physician-to-physician, nurse-to-nurse, and social worker-to-social worker contacts and documentation prior to a patient regressive move. Criteria for a regressive move may include: a. Criminal re-offense or additional felony charges b. A credible escape plan, escape attempt or return from escape status


c. Serious or repeated assaultive behavior d. Forensic Community Based Services (FCBS) patients may be returned to an

inpatient unit from community placement if their condition destabilizes. e. Acute suicidal behavior

2. The goal will be to return the patient to the referring unit within 7-30 days. It is the responsibility of the sending team to develop written behavioral criteria for the patient’s return, utilizing CAMP-R criteria: Controllable, Attainable, Measurable, Positive, and Related to Risk.

3. Clinical Team Leaders/Coordinators will coordinate with psychologists, social

workers, psychiatrists, and nursing staff during team consultation to develop criteria for returns within 72 hours of regression. The criteria for return to the unit will be presented to the patient at the transfer Plan of Care. Program Directors will be appraised of criteria for return and Program Directors or designee will attend team consultation to assist with development of criteria.

4. Staff from the sending unit must attend the transfer Plan of Care and identify the

specific criteria for the patient’s return. The Clinical Team Leader/Coordinator will maintain staff contact with the regressed patient a minimum of once per day during the work week. During the visit, a representative of the sending team will speak to the patient, review the medical record, consult with the staff, and document in the medical record, specifically addressing progress made towards the return criteria. The receiving unit physician may determine decreased frequency or cessation of visits if the stay will be prolonged and notify the Clinical Team Leader/Coordinator.

5. Unless there are continuing clinical indications (e.g., the patient continues

seriously assaultive behavior on the more secure unit, is legally charged with a new crime, etc.), the patient will be returned to the sending unit within 30 days. If either the sending unit or receiving unit does not believe the patient is ready for return, they must schedule a staffing involving both units to clearly discuss and document the reason why and what interventions both teams will address to prepare the patient for return to the sending unit.

6.In the event of an impasse, a CPC review will be requested. D. Risk Assessment Measures

1. CMHIP uses the following risk assessment measures: a. Psychopathy Checklist Revised (PCL-R) b. Violence Risk Scale (VRS) c. HCR-20 d. Violence Risk Appraisal Guide (VRAG) e. Spousal Assault Risk Assessment Guide (SARA) f. Sexual recidivism measures: Static 99, Violence Risk Scale-Sex Offender

Version (VRS-SO), Sexual Offender Risk Appraisal Guide (SORAG), Stable 2007, Acute 2007, Affinity Assessment and/or Penile Plethysmograph


A physician’s order is required to initiate a risk assessment or risk assessment update. For NGRI patients, a risk assessment will be ordered within six months of admission, and when an update is needed. For ITP patients, a risk assessment will be ordered when the clinical treatment team considers Off Grounds Supervised Privileges (OFGS) and prior to scheduling a Disposition hearing.

2. The Department of Psychology is responsible for completing initial risk

assessments within six months of an NGRI patient admission. The Disposition Committee Chair will assign the risk assessments. The initial risk assessment will include, at minimum: VRS & PCL-R. For the purpose of this assessment, psychologists are responsible for collateral interviews with family, friends, and employers. Psychologists will not provide risk assessments on their own therapy cases per the American Psychological Association’s ethical code. The Department of Psychology will also complete risk assessments on referred ITP patients.

3. VRS updates are indicated when an NGRI patient makes a significant change, e.g., becomes stabilized on medications, begins attending substance abuse treatment, experiences progress in individual therapy, etc.

4. The Social Work Department is responsible for obtaining releases for all collateral

(outside this hospital) information. Requests for records are forwarded to the Social Worker designated to obtain and archive collateral patient information. For NGRI patients, requests for information will occur within one month of the patient’s admission as NGRI. These collateral data include: official elementary, middle, high school, and college transcripts, police reports for all NGRI and all additional aggressive felony offenses, all prior psychiatric hospitalizations and mental health treatment records, all DOC records particularly mental health and behavioral records, and all military records if applicable. Social Workers will document contact with family members with focus on risk relevant variables such as: history of sexual or physical victimization, history of neglect, prior Conduct Disorder symptoms (see DSM IV), history of suicide attempts or ideation, and history of general functioning in the community. The same process will be followed to obtain collateral information for ITP patients receiving risk assessments.

5. For ITP patients, a risk assessment will be considered for those patients who have

remained in the hospital for more than one year, have not been restored to competency, and are being considered appropriate for OFGS privileges. Additional factors include:

a. The patient is not a current escape risk b. The patient’s history suggests he/she is likely to score within the low to

moderate risk range on the PCL-R c. The goal is to obtain advanced privileges for these patients and/or privileges

leading eventually to Temporary Physical Removal for Community


Placement, with outpatient treatment through FCBS. The standard disposition process, as outlined for NGRI patients, will be followed for eligible ITP patients.

E. “Fast Tracking” Patient Progressive Movement

“Fast Tracking” refers to moving low-risk NGRI patients through security stages more quickly.

1. While performing the initial risk assessment within the first six months of

hospitalization, CMHIP psychologists will assess all new NGRI patients for appropriateness for fast track referral. Established fast track criteria include: a. VRS/VRSSO score < 35 and PCL-R score < 20 b. Index offense is not high profile (e.g., not murder, rape, other contact sexual

offenses, or severe assault) c. Patient is participating in the treatment interventions including medications d. Mental illness is stabilized, on medications, if indicated e. Minimum of Contemplation or Preparation Stage of Change on primary risk

factors. f. Positive support system in the community.

2. If the patient meets fast track criteria, the psychologist will notify the treatment

team and the Disposition Committee Chair. The patient will meet with the Disposition Committee, and the Committee will generate a report to the Court requesting Temporary Physical Removal (TPR) for off grounds privileges through Community Placement (CP) privileges.

Should the district attorney object, the Disposition Committee or clinical

treatment treating team can rescind the request. If the treating psychiatrist and clinical treatment team wish to pursue, the treating psychiatrist may proceed to testify in court. Alternatively, in the event that the clinical treatment team chooses not to testify in court or pursue the court hearing, the CPC or Disposition Committee may testify.

3. If the court approves TPR, the treating psychiatrist can grant privileges up to Off

Grounds Supervised privileges (OFGS) without return to the Disposition Committee. The treating psychiatrist and clinical treatment team must return to the Disposition Committee to request Off Grounds Unsupervised privileges and Community Placement. Specific steps the patient needs to achieve for full privileges must be clearly outlined on the Plan of Care.



SECTION – PATIENT CARE POLICY NO. 1.65 Effective Date: 9/10/14

TITLE: NOT GUILTY BY REASON OF INSANITY (NGRI) AND INCOMPETENT

TO PROCEED (ITP) DISPOSITION COMMITTEE This is a new policy in the CMHIP Policy and Procedure Manual. I. DEFINITION/PURPOSE

It is the policy of CMHIP to pursue patient privileges for patients with legal involvement in an appropriate, safe and efficient manner. The purpose of this policy is to describe the Disposition Committee structure and procedures to obtain patient privileges. A court order from the committing court is required before Not Guilty by Reason of Insanity (NGRI) and Incompetent to Proceed (ITP) status patients may be taken off grounds for use of privileges. The Disposition Committee provides objective review and recommendations to address patient risk factors for community safety, and readiness for privilege and community placement requests. The Disposition Committee recommends community supervision needs.

Temporary Physical Removal (TPR) is the language used in the Colorado Statutes to describe removal of the patient from inpatient custody temporarily, as when the patient is approved to use off grounds privileges or be allowed to reside in the community with continued hospital supervision (e.g., extended pass or community placement). TPR privileges cannot be implemented until the hospital obtains either: 1. A court order for TPR from the committing court, or 2. A lack of objections from the committing court or legal parties within 35 days after a

written request for TPR is sent from CMHIP for privilege use or community placement.

II. ACCOUNTABILITY

Individuals responsible for implementing this policy include all CMHIP staff. III. PROCEDURES

A. Disposition Committee Privilege Review

1. The Disposition Committee recommends eligibility of NGRI and ITP patients for readiness for privileges and placements (see CMHIP policy 1.55). The committee must review requests for the following privileges: a. On Grounds Supervised Privileges (ONGS): Committee review is mandatory

for patients with a history of escape from CMHIP or from any other institutional commitment. The committee must review the case before the patient receives this level of privileges for the first time or for reinstatement after an escape or escape attempt.

NOT GUILTY BY REASON OF INSANITY/INCOMPETENT TO PROCEED DISPOSITION COMMITTEE POLICY 1.65 Page 2

b. On Grounds Unsupervised Privileges (ONGU): Committee review is

mandatory for patients to receive this level of privilege for the first time, or to reinstate this privilege if the patient lost this privilege due to criminal* behavior, or due to a request from the treatment team.

c. Temporary Physical Removal Off Grounds Supervised Privileges (TPR OFGS): The treatment team shall refer the request when clinically indicated.

d. Temporary Physical Removal Off Grounds Unsupervised Privileges (TPR OFGU): The treatment team shall refer the request when the patient has demonstrated appropriate use of off grounds supervised privileges.

e. Temporary Physical Removal Community Placement (TPR CP): The team shall refer the request when the patient is ready to reside in a community setting.

f. Conditional Release (CR): For NGRI patients only (not applicable to ITP legal status), following request by treating clinicians, Superintendent, or as ordered by the court. CR cannot be implemented until the hospital receives a signed Order for Conditional Release from the Court.

*Criminal behavior means all behavior, which could result in felony convictions, OR behavior involving physical violence to others. This includes escape or attempted escape. DISPOSITION COMMITTEE PRIVILEGE REVIEW SUMMARY TABLE

Purpose of Review

1x Review for Pts with Escape Hx

Except Review if Escape Since Last

Review

1x Review for All Patients

Regardless of Escape Hx

Disposition Committee

Review Action Sheet

Referral Form (identifies docs

to be submitted)

Patient Interview with

Committee On-Grounds Supervised Privileges (ONGS) X X X X

On-Grounds Unsupervised Privileges (ONGU)

X X X X

TPR Off-Grounds Supervised Privileges (TPR OFGS)

X X X X

TPR Off-Grounds Supervised Privileges (OFGS) (ITP)

Disposition Committee involvement with ALL NGRI patients. Disposition Committee involvement with ITP patients will be accompanied with a completed Risk Assessment and must follow a discussion and referral from the ITP Consultation Committee. The District Attorney has 35 days to object to TPR; though CMHIP confirms the lack of objection prior to granting Off-Grounds Supervised privileges. If the D.A. objects, the issue can be heard by the judge and the team will testify. Off-Grounds privileges, at any level, cannot be granted without either a Temporary Physical Removal court order or acknowledgement of lack of D.A. objection to these privileges.

TPR Off-Grounds Unsupervised Privileges (OFGU) **

X X X X

TPR Community Placement**

X X X X

Conditional Release**

X X X X

**The Disposition Committee will not make recommendations regarding the advisability of sex offender registration for patients.


2. The Disposition Committee may also be asked to review additional cases at the request of treating clinicians or the Superintendent. The Superintendent’s approval is necessary prior to implementing Disposition Committee recommendations.

3. The Disposition Committee meets once per week. The Disposition Committee

Coordinator is available for questions regarding forms and procedure.

4. Disposition Committee Composition

a. Psychiatrist (not from referring treatment team)

b. Senior Forensic Advisor to the Superintendent and Committee Chair

c. Forensic Community Based Services (FCBS) Program Director

d. Treatment team staff will be required to attend and present the case/request. The treating psychiatric provider, the unit social worker, and the patient must attend at minimum.

B. Disposition Committee Review

1. A risk assessment must be completed for all patients before referral to the

Disposition Committee for all levels of privileges requested except ONGS. NGRI patients will have these assigned and completed by the Psychology Department in the first six months after admission. Because ITP patients have not been adjudicated of their index offenses, the risk assessment procedure is slightly different from that of NGRI patients who have been adjudicated. The Senior Forensic Advisor to the Superintendent (Disposition Committee Chair) shall be contacted to determine the level of risk assessment needed for ITP patients (see ITP Risk Assessment Checklist).

2. Unit staff complete the Disposition Committee Referral Form. Full instructions

regarding completion of the referral form may be accessed on the LAN at Y:\CAPP\DispoInfo\DispoInfo.mdb. The Disposition Committee Coordinator establishes a Disposition File for the patient.

3. Unit staff review the patient's Disposition Committee File to determine what

required documents are missing and thus need to be obtained. Determination of what documents are required is based on a review of the purpose for the Disposition Committee review and the Document Checklist on page 1 of the Referral Form to Forensic Community Based Services. The Disposition Committee Referral Form and the required documents indicated comprise the Disposition Committee Packet.

4. The unit Social Worker is responsible for obtaining necessary outside agency

collateral documents and ensuring that one copy is sent to the Disposition Coordinator for the Disposition chart.

5. When completing the Disposition Committee Referral Form, note special needs

for the Disposition Committee Packet for these privilege requests:


a. Community Placement (CP): When requesting Community Placement, the unit social worker from the referring team will send a completed FCBS Referral Form and Requirements for Community Placement Form. The assigned FCBS Case Manager will establish contact with the treatment team and attend Plan of Care reviews when notified of the referral to Disposition Committee for CP or upon request by the referring team.

b. Conditional Release (CR, NGRI only): The treatment team may request a CR evaluation, the patient may file a Writ for Release once per year, or the Court may order the hospital to perform a release evaluation if it has been more than 1 year since the last court review. If the Court orders a release evaluation and sets a hearing in less than 60 days, the Disposition Coordinator will consult with the treatment team to inquire if the hearing date allows enough time to update the assessments. If the treatment team supports CR, a proposed Order for Conditional Release shall be attached to the Disposition Committee packet.

6. Unit staff makes four copies of all required documents that make up the

Disposition Committee Packet, including the Disposition Committee Referral Form for each packet. NOTE: Some police reports are quite extensive and it is unrealistic to make complete copies. When this is the case, unit staff makes copies of a summarizing portion (often the affidavit for arrest) and note that additional information is in the Disposition Committee File located in Building 126 and not copied to the packet.

7. The treatment team will submit the four packets to the Disposition Coordinator at

least seven (7) days prior to Disposition Review to allow adequate time for Disposition Committee members to review all documents.

8. The Disposition Coordinator checks that all required documents are present in the

packet, distributes the copies to Committee members, and schedules the committee review date.

9. Committee members will interview the patient, review the medical record and all

submitted documents, receive verbal input from treating clinicians, and discuss the case to reach a decision for Committee recommendations

10. The Disposition Committee will make a recommendation on the patient’s

eligibility, complete the Disposition Committee Review Action Sheet, and forward to the Disposition Coordinator for processing. In addition, a Disposition Committee Report is required when the Committee recommends TPR OFGS, TPR OFGU, TPR CP, or CR. The Disposition Coordinator will forward these and any other supporting documents to the Superintendent for approval or denial. The Superintendent may request additional information or modification of recommendations on a case-by-case basis. If the Disposition Committee and/or Superintendent does not approve, they will indicate on the Review Action Sheet modifications of the original request and/or what the patient must accomplish to receive the privileges requested.


11. The Disposition Coordinator will send a copy of the Disposition Committee Review Action Sheet and Disposition Committee Report if indicated, to the treatment team immediately following the review. These will explain the reasons for approval or denial of the requested privileges. The treating team is responsible for relaying this information to the patient.

12. Upon Committee and Superintendent’s approval of requests for TPR OFGS, TPR

OFGU or TPR CP, the Disposition Coordinator will submit the Disposition Report and related documents to the Court and District Attorney’s Office as written notice via certified mail, that on or after 35 days from the date of mailing such notice, he/she will authorize TPR from the hospital. The District Attorney and/or Court have 35 days from the date of mailing to object to the hospital’s request. Should the District Attorney or Court object within 35 days, a hearing will be scheduled and the team staff will testify at the hearing. In some cases, upon team request, the Senior Forensic Advisor to the Superintendent (Disposition Committee Chair) will testify.

13. Upon Committee and Superintendent approval for CR request (NGRI only), the

Disposition Coordinator will submit the Disposition Report and related documents to the Court and District Attorney’s Office via certified mail with return receipt. If the parties object and a hearing is scheduled, the team staff will testify. In some cases, upon team request, the Senior Forensic Advisor to the Superintendent (Disposition Committee Chair) will testify. (Note: The “35 day” stipulation does not apply for CR - only TPR).

C. Expediting Temporary Physical Removal

1. While performing the initial risk assessment within the first six months of

hospitalization, CMHIP psychologists will assess all new NGRI patients for appropriateness for expeditious TPR. This process is to expedite the required paperwork for TPR eligibility. The patient must meet all three of the following criteria: a. VRS/VRSSO score < 35 and PCL-R score < 20 b. Index offense is not high profile (e.g. not murder, rape, other sexual offenses,

or severe assault). c. Mental illness is stabilized, on medications if indicated

2. If the patient meets criteria, the Psychologist will notify the Disposition Committee Chair. The Chair will query the team psychiatrist regarding expediting the paperwork for TPR. Should the treating psychiatrist agree the Disposition Coordinator will mail a letter to the court with the completed risk assessment requesting TPR up to use of OFGU privileges.

3. If the court approves TPR, the treating psychiatrist can grant OFGS privileges

without returning to the Disposition Committee. The treating psychiatrist and treatment team must return to the Disposition Committee to request TPR OFGU and TPR CP.


4. Should the District Attorney object, the Disposition Committee or treating team will, only in this case of expeditious TPR, rescind the request.

D. Privilege Tracker Data System for NGRI and ITP Patients

1. The “Dispo Tracker” is an automated data system designed to track

comprehensive information regarding the privilege levels of the NGRI and ITP patients. It tracks the patient’s progression of privileges for his/her hospital stay including community placement and conditional release. Data is entered for important steps of the patient privilege process to provide treatment staff with important information regarding the privilege level for daily activities and progression eligibility. The Disposition Coordinator is responsible for entry for all data in the Dispo Tracker. Unit treatment staff have “READ ONLY” access to the system. LAN location: Y:\CAPP\DispoInfo\DispoInfo.mdb

2. The Disposition Coordinator will maintain/update the automated Disposition

Committee Schedule in the Disposition Tracker. The Disposition Coordinator must be contacted for a password.

3. Copies of completed Disposition Reports are located on the LAN in pdf format

for reference. LAN location: Y:\CAPP\DispoInfo\DispoRpts (Scanned)

E. Disposition Committee Request Time Frames

The process from team referral to court approval should be completed within 60 days unless there are unusual circumstances. These dates are monitored through the Disposition Tracker. Any unreasonable delays, any clinically contraindicated delays, and any patterns of delay will be addressed by the Hospital Administration. Deviations shall be identified and analyzed with recommendations for correction of any systemic problems.

F. Repeat Reviews

In some instances, repeat reviews may be necessary. Repeat reviews are required for all privilege levels if the patient escaped or attempted escape since the last Disposition Committee review. Repeat reviews are required for all other privilege levels if the patient lost that specific level of privilege due to criminal* behavior. Repeat reviews may be requested when a patient clinically deteriorates (e.g., increased psychotic symptoms) without violent or criminal* behavior or, after an inpatient hospitalization, wishes return to community placement.

*Criminal behavior means all behavior, which could result in felony convictions, OR behavior involving physical violence to others. This includes escape or attempted escape. ____________________________________ ________________________ Birgit M. Fisher, PhD Date Interim Superintendent





TITLE: INCOMPETENT TO PROCEED (ITP) CONSULTATION COMMITTEE This is a new policy in the CMHIP Policy and Procedure Manual. I. DEFINITION/PURPOSE

It is the policy of CMHIP to pursue patient progressive movement and privileges for ITP patients in an appropriate, safe and efficient manner. The purpose of this policy is to describe the ITP Consultation Committee structure and procedures for patient referrals to the committee. Note: This policy refers to ITP patients being treated as inpatients at CMHIP. A criminal court may order that a defendant be released on bond and allowed to reside in the community. Defendants on bond are not committed to the Colorado Department of Human Services (CDHS). CDHS will provide updated evaluation reports to the court at the intervals indicated in the statute; they will not provide case management or treatment services. In these cases, the Court Services Director will communicate with the committing court to explain the role of CDHS.

II. ACCOUNTABILITY

Individuals responsible for implementing this policy include all CMHIP staff.

III. PROCEDURES

A. ITP Consultation Committee Structure

1. The ITP Consultation Committee reviews referred cases to assist teams with resources to formulate a progression plan and resolve impediments to placements or progression including legal issues, benefits acquisition, assignment of a legal guardian, etc.

2. The ITP Consultation Committee meets once per week.

3. The composition of the ITP Consultation Committee includes the following:

a. Hospital Benefits Specialist and Committee Chair b. Legal Department staff c. Assistant Superintendent d. Forensic Community Based Services (FCBS) Staff e. Hospital Patient Movement Coordinator f. Ad Hoc attendees: Senior Forensic Advisor to the Superintendent, Social

Work Department representation, unit treatment staff, etc.

INCOMPETENT TO PROCEED (ITP) CONSULTATION COMMITTEE POLICY NO. 1.67 PAGE 2

4. The ITP Consultation Committee reviews ITP patient cases that are:

a. Referred and presented to the committee by the treatment team staff.

Presenting staff must include at minimum the psychiatric provider and the unit social worker.

b. Identified by the Consultation Committee as appropriate cases for possible

progression or community placement. Criteria for review may include patients recommended to the courts as not restorable to competency in the foreseeable future, patients with multiple admissions who have not remained in the community successfully when previously discharged, and other cases with special circumstances.

B. ITP Privilege Progression and Community Placement Procedures

1. When a treatment team wishes to pursue increased privileges or Community Placement (CP) for an ITP status patient, the unit staff shall refer the case to the ITP Consultation Committee for discussion. Referrals should be communicated to legal records staff either by phone or by email. The treatment team and/or staff may not pursue privileges or placements for ITP patients without consulting the ITP Consultation Committee first.

2. The ITP Consultation Committee will monitor admissions and refer cases to

review for possible Temporary Physical Removal community placement (TPR CP) status with FCBS case management. The committee will notify the treatment team they are scheduling review of a case and invite team staff to attend.

3. When a patient is identified as appropriate for possible TPR and CP, the

Committee will:

a. Contact the Disposition Committee Chair (the Senior Forensic Advisor to the Superintendent) to assess the level of risk assessment needed. The Disposition Chair will inform the treatment team what information and testing is needed.

b. Contact the legal parties assigned to the patient to explain the CMHIP

processes in forensic risk assessment and case management and explore the willingness to pursue case management options.

4. The unit social worker will:

a. Complete an FCBS Referral Form. FCBS will initiate contact and begin

attendance at the plan of care reviews if the referral is accepted. b. Complete a Disposition Committee referral form and information packet using

the same process as for an NGRI patient (see CMHIP policy 1.65). The

INCOMPETENT TO PROCEED (ITP) CONSULTATION COMMITTEE POLICY NO. 1.67 PAGE 3

complete packet is submitted to the Disposition Committee Coordinator, and a Disposition Committee review date is scheduled. The team must work with the assigned FCBS Case Manager to evaluate and select a specific placement that would be most appropriate for CP requests for the Disposition Committee to consider.

c. If the patient is going to be followed by a MHC in addition to FCBS, the team

must notify the MHC, including sending a referral packet, informing and inviting the MHC to attend the Disposition Committee meeting.

5. The Disposition Committee will complete a review and document their

recommendations on the “Disposition Committee Review Action Sheet.” The recommendation will be forwarded to the Superintendent and processed the same as for all Disposition Reviews (see CMHIP policy 1.65). If Community Placement is approved, FCBS will provide case management (see FCBS Procedure Manual).





TITLE: HAWKINS BUILDING TREATMENT MALL SAFETY AND SECURITY This replaces policy 1.70, HSFI Treatment Mall Safety and Security, dated

11/14/12. I. DEFINITION/PURPOSE

It is the policy of CMHIP to create, promote and maintain a safe and secure environment for all staff and patients utilizing the Hawkins Building Treatment Mall. The purpose of this policy is to establish guidelines and procedures to address safety and security when staff and patients are utilizing the treatment mall. This includes management of behavioral emergencies, medical emergencies and other emergency situations.

II. ACCOUNTABILITY Individuals responsible for implementing this policy include all Hawkins Building staff: group facilitators, co-facilitators, nursing, unit clinical and Treatment Mall clinical staff and security staff.

III. PROCEDURE A. Use of Personal Duress Alarms (PDAs)

1. All staff members are expected to wear PDAs at all times when on units, in the Treatment Mall and in locations where there are patients. a. PDAs are not to be covered by clothing, as this will block the sensor in the

event staff need to activate the PDA to send a duress alarm. b. PDAs must be on level 2 or 3 in order to activate. Level ‘3’ will activate

automatically if a staff member is down or if the PDA is turned at an angle. c. PDAs may be checked out from Central Control if a staff member does not

have one available from the unit or does not have a PDA assigned to him/her. d. Each staff member is expected to ensure the sensor is tracking his/her PDA

when moving throughout the building. The PDA will send out a beeping sound indicating it is being tracked at its most current location.

e. PDAs assigned to the Treatment Mall staff member will be turned to the ‘1’ level at the end of his/her assigned shift and locked in the office.

2. PDAs that are not functional will be turned in to the immediate supervisor for

repairs. The immediate supervisor will turn in any non-functional PDA to Central Control.

HAWKINS BUILDING TREATMENT MALL SAFETY AND SECURITY POLICY NO. 1.70 PAGE 2

B. Group Facilitators and Co-Facilitators

1. All groups conducted in the Treatment Mall must have a group facilitator and a co-facilitator in the group room and in all other treatment/activity areas when patients are engaged in a group/activity.

2. Staff-to-patient ratio is at a minimum 2 staff for every 10 patients in treatment

activities. 3. Treatment/activity will be canceled if there is not a co-facilitator or adequate

staff-to-patient ratio. C. Hall Monitors

Hall monitors are CMHIP staff or patient peer specialists who perform role of promoting and maintaining an environment of safety and security. These individuals are a resource to patients and staff when assistance is needed.

D. Roles and Responsibilities of the Hall Monitor 1. Carries a functional PDA, a Nextel radio and a set of quick cuffs at all times.

(Peer Specialists will not carry a set of quick cuffs.) 2. Remains in his/her assigned area in the Treatment Mall when patients are in

treatment/activity group rooms. 3. Assesses the safety of staff and patients during treatment activities by walking by

the group rooms. 4. Unlocks patient restrooms in the Treatment Mall when a patient needs to use the

restroom. (Peer Specialist will not perform this duty/responsibility). a. Hall monitor does an environmental scan each time the restroom is unlocked. b. Hall monitor may check on the patient if patient is using restroom longer than

three (3) minutes by knocking on the door for a response or can enter the restroom if there is no response.

5. Assists the group facilitator when a patient needs to return to the home unit during

a group. The hall monitor can either escort the patient back to the home unit or stay in the group room while one of the facilitators escorts the patient back to the unit. When returning a patient to a unit, the hall monitor will notify Central Control of the movement so staff can monitor the movement via cameras.

6. Enters a treatment area to assist in the management of a behaviorally unruly

patient. (Peer Specialist will not perform this duty/responsibility, but may initiate a duress using the PDA).

HAWKINS BUILDING TREATMENT MALL SAFETY AND SECURITY POLICY NO. 1.70 PAGE 3

a. The situation is assessed to either activate the duress; utilize de-escalation skills while other patients are removed from the agitated patients; or to remove the agitated patient to the hallway away from other patients.

b. It will be the responsibility of the facilitators to contact the unit for additional assistance if a ‘duress’ is not required.

c. If a duress is required, one facilitator maintains the safety of other patients away from the agitated patient. The other facilitator assists the hall monitor with management of the patient either by approved Verbal Judo, CTI techniques and/or use of RIPP restraints.

7. The primary responsibility of staff is to contain the patient until staff from other

units assist. This may mean that the two facilitators may have to wait for additional staff to obtain the quick cuffs from the RIPP restraint bag.

E. Location and use of RIPP Restraints in the Treatment Mall

1. RIPP restraint sets are strategically located throughout the Treatment Mall to facilitate containment of a patient when needed. The full sets are identical to those on each unit. The small sets contain 2 sets of quick cuffs and 2 sets of back straps. a. The small sets are in the cabinets in each identified group room and are

marked for easy access. b. Facilitators will unlock the cabinet in which the RIPP restraints are stored.

The cabinet will remain unlocked until the last scheduled group is completed. c. The last facilitator will ensure the cabinet is locked at the end of each day.

2. Location of RIPP Restraint Sets

1 full set in Gym Office

2 small sets in the Yard- Rooms M-104 and M-100 1 small set in Room H101C 1 small set in Room K-106 1 full set in Dining room #6 1 small set in Room D106





TITLE: HAWKINS BUILDING TREATMENT MALL UNESCORTED PATIENT

MOVEMENT This is a replaces policy 1.71, High Security Forensic Institute (HSFI)

Treatment Mall Unescorted Patient Movement dated 11/14/12. I. DEFINITION/PURPOSE

It is the policy of CMHIP to maintain safety and security in the Hawkins Building (Building 140) while supporting therapeutic responsibility and independence of patients utilizing the treatment mall. The purpose of this policy is to identify guidelines and expectations of patients going to treatment mall groups unescorted by staff and Hawkins Building staff’s responsibilities/guidelines to support safety and security of patients.

II. ACCOUNTABILITY Individuals responsible for implementing this policy include nursing, clinical and security staff.

III. PROCEDURE A. Patients Assigned to Go Off Unit to Treatment Mall Groups

1. The group facilitator/treatment team will identify patients who attend specific treatment mall groups.

2. Facilitator/co-facilitator provides names of patients to the Lead Nurse or designee

either the day before or the day of the group. 3. The treatment team will review the patient’s behavioral stability and identify if

he/she is on precautions, to determine whether a patient is stable to go off the unit unescorted by staff.

a. Patients on 1:1 observation status will not be allowed to leave the unit to

attend the Treatment Mall.

b. Unit staff will inform group facilitators of patients who have pertinent medical conditions such as a seizure disorder, etc.

c. Patients on Assault Precautions Level I and II will not be allowed to leave the unit for treatment mall groups.

d. Patients on Suicide Precautions Level II will not be allowed to leave the unit for treatment mall groups.

HAWKINS BUILDING TREATMENT MALL UNESCORTED PATIENT MOVEMENT POLICY NO. 1.71 PAGE 2

e. Patients on Suicide Precautions Level I will require a staff member or group facilitator to escort them to the group and back. The group facilitator will be given the Suicide Precautions (form 305) and will complete the form during the group. Suicide Precautions (form 305) will be returned to the charge nurse/nurse on wellness checks when the patient is returned to the unit.

4. The group facilitator will report to the charge nurse if any patient had behavioral

or medical problems and documents the incident in the patient’s medical record.

B. Procedure for Patients Leaving the Unit to Treatment Mall Groups

1. Unit staff will have patients line up at least 5 minutes before the scheduled group. 2. The Patient Wellness Form, #5604 will coincide with the NCR Off Unit Group

List used to track groups of patients escorted from the unit for group. 3. The NCR Off Unit Group List will be completed in its entirety by the group

facilitator to include: ¾ date ¾ destination ¾ signature of nursing staff ¾ therapist in charge ¾ phone/pager/Nextel # ¾ patient’s attending psychiatrist ¾ time of departure ¾ check in and check out times ¾ staff initials ¾ patient privilege level ¾ additional check out destination/initials

4. The group facilitator must ensure all patients going to group are identified on the

NCR Off Unit Group List.

a. The pink copy remains on the unit attached to the Patient Wellness form (#5604).

b. The yellow and white copies are sent with the group, carried by one of the patients.

c. The group facilitator keeps the yellow copy and sends the white copy back with a patient to the unit upon completion of the group.

5. The group facilitator calls the unit and advises unit staff that the group facilitator

is ready for the patients to walk to the group. 6. The group facilitator does a patient check from the group pass and if discrepancies

are noted, the facilitator will call the unit.

HAWKINS BUILDING TREATMENT MALL UNESCORTED PATIENT MOVEMENT POLICY NO. 1.71 PAGE 3

7. Units may request, in writing on the ‘Off Unit Group List,’ a ‘call back’ on all or on any specific patient.

8. Upon completion of the group, the unit is called advising unit staff that the

patients are returning to the unit.

C. Procedure When the Facilitator Does Not Account for a Patient on the NCR Off Unit Group List

1. The facilitator will immediately call the unit to verify if the patient left for the

group. 2. Unit staff confirms whether the patient remained on the unit or if he/she did leave. 3. If the patient did leave with other patients, the group facilitator will immediately

call Central Control to assist in locating the patient. 4. Unit staff, if able, will immediately send staff to assist in locating the patient.
