59A-3.110. Intensive Residential Treatment Facility Services (Transferred)

Services shall be designed to meet the needs of the emotionally disturbed patient and must conform to stated purposes and objectives of the program.

(1) Intake and Admission. Every IRTF shall develop written policies and procedures governing the facilities intake and admissions process.

(a) Acceptance of a child or adolescent for inpatient treatment shall be based on the assessment, arrived at by the multidisciplinary clinical staff involved and clearly explained to the patient and the family. Whether the family voluntarily requests services or the patient is referred by the court, the special hospital shall involve the family’s participation to the fullest extent possible. Discharge planning shall begin at the time of intake and admission.

(b) Acceptance of the child or adolescent for treatment shall be based on the determination that the child or adolescent requires treatment of a comprehensive and intensive nature and is likely to benefit by the programs that the facility has to offer.

(c) Admission shall be in keeping with stated policies of the special hospital and shall be limited to those patients for whom the special hospital is qualified by staff, program and equipment to give adequate care.

(d) Staff members who will be working with the patient, but who did not participate in the initial assessment shall be oriented regarding the patient and the patient’s anticipated admission prior to meeting the patient. When the patient is to be assigned to a group, the other patients in the group shall be prepared for the arrival of the new member. There shall be a specific staff member assigned to the new patient to observe him and help with the unit orientation period.

(e) The admission procedure shall include documentation concerning:

1. Responsibility for and amount of financial support;

2. Responsibility for medical and dental care, including consent for medical and surgical care and treatment;

3. Arrangements for appropriate family participation in the program, phone calls and visits when indicated;

4. Arrangements for clothing, allowances and gifts; and

5. Arrangements regarding the patient’s leaving the facility with or without medical consent.

(f) Decisions for admission shall be based on the initial assessment of the patient made by the appropriate multidisciplinary clinical staff. This assessment must be documented on the record of treatment on admission.

(g) The admission order must be written by a staff or consultant physician.

(2) Assessment and Treatment Planning Including Discharge. Every IRTF shall develop written policies and procedures to ensure an initial assessment of the patient’s physical, psychological and social status, appropriate to the patient’s developmental age, is completed to determine the need and type of care or treatment required, and the need for further assessment. These policies and procedures shall include the assessment process as well as treatment planning including discharge planning, and include methods for involving family members or significant others (i.e., guardians, counselors, friends) in assessment, treatment, discharge, and follow-up care plans.

(a) Assessment. The facility is responsible for a complete assessment of the patient, some of which may be required just prior to admission, by professionals acceptable to the facility’s staff. The complete assessment shall include:

1. Physical. Subparagraphs a., b. and c. must be completed by a physician, ARNP or PA on the staff of the facility prior to admission or within 24 hours after admission.

a. Complete medical history, including history of medications;

b. General physical examinations;

c. Neurological assessment;

d. Motor development and functioning;

e. Dental assessment;

f. Speech, hearing and language assessment;

g. Vision assessment;

h. Review of immunization status;

i. Laboratory workup including routine blood work and analysis;

j. Chest x-ray and/or tuberculin test;

k. Serology; and,

l. Urinalysis.

m. If any of the physical health assessments indicate the need for further testing or definitive treatment, arrangements shall be made to carry out or obtain the necessary evaluations or treatment by clinicians, physicians, ARNPs or PAs trained as applicable, and plans for these treatments shall be coordinated with the patient’s overall treatment plan.

2. Psychiatric/Psychological.

a. The assessment includes direct psychiatric evaluation and behavioral appraisal, evaluation of sensory, motor functioning, a mental status examination appropriate to the age of the patient and a psychodynamic appraisal. A psychiatric history, including history of any previous treatment for mental, emotional or behavioral disturbances shall be obtained, including the nature, duration and results of the treatment, and the reason for termination.

b. The psychological assessment includes appropriate testing.

3. Developmental/Social.

a. The developmental history of the patient includes the prenatal period and from birth until present, the rate of progress, developmental milestones, developmental problems, and past experiences that may have affected the development. The assessment shall include an evaluation of the patient’s strengths as well as problems. Consideration shall be given to the healthy developmental aspects of the patient, as well as to the pathological aspects, and the effects that each has on the other shall be assessed. There shall be an assessment of the patient’s current age, appropriate developmental needs, which shall include a detailed appraisal of his peer and group relationships and activities.

b. The social assessment includes evaluation of the patient’s relationships within the structure of the family and with the community at large, and evaluation of the characteristics of the social, peer group, and institutional settings from which the patient comes. Consideration shall be given to the patient’s family circumstances, including the constellation of the family group, their current living situation, and all social, religious, ethnic, cultural, financial, emotional and health factors. Other factors that shall be considered are past events and current problems that have affected the patient and family; potential of the family’s members meeting the patient’s needs; and their accessibility to help in the treatment and rehabilitation of the patient. The expectations of the family regarding the patient’s treatment, the degree to which they expect to be involved, and their expectations as to the length of time and type of treatment required shall be assessed.

4. Nursing. The nursing assessment shall be performed by a person, who at a minimum, is duly licensed in the State of Florida to practice as a registered nurse and shall include the evaluation of:

a. Self-care capabilities including bathing, sleeping, eating;

b. Hygienic practices such as routine dental and physical care and establishment of healthy toilet habits;

c. Dietary habits including a balanced diet and appropriate fluid and calorie intake;

d. Response to physical diseases (e.g., acceptance by the patient of a chronic illness as manifested by his compliance with prescribed treatment);

e. Responses to physical handicaps (e.g., the use of prostheses for coping patterns used by the visually handicapped); and,

f. Responses to medications (e.g., allergies or dependence).

5. Educational/Vocational. The patient’s current educational/vocational needs in functioning, including deficits and strengths, shall be assessed. Potential educational impairment and current and future educational vocational potential shall be evaluated using, as indicated, specific educational testing and special educators or others.

6. Recreational. The patient’s work and play experiences, activities, interests and skills shall be evaluated in relation to planning appropriate recreational activities.

(b) Treatment Planning. An initial treatment plan shall be formulated, written and interpreted to the staff and patient within 72 hours of admission. The comprehensive treatment plan shall be developed for each child by a multidisciplinary staff, within 14 days of admission. This plan must be reviewed at least monthly, or more frequently if the objectives of the program indicate. Review shall be noted in the record. A psychiatrist as well as multidisciplinary professional staff must participate in the preparation of the plan and any major revisions.

1. The treatment plan shall be based on the assessment and shall include clinical consideration of the physical, developmental, psychological, chronological age, family, education, social and recreational needs. The reason for admission shall be specified as shall specific treatment goals, stated in measurable terms, including a projected time frame, treatment modalities to be used, staff who are responsible for coordinating and carrying out the treatment, and expected length of stay and designation of the person or agency to whom the child will be discharged.

2. The degree of the family’s involvement (parent or parent surrogates) shall be defined in the treatment planning program.

3. Collaboration with resources and significant others shall be included in treatment planning, when the treatment team determines it will not interfere with the child’s treatment.

4. Procedures that place the patient at physical risk or pain shall require special justification. The rationale for their use shall be clearly set forth in the treatment plan and shall reflect the prior involvement and specific review of the treatment plan by a child psychiatrist. When potentially hazardous procedures or modalities are contemplated for treatment, there shall be additional program specific policies governing their use to protect the rights and safety of the patient. The facility shall have specific written policies and procedures governing the use of electroconvulsive therapy or other forms of convulsive therapy. If such procedures are to be used they shall be carried out in a setting with emergency equipment available and shall be administered only by medical personnel who have been trained in the use of such equipment. Policies and procedures shall insure that:

a. Electroconvulsive therapy or other forms of convulsive therapy shall not be administered to any patient unless, prior to the initiation of treatment, two child psychiatrists with training or experience in the treatment of adolescents, who are not affiliated with the treating facility, have examined the patient, consulted with the responsible child psychiatrist and have written and signed reports which show concurrence with the administration of such treatment. Such reviews shall be carried out only by American Board of Psychiatry certified or American Board of Psychiatry eligible child psychiatrists;

b. All signed consultation reports, either recommending or opposing the administration of such treatment, shall be made a part of the patient’s clinical record;

c. Written informed consent of members of the family authorized to give consent, and where appropriate the patient’s consent shall be obtained and made a part of the patient’s clinical records. The person who is giving such consent may withdraw consent at any time;

d. Lobotomies or other surgical procedures for intervention or alterations of a mental, emotional or behavioral disorder shall not be performed on patients.

(c) Discharge. Discharge planning begins at the time of admission. A discharge date shall be projected in the treatment plan. Discharges shall be signed by a staff physician of the facility. A discharge summary shall be included in the records. Discharge planning shall include input from the multidisciplinary staff and will include family participation.

1. Discharge planning shall include a period of time for transition into the community (e.g., home visits gradually lengthened) for those patients who have been in the program for six months or longer. There must be a written plan for follow-up services, either by the facility or by another agency.

(3) Staff Coverage. Every IRTF shall develop written policies and procedures to ensure the program is staffed with appropriately trained and qualified individuals to meet the needs of the patients. There shall be a master clinical staffing pattern which provides for adequate clinical staff coverage at all times.

(a) There shall be at least one registered nurse on duty at all times. Services of a registered nurse shall be available for all patients at all times.

(b) A physician shall be on call twenty-four (24) hours a day and accessible to the facility within forty-five (45) minutes.

(c) Special attention shall be given to times which probably indicate the need for increased direct care (e.g., weekends, evenings, during meals, transition contained herein, and substantiated by the results between activities, and waking hours).

(d) Staff interaction shall insure that there is adequate communication of information regarding patients (e.g., between working shifts or change of personnel) with consulting professional staff for routine planning and patient review meetings. These interactions shall be documented in writing.

(4) Program Activities. Every IRTF must develop an organizational chart with a description of each unit or department and its services, goals, policies and procedures, its relationship to other services and departments and how these are to contribute to the priorities and goals of the program, and ways in which the program carries out any community education consultation programs. Program goals of the facility shall include those activities designed to promote the physical and emotional growth and development of the patients, regardless of pathology or age level. There should be positive relationships with general community resources, and the facility staff shall enlist the support of these resources to provide opportunities for patients to participate in normal community activities as they are able. All labeling of vehicles used for transportation of patients shall be such that it does not call unnecessary attention to the patients.

(a) Group Size. The size and composition of each living group shall be therapeutically planned and depend on the age, developmental level, sex and clinical conditions. It shall allow for staff-patient interaction, security, close observation and support.

(b) Routine Activities. Basic routine shall be delineated in a written plan which shall be available to all personnel. The daily program shall be planned to provide a consistent well structured yet flexible framework for daily living and shall be periodically reviewed and revised as the needs of the individual patient or the living group change. Basic daily routine shall be coordinated with special requirements of the patient’s treatment plan.

(c) Social and Recreation Activities. Program of recreational and social activities shall be provided for all patients for daytime, evenings and weekends, to meet the needs of the patients and goals of the program. There shall be documentation of these activities as well as schedules maintained of any planned activities.

(d) Religious Activities. Opportunity shall be provided for all patients to participate in religious services and other religious activities within the framework of their individual and family interests and clinical status. The option to celebrate holidays in the patient’s traditional manner shall be provided and encouraged.

(e) Education. The facility shall arrange for or provide an educational program for all patients receiving services in that facility.

1. The particular educational needs of each patient shall be considered in both placement and programming.

2. Children or adolescents placed in the special hospital by a public agency or at the expense of a public agency shall receive education consistent with the requirements of Chapter 6A-6, F.A.C., as applicable.

(f) Vocational Programs. The facility shall arrange for, or provide, vocational or prevocational training for patients in the facility for whom it is indicated.

1. If there are plans for work experience developed as part of the patient’s overall treatment plan, the work shall be in the patient’s interest with payment where appropriate, as determined by the treatment facility and the vocational program, and never solely in the interest of the facility’s goals or needs.

2. Patients shall not be solely responsible for any major phase or institutional operation or maintenance, such as cooking, laundering, housekeeping, farming or repairing. Patients shall not be considered as substitutes for employed staff.

(g) Nutrition and Standards. There shall be a provision of planning and preparation of special diets as needed (e.g., diabetic, bland, high calorie). Menus shall be evaluated by a consultant dietitian relative to nutritional adequacy at least monthly, with observation of food intake and changes seen in the patient.

(5) Physical Care. The facility shall have available, either within its own organizational structure or by written agreements or contracts with outside health care clinicians or facilities, a full range of services for the treatment of illnesses and the maintenance of general physical health.

(a) The facility shall develop a written plan for medical services which delineates the ways the facility obtains or provides all general and specialized medical, surgical, nursing, pharmaceutical and dental services.

1. Insofar as Rules 59A-3.110 and 59A-3.300 through 59A-3.303, F.A.C., are intended to establish minimum requirements for intensive residential treatment facilities for children and adolescents that have a primary purpose of treating emotional and mental disorders, such facilities are not required to establish and maintain medical buildings and equipment required of general or specialty hospitals as specified in Rules 59A-3.080 through 59A-3.281, F.A.C. Services which require such specialized buildings and equipment may be obtained from outside health care providers by written agreement or contract. This shall not preclude the facility from maintaining a medical services area or building which does not meet the requirements of Rules 59A-3.065 through 59A-3.281, F.A.C., for the purpose of isolating patients with contagious diseases, conducting physical examinations, providing preventive medical care services, or providing first aid services.

2. If the facility chooses to establish and operate a specialty or general hospital for the purposes of offering medical care more intensive than those specified in subsection 59A-3.065(32), F.A.C., the plans for construction shall be submitted for review in accordance with Rule 59A-3.080, F.A.C., and such facilities shall be required to be licensed, built and operated in accordance with Rules 59A-3.065 through 59A-3.281, F.A.C.

(b) Patients who are physically ill may be cared for on the grounds of the facility if medically feasible as determined by a physician, ARNP or PA. If medical isolation is necessary, there shall be sufficient and qualified staff available to provide care and attention.

(c) Provisions shall be made in writing for patients from the facility to receive care from outside health care providers and hospital facilities, in the event of serious illness which the facility cannot properly handle. Such determinations shall be made by a licensed physician.

(d) Every patient shall have a complete physical examination annually and more frequently if indicated. This examination shall be as inclusive as the initial examination. Efforts shall be made by the institution to have physical defects of the patients corrected through proper medical care. Immunization shall be kept current (DT, polio, measles, mumps, M-M-R).

(e) Each member of the program staff shall be trained to recognize common symptoms of the illnesses of patients, and to note any marked dysfunctions of patients.

(f) Staff shall have knowledge of basic health needs and health problems of patients, such as mental health, physical health and nutritional health. Staff shall teach attitudes and habits conducive to good health through daily routines, examples and discussion, and shall help the patients to understand the principles of health.

(g) Each program shall have a planned program of dental care and dental health which shall be consistently followed. Each patient shall receive a dental examination by a qualified dentist and prophylaxis at least once a year. Reports of all examinations and treatment shall be included in the patient’s clinical record.

(6) Emergency Services. All clinical staff shall have training in matters related to handling emergency situations.

(a) Policies and procedures shall be written regarding handling and reporting of emergencies and these shall be reviewed at least yearly thereafter by all staff.

(b) There shall be a physician on call twenty-four (24) hours a day; his/her name and where he/she can be reached shall be clearly posted in accessible places for program staff.

(c) All staff providing direct patient care must maintain current first aid certificate.

(d) An emergency medication kit shall be made available and shall be constituted to meet the needs of the facility. The emergency medication kit shall contain items selected by the staff or consultant medical doctor and staff or consultant pharmacist which shall be maintained and safeguarded in accordance with federal and state laws and regulations pertaining to the specific drug items included.

(e) There shall be an adequate number of first aid kits available to program staff at all times. Contents of the first aid kits shall be selected by the staff or consultant medical personnel and shall include items designed to meet the needs of the facility.

(f) The program shall have written policies and procedures of obtaining emergency diagnosis and treatment of dental problems. The program shall have written agreement with a licensed dentist(s) who is a consultant or a member of the staff for emergency dental care.

(g) The facility shall have a written plan to facilitate emergency hospitalization in a licensed medical facility. The facility shall make available a written agreement from a licensed hospital verifying that routine and emergency hospitalization will be provided.

(h) The special hospital shall have a written plan for providing emergency medical and psychiatric care.

1. There shall be a written posted plan which shall clearly specify who is available and authorized to provide necessary emergency psychiatric or medical care, or to arrange for referral or transfer to another facility to include ambulance arrangements, when necessary.

2. There shall be a written plan regarding emergency notification to the parents or legal guardian. This plan and arrangements shall be discussed with all families or guardians of patients upon admission.

(7) Pharmaceutical Services. Pharmaceutical services, if provided, shall be maintained and delivered as described in the applicable sections of Chapters 465 and 893, F.S.

(8) Laboratory and Pathology Services.

(a) The facility shall provide clinical and pathology services within the institution, or by contractual arrangement with a laboratory commensurate with the facility’s needs and which is registered under the provisions of Chapter 483, F.S.

1. Provision shall be made for the availability of emergency laboratory services 24 hours a day, 7 days a week, including holidays.

2. All laboratory tests shall be ordered by a licensed practitioner in accordance with Section 483.041(7), F.S.

3. All laboratory reports shall be filed in the patient’s medical record.

4. The facility shall have written policies and procedures governing the collection, preservation and transportation of specimens to assure adequate stability of specimens.

(b) Where the facility depends on an outside laboratory for services, there shall be a written contract detailing the conditions, procedures and availability of work performed. The contract shall be reviewed and approved by the medical staff, administrator and the governing body.

(9) Patients’ Rights. Every effort shall be made to safeguard the legal and civil rights of patients and to make certain that they are kept informed of their rights, including the right to legal counsel and all other requirements of due process.

(a) Individual dignity and human rights are guaranteed to all clients of mental health facilities in Florida by the Florida Mental Health Act, known as the “Baker Act,” Chapter 394, F.S.

(b) Each facility shall be administered in a manner that protects the client’s rights, his life, and his physical safety while under treatment.

1. The special hospital’s space and furnishings should be designed and planned to enable the staff to respect the patient’s right to privacy and, at the same time, provide adequate supervision according to the development and clinical needs of the patients. Provisions for an individual patient’s rights regarding privacy shall be made explicit to the patient and family. A written policy concerning patient’s rights shall be provided to the patient of authentic research or studies, or innovations of client’s record.

2. The special hospital center’s policies shall allow patient visitation and communication with all members of the family and other visitors as clinically indicated and when such visits are consistent with the facility’s program. When therapeutic considerations recommended by the responsible licensed psychologist or physician necessitate restriction of communication or visits, as set forth in the programs policies and procedures, these restrictions shall be evaluated at least weekly by the clinical staff for their continuing effectiveness. These restrictions shall be documented and signed by the responsible psychologist or physician and be placed in the patient’s record. The special hospital shall make known to the patient, the family and referring agency its policies regarding visiting privileges on and off the premises, correspondence and telephone calls. These policies shall be stated in writing and shall be provided to the patient and family and updated when change in policy occurs. When limitations on such visits, calls or other communications are indicated by practical reason, e.g., the expense of travel or telephone calls, such limitations shall be determined with participation of the patient’s family or guardian.

3. Patients shall be allowed to request an attorney through their parents or guardians. This shall be established as written policy, and the policy shall be provided to families and patients.

4. Patient’s opinions and recommendations shall be considered in the development and continued evaluation of the therapeutic program. The special hospital shall have written policies to carry out appropriate procedures for receiving and responding to patient communications concerning the total program.

5. The special hospital shall have written policies regarding methods used for control of patients’ behavior. Such written policies shall be provided to the appropriate staff and to the patient and his family. Only staff members responsible for the care and treatment of patients shall be allowed to handle discipline. Patients shall not be subject to cruel, severe, unusual or unnecessary punishment. Patients shall not be subjected to remarks which ridicule them or their families, or others.

6. Protective restraint consists of any apparatus or condition which interferes with the free movement of the patient. Only in an emergency shall physical holding be employed unless there are physician’s orders for a mechanical restraint. Physical holding or mechanical restraints, such as canvas jackets or cuffs, shall be used only when necessary to protect the patient from injury to himself or others. Use of mechanical restraints reflect a psychiatric emergency and must be ordered by the responsible staff/consultant physician, be administered by trained staff and be documented in the patient’s clinical records. The need for the type of restraint used and the length of time it was employed and condition of the patient shall be recorded in the patient’s record. An order for a mechanical restraint shall designate the type of restraint to be used, the circumstance under which it is to be used and the duration of its use. A patient in a mechanical restraint shall have access to a staff member at all times during the period of restraint.

7. The facility shall have written policies and procedures which govern the use of seclusion. The use of seclusion shall require clinical justification and shall be employed only to prevent a patient from injuring himself or others, or to prevent serious disruption of the therapeutic environment. Seclusion shall not be employed as punishment or for the convenience of staff. A written order from a physician shall be required for the use of seclusion for longer than one hour. Written orders for seclusion shall be limited to twenty-four (24) hours. The written approval of the medical director or the director of psychiatrist services shall be required when seclusion is utilized for more than twenty-four (24) hours. Staff who implement written orders for seclusion shall have documented training in the proper use of the procedures. Appropriate staff shall observe and visually monitor the patient in seclusion every fifteen (15) minutes, documenting the patient’s condition and identifying the time of observation. A log shall be maintained which will record on a quarter- hour basis the observation of the patient in seclusion, and will also indicate when the patient was taken to the bathroom, when and where meals were served, when other professional staff visited, etc., and shall be signed by the observer. The need or reason for seclusion shall be made clear to the patient and shall be recorded in the patient’s clinical record. The length of time in seclusion shall also be recorded in the clinical record, as well as the condition of the patient. A continuing log shall be maintained by the facility that will indicate by name the patients placed in seclusion, date, time, specified reason for seclusion and length of time in seclusion. In an emergency, orders may be given by a physician over the telephone to a registered professional nurse. Telephone orders must be reviewed within twenty-four (24) hours by the director of psychiatric services.

8. The special hospital shall not exploit a patient or require a patient to make public statements to acknowledge his gratitude to the treatment center.

9. Patients shall not be required to perform at public gatherings.

10. The special hospital shall not use identifiable patients’ pictures without written consent. The signed consent form shall be on file at the facility before any such pictures are used. A signed consent form must indicate how pictures shall be used and a copy shall be placed in the patient’s clinical record.

(10) Records. The form and detail of the clinical records may vary but shall minimally conform to the following standards:

(a) Content. All clinical records shall contain all pertinent clinical information and each record shall include:

1. Identification data and consent forms; when these are not obtainable, reason shall be noted;

2. Source of referral;

3. Reason for referral, example, chief complaint, presenting problem;

4. Record of the complete assessment;

5. Initial formulation and diagnosis based upon the assessment;

6. Written treatment plan;

7. Medication history and record of all medications prescribed;

8. Record of all medication administered by facility staff, including type of medication, dosages, frequency of administration, persons who administered each dose, and route of administration;

9. Documentation of course of treatment and all evaluations and examinations, including those from other facilities, for example, emergency rooms or general hospitals;

10. Periodic treatment summaries; updated at least every 90 days;

11. All consultation reports;

12. All other appropriate information obtained from outside sources pertaining to the patient;

13. Discharge or termination summary report; and,

14. Plans for follow-up and documentation of its implementation.

(b) Identification data and consent form shall include the patient’s name, address, home telephone number, date of birth, sex, next of kin, school and what grade, date of initial contact or admission to the program, legal status and legal document, and other identifying data as indicated.

(c) Progress Notes. Progress notes shall include regular notations at least weekly by staff members, consultation reports and signed entries by authorized identified staff. Progress notes by the clinical staff shall:

1. Document a chronological picture of the patient’s clinical course;

2. Document all treatment rendered to the patient;

3. Document the implementation of the treatment plan;

4. Describe each change in each of the patient’s conditions;

5. Describe responses to and outcome of treatment; and,

6. Describe the responses of the patient and the family or significant others to significant inter-current events.

(d) Discharge Summary. The discharge summary shall include the initial formulation and diagnosis, clinical resume, final formulation and final primary and secondary diagnoses, the psychiatric and physical categories. The final formulation shall reflect the general observations and understanding of the patient’s condition during appraisal of the fundamental needs of the patients. Records of discharged patients shall be completed following discharge within a reasonable length of time, and not to exceed 15 days. In the event of death, a summation statement shall be added to the record either as a final progress note or as a separate resume. This final note shall take the form of a discharge summary and shall include circumstances leading to death. All discharge summaries must be signed by a staff or consultant physician.

(e) Recording. Entries in the clinical records shall be made by staff having pertinent information regarding the patient, consistent with the facility policies, and authors shall fully sign and date each entry. When mental health trainees are involved in patient care, documented evidence shall be in the clinical records to substantiate the active participation of supervisory clinical staff. Symbols and abbreviations shall be used only when they have been approved by the clinical staff and when there is an explanatory notation. Final diagnosis, both psychiatric and physical, shall be recorded in full, and without the use of either symbols or abbreviations.

(f) Policies and Procedures. The facility shall have written policies and procedures regarding clinical records which shall provide that:

1. Clinical records shall be confidential, current and accurate;

2. The clinical record is the property of the facility and is maintained for the benefit of the patient, the staff and the facility;

3. The facility is responsible for safeguarding the information in the record against loss, defacement, tampering or use by unauthorized persons;

4. The facility shall protect the confidentiality of clinical information and communication between staff members and patients;

5. Except as required by law, the written consent of the patient, family, or other legally responsible parties, is required for the release of clinical record information;

6. Records may be removed from the facility’s jurisdiction and safekeeping only according to the policies of the facility or as required by law; and,

7. That all staff shall receive training, as part of new staff orientation and with periodic update, regarding the effective maintenance of confidentiality of the clinical record. It shall be emphasized that confidentiality refers as well to discussions regarding patients inside and outside the facility. Verbal confidentiality shall be discussed as part of all employee training.

(g) Maintenance of Records. Each facility shall provide for a master filing system which shall include a comprehensive record on each patient’s involvement in every program aspect.

1. Appropriate records shall be kept on the unit where the patient is being treated or be directly and readily accessible to the clinical staff caring for the patient;

2. The facility shall maintain a system of identification and coding to facilitate the prompt location of the patient’s clinical records;

3. There shall be policies regarding the permanent storage, disposal or destruction of the clinical records of disclosure of confidential information later in life;

4. The clinical record services required by the facilities shall be directed, staffed and equipped to facilitate the accurate processing, checking, indexing, filing, retrieval and review of all clinical records. The clinical records service shall be the responsibility of an individual who has demonstrated competence and training or experience in clinical record administrative work. Other personnel shall be employed as needed, in order to effect the functions assigned to the clinical record services;

5. There shall be adequate space, equipment and supplies, compatible with the needs of the clinical record service, to enable the personnel to function effectively and to maintain clinical records so that they are readily accessible.

(11) Program and Patient Evaluation. The staff shall work towards enhancing the quality of patient care through specified, documented, implemented and ongoing the designing professions having as their purpose processes of clinical care evaluation studies and utilization review mechanisms.

(a) Individual Case Review.

1. There shall be regular staff meetings or unit meetings to review and monitor the progress of the individual child or adolescent patient. Each patient’s case shall be reviewed within a month after admission and at least monthly during residential treatment. This shall be documented. This meeting may also be used for review and revision of treatment plans.

2. The facility shall provide for a follow-up review on each discharged patient to determine effectiveness of treatment and disposition.

(b) Program Evaluation.

1. Clinical Care Evaluation Studies. There shall be evidence of ongoing studies to define standards of care consistent with the goals of the program effectiveness of the program, and to identify gaps and inefficiencies in service. Evaluation shall include follow-up studies. Studies shall consist of the following elements:

a. Selection of an appropriate design;

b. Specification of information to be included;

c. Collection of data;

d. An analysis of data with conclusions and recommendations;

e. Transmissions of findings; and,

f. Follow-up on recommendations.

2. Utilization Review. Each facility shall have a plan for and carry out utilization review. The review shall cover the appropriateness of admission to services, the provision of certain patterns of services, and duration of services. There shall be documentation of utilization review meetings either in minutes or in individual clinical records. The improvement of patient care, shall receive special consideration following a request and documentation of the proposed project by the individual sponsor.

Rulemaking Authority 395.1055 FS. Law Implemented 395.1055 FS. History–New 1-1-77, Formerly 10D-28.92, 10D-28.110, Amended 9-4-95, 10-16-14.