65E-12.106. Common Minimum Program Standards

(1) Advisory or Governing Board. The CSU or SRT shall have either a formally constituted advisory or governing board for the CSU or SRT or operate under a provider board which has ultimate authority for establishing policy and overseeing the operation of the CSU or SRT. The board shall operate under a mission statement and a set of bylaws governing its operation.

(a) Selection and Terms of Office. If an advisory or governing board exists, the method of selection of members and terms shall be specified in the corporate bylaws of the corporation. The membership of such an advisory or governing board shall include broad representation from the professional disciplines and the community, including a consumer and a consumer’s family member, and shall meet quarterly.

(b) Records. Records of the CSU or SRT with an advisory or governing board shall include the name, address, and terms of office of members; written minutes of meetings; attendance; and specific recommendations or decisions of the board.

(2) Personnel Policies. Personnel policies shall be made available in writing to all personnel. Policies shall include rules governing the ethical conduct of staff and volunteers, rights and confidentiality of information regarding individuals  receiving services.

(a) Performance Evaluation of Staff. An annual performance evaluation of all personnel shall be conducted. The program shall provide for the signature of the employee acknowledging receipt of the evaluation.

(b) Personnel Records. Records on all employees and volunteers shall be maintained by the CSU or SRT. Each employee record, available for employee review shall contain:

1. The employee’s current job description with minimum qualifications for the position;

2. The employment application or resume with evidence that references were checked prior to employment;

3. The employee’s annual evaluations;

4. A copy of the employee’s professional license, if applicable;

5. A receipt indicating that the employee has been trained and understands program policies and procedures, patient rights as stated in Section 394.459, F.S., ethical conduct, and confidentiality of information regarding individuals receiving services;

6. Documentation that the employee has been trained and understands the legal mandate under Section 415.103, F.S., to report suspected abuse and neglect as well as the use of the Florida Abuse Hotline; and,

7. Documentation that the employee or volunteer has been fingerprinted and screened, if appropriate, in accordance with Section 394.4572, F.S.

8. Documentation of training as required by Section 381.0035, F.S., for all non-licensed staff.

(c) Fingerprint Screening. All personnel, as defined in Section 394.4572, F.S. shall be screened in accordance with Sections 394.4572 and 408.809, F.S. Each CSU and SRT shall maintain fingerprint screening records as follows:

1. A current list which identifies, by position title, all positions which require fingerprint screening.

2. A continuously updated record of all active personnel which identifies for each person his position title, date of hire, and the date of the most recent fingerprint screening.

(3) Staff Development and Training. Each CSU and SRT shall provide staff development and training for all facility staff, including part-time, temporary, and volunteers, and shall develop policies and procedures for implementing these activities. Policies and procedures shall be reviewed annually. There shall be a qualified and experienced staff person responsible for staff development and training who is, under the supervision of, or receives consultation from, a mental health professional licensed under Chapter 491, F.S. All staff development and training activities shall be documented and shall include activity or course title; number of contact hours; instructor’s name; credentials; and, date. The participation of each employee shall be documented in accordance with systemic procedures either in the employee’s personnel file or staff development and training file. Attendance at professional workshops and conferences should also be documented accordingly.

(4) Financial Records. Financial records that identify all income by source, and report all expenditures by category, shall be maintained in a manner consistent with Chapter 65E-14, F.A.C.

(5) Confidentiality and Clinical Records. Every CSU and SRT shall maintain a record on each individual receiving services, assuring that records and identifying information are maintained in a confidential manner, and securing valid lawful consent prior to the release of information in accordance with Section 394.4615, F.S. Clinical records may be stored on paper, magnetic material, film, or other media, including electronic storage. All staff shall receive training as part of staff orientation, with at least a triennial update on file, regarding the effective maintenance of confidentiality of clinical records, including electronic records. It shall be emphasized that confidentiality includes oral discussions regarding individuals receiving services inside and outside the CSU or SRT and shall be discussed as part of employee training.

(a) Clinical Record System. Each CSU and SRT shall have policies and procedures, in accordance with Section 394.4615, F.S., for a clinical record system. The clinical record is the focal point of treatment documentation and is a legal document. Entries placed in the clinical record to document the individual’s progress or facility’s actions must be objective, legible, accurate, dated, timed when appropriate, and authenticated with the writer’s signature, title, and discipline. Electronic signatures, as defined in Chapter 668, Part I, F.S., are permissable. The clinical record shall be organized and maintained for easy access. Clinical record services shall be the responsibility of an individual who has demonstrated competence and training or experience in clinical record management. Adequate space shall be provided for the storage and retrieval of the records. The records shall be kept secure from unauthorized access, and each program shall adopt policies and procedures which regulate and control access to and use of clinical records.

(b) Record Retention and Disposition. An individual’s complete clinical record shall be retained for a minimum period of 6 years following discharge. If any litigation claim, negotiation, audit, or other action involving the records has been started before the expiration of the six-year period, the records shall be retained until completion of the action and resolution of all issues which arise from such actions.

(c) Content of Clinical Records. The required signature of treatment personnel shall be original as opposed to the facsimile. The required signature of treatment personnel shall be original as opposed to the facsimile. Policies and procedures shall require the clinical record to clearly document the extent of progress toward short-term objectives and long-term view. Clinical record documentation for each order or treatment decision shall include its respective basis or justification, actions taken, description of behaviors or response, and staff evaluation of the impact of the treatment on the individual’s progress. Clinical records shall contain:

1. The name and address of the  individual receiving services;

2. Name, address, and telephone number of guardian, representatives, or others as specified by the individual receiving services;

3. The source of referral and relevant referral information;

4. Intake interview and initial physical assessment;

5. The signed and dated informed consent for treatment as mandated under Sections 394.459(3) and 394.4615, F.S.;

6. Documentation of orientation to program and program rules;

7. The medical history and physical examination report with diagnosis;

8. The report of the mental status examination and psychosocial, psychological, nursing, rehabilitation, nutritional, and  mental health assessments as appropriate;

9. The original service plan developed, dated and signed by the individual receiving services and treatment staff. The plan shall contain short-term treatment objectives that relate to crisis stabilization and the description and frequency of services to be provided;

10. The signed and dated service plan reassessments and reviews;

11. Examination, diagnosis and progress notes by physician, psychiatric nurses, treatment staff and other mental health professionals that relate to the service plan objectives;

12. Laboratory and radiology results, if applicable;

13. Documentation of seclusion or restraint observations, if utilized;

14. A record of all contacts with medical and other services;

15. A record of medical treatment and administration of medication, if administered;

16. An original or original copy of all physician or psychiatric nurse medication and treatment orders;

17. Signed consent for the release of information, if information is released;

18. An individualized discharge plan;

19. Forms CF-MH 3042a, CF-MH 3042b, and CF-MH 3084, as appropriate;

20. A current, originally authorized CF-MH 3084, Feb 2005, “Baker Act Service Eligibility,” which is incorporated herein by reference for all individuals receiving services and available at http://www.flrules.org/Gateway/reference.asp?No=Ref-08945 and from the department’s website at https://eds.myflfamilies.com/DCFFormsInternet/Search/DCFFormSearch.aspx; and,

21. If the individual receiving services has a community case manager, documentation  of  contacts between the community case manager and CSU or SRT staff and  the person receiving service.

(6) Consent to Treatment. Any CSU or SRT rendering treatment for mental illness to any individual, pursuant to Chapter 394, F.S., and Chapter 65E-5, F.A.C., shall have on file a valid and signed informed consent for treatment. Forms CF-MH 3042a, “General Authorization for Treatment Except Psychotropic Medications,” Feb 05 and CF-MH 3042b, “Specific Authorization for Psychotropic Medications,” Feb 05, or substantially similar forms, may be used. Forms CF-MH 3042a and 3042b are incorporated by reference and are available at http://www.flrules.org/Gateway/reference.asp?No=Ref-09031 and http://www.flrules.org/Gateway/reference.asp?No=Ref-090312, respectively, and from the department’s website at https://eds.myflfamilies.com/DCFFormsInternet/Search/DCFFormSearch.aspx.

(7) Admission and Discharge Criteria. Each CSU and SRT shall develop and utilize policies and procedures pursuant to Chapter 394, F.S., for the intake, screening, admission, referral, disposition, and notification of the individual or their guardians, representatives, or others as specified by the individual seeking treatment. There shall be adequate intake procedures to ensure that individuals being received from an emergency room, agency, facility, or other referral source shall have all the required paperwork and documentation for admission. If an individual has a case manager, the case manager shall be notified and shall provide appropriate information and participate in the development of the discharge plan. Individuals receiving services, guardians, or others as specified by the individual receiving services shall be informed of their eligibility or ineligibility status for publicly funded CSU or SRT services, either at admission or shortly thereafter.

(a) Admissions Criteria. All persons admitted shall meet the criteria defined under Section 394.455(28), 394.4625, or 394.463, F.S.

(b) Supervisory Clinical Review. The program policies and procedures shall specify administrative procedures for the ongoing review of clinical decisions regarding admission, treatment, and disposition. This shall include staffings, individual supervision, and record reviews.

(c) Orientation to Program and Abuse Reporting. Each CSU and SRT shall conduct and document an orientation session with each individual receiving services, guardians, and others as specified by the individual receiving services, regarding admission and discharge standards, rules, procedures, activities and concepts of the program. A written copy of the above shall be provided to individuals receiving services and their guardians. Individuals receiving services shall be informed in writing of rights, protection standards, possible searches and seizures, in-house grievance protocol, function of the human rights advocacy committee and current procedures for reporting abuse, neglect, or exploitation to the Abuse Hotline as required by Section 415.1034, F.S. Programs shall not discourage or prevent anyone from contacting the Abuse Hotline.

(8) Protection of Individuals Receiving Services. Unless abridged by a court of law, the rights of individuals who are admitted to CSU and SRT programs shall be assured as mandated under Chapter 394, Part I, F.S., and Chapter 65E-5, F.A.C. Each CSU and SRT shall be operated in a manner that protects the individual’s rights, life, and physical safety while receiving evaluation and treatment. In addition to all rights granted under Chapter 394, Part I, F.S., individuals receiving services  shall be:

(a) Assigned a primary therapist or counselor; and,

(b) Assured that any search or seizure is carried out in a manner consistent with program policies and procedures to ensure safety and security and is consistent with therapeutic practices.

1. Searches and Seizures. Whenever there is a reason to believe that the security of a facility or the health of anyone is endangered or that contraband or objects which are illegal to possess are present on the premises, a search of an individual’s room, locker, or possessions shall be conducted if authorized by the program director or designee, as defined in program policies and procedures.

2. Presence of Individual. Whenever feasible, the individual receiving services shall be present during a search.

3. Absence of Individual. When it is impossible  for the individual to be physically present during the search, they shall be given prompt written notice of the search and of any article confiscated.

4. Documentation. Written reports of all searches shall be documented in the individual’s clinical record. A written inventory of items confiscated shall be forwarded to the program director or designee.

(c) Facility policy shall prohibit any retaliation or reprisal against either the individual or against staff for reporting suspected abuse, neglect or exploitation, or violations of the individual’s rights. A copy of this facility policy shall be posted in a common area and provided to individuals receiving services upon request.

(9) Quality Assurance Program. Every CSU and SRT shall comply with the requirements of Section 394.907, F.S.

(a) Inclusions. Every CSU and SRT shall have, or be an active part of, an established multidisciplinary quality assurance program and develop a written plan which addresses the minimum guidelines to ensure a comprehensive integrated review of all programs, practices, and facility services, including the following: facilities safety and maintenance; care and treatment practices; resource utilization review; peer review; infection control; records review; maintenance of clinical records; pharmaceutical review; professional and clinical practices; curriculum, training and staff development; and incidents with appropriate policies and procedures. The quality assurance program must include:

1. Composition of quality assurance review committees and subcommittees, purpose, scope, and objectives of the quality assurance committee and each subcommittee, frequency of meetings, minutes of meetings, and documentation of meetings;

2. Procedures to ensure selection of both difficult and randomly selected cases for review;

3. Procedures to be followed in reviewing cases and incident reports;

4. Criteria and standards used in the review process and procedures for their development;

5. Procedures to be followed to assure dissemination of the results and verification of corrective action;

6. Tracking capability of incident reports, pertinent issues and actions; and,

7. Procedures for measuring and documenting progress and outcome of individuals receiving services.

(b) Process. The quality assurance program shall conduct two separate complementary review processes on a monthly basis to include peer review and utilization review. The effects of the peer and utilization reviews shall ensure the following.

1. The admission is necessary and appropriate.

2. The services are the least restrictive means of intervention.

3. Rights are being protected.

4. Family or significant others are involved in the treatment and discharge planning process as much as feasible with the consent of the individual receiving services.

5. The service plan is comprehensive, relative to the full range of the needs of the individual receiving services at the CSU or SRT.

6. Minimal standards for clinical records and consent to treatment are being met as required by subsections 65E-12.106(5) and (6), F.A.C., of this rule.

7. Medication is prescribed and administered appropriately. All medication errors shall be reported under the CSU or SRT’s incident reporting system and subject to internal review by the quality assurance program.

8. There has been appropriate handling of medical emergencies.

9. Special treatment procedures, for example, seclusion and restraints, emergency treatment orders, and medical emergencies, are conducted according to facility policy.

10. High risk situations and special cases are reviewed within 24 hours. These shall include suicide attempts, death, serious injury, violence, sexual assaults, and abuse of any individual.

11. All incident reports are reviewed by the facility director within 3 working days.

12. The length of stay is supported by clinical documentation.

13. Supportive services are ordered and obtained as needed.

14. Continuity of care is provided through care coordination activities.

15. Delay in receiving services is minimal.

(c) The quality assurance committee shall submit a quarterly report to the CSU or SRT director and board of directors for their review and appropriate action.

(10) Critical Incident Reporting.

(a) Every CSU and SRT shall develop policies and procedures for submitting critical incidents into the Department’s statewide designated electronic system specific to critical incident reporting.

(b) Every CSU and SRT shall report critical events within one (1) business day of the incident occurring.

1. Adult Death. An individual 18 years old or older whose life terminates:

a. While receiving services, or

b. When it is known that an adult died within thirty (30) days of discharge from a CSU or SRT.

c. The final classification of an adult’s death is determined by the medical examiner. In the interim, the manner of death shall be reported as one of the following:

(I) Accident. A death due to the unintended actions of one’s self or another.

(II) Homicide. A death due to the deliberate actions of another.

(III) Natural Expected. A death that occurs, because of, or from complications of, a diagnosed illness for which the prognosis is terminal.

(IV) Natural Unexpected. A sudden death that was not anticipated and is attributed to an underlying disease either known or unknown prior to the death.

(V) Suicide. The intentional and voluntary taking of one’s own life.

(VI) Undetermined. The manner of death has not yet been determined.

(VII) Unknown. The manner of death was not identified or made known.

2. Child Arrest. The arrest of a child.

3. Child Death. An individual who is less than 18 years of age whose life terminates:

a. While receiving services, or

b. When it is known that a child died within 30 days of discharge from a CSU or SRT;

c. The final classification of a child’s death is determined by the medical examiner. In the interim, the manner of death will be reported as one of the following:

(I) Accident. A death due to the unintended actions of one’s self or another.

(II) Homicide. A death due to the deliberate actions of another.

(III) Natural Expected. A death that occurs, because of, or from complications of, a diagnosed illness for which the prognosis is terminal.

(IV) Natural Unexpected. A sudden death that was not anticipated and is attributed to an underlying disease either known or unknown prior to the death.

(V) Suicide. The intentional and voluntary taking of one’s own life.

(VI) Undetermined. The manner of death has not yet been determined.

(VII) Unknown. The manner of death was not identified or made known.

4. Child-on-Child Sexual Abuse. Any sexual behavior between children less than 18 years of age which occurs without consent, without equality, or because of coercion.

5. Elopement. An unauthorized absence of any individual.

6. Employee Arrest. The arrest of an employee for a civil or criminal offense.

7. Employee Misconduct. Work-related conduct or activity of an employee that results in potential liability for the Department or the Agency for Health Care Administration (Agency); death or harm to an individual receiving services; abuse, neglect or exploitation of an individual receiving services; or which results in a violation of statute, rule, regulation, or policy. This includes falsification of records; failure to report suspected abuse or neglect; contract mismanagement; or improper commitment or expenditure of state funds.

8. Missing Child. When the whereabouts of a child in the custody of the Department are unknown and attempts to locate the child have been unsuccessful.

9. Security Incident – Unintentional. An unintentional action or event that results in compromised data confidentiality, a danger to the physical safety of personnel, property, or technology resources; misuse of state property or technology resources; or, denial of use of property or technology resources. This excludes instances of compromised information of individuals in treatment.

10. Sexual Abuse/Sexual Battery. Any unsolicited or non-consensual sexual activity by one individual receiving services to another individual receiving services; or, sexual activity by a service provider employee or other person to an individual receiving services, or an individual receiving services to an employee regardless of the consent of the individual receiving services. This may include sexual battery, as defined in Chapter 794, F.S.

11. Significant Injury to Individuals in Treatment. Any severe bodily trauma received by an individual in a CSU or SRT that requires immediate medical or surgical evaluation or treatment in a hospital emergency department to address and prevent permanent damage or loss of life.

12. Significant Injury to Staff. Any serious bodily trauma received by a staff member as result of a work-related activity that requires immediate medical or surgical evaluation or treatment in a hospital emergency department to prevent permanent damage or loss of life.

13. Suicide Attempt. A potentially lethal act which reflects an attempt by an individual to cause his or her own death as determined by a licensed mental health professional or other licensed healthcare professional.

14. Other. Any major event not previously identified as a reportable critical incident but has, or is likely to have, a significant impact on individuals receiving services, on the Department, or on the Agency, such as:

a. Human acts that jeopardize the health, safety, or welfare of individuals receiving services, such as kidnapping, riot, or hostage situation;

b. Bomb or biological/chemical threat of harm to personnel or property involving an explosive device or biological/chemical agent received in person, by telephone, in writing, via mail, electronically, or otherwise;

c. Theft, vandalism, damage, fire, sabotage, or destruction of state or private property of significant value or importance;

d. Death of an employee or visitor while on the grounds of the CSU or SRT;

e. Significant injury of a visitor while on the grounds of the CSU or SRT that requires immediate medical or surgical evaluation or treatment in a hospital emergency department to prevent permanent damage or loss of life, or

f. Events regarding individuals receiving services or providers that have led to or may lead to media reports.

(c) Seclusion and Restraint Event Reporting.

All public and private designated Baker Act receiving facilities and all SRTs shall develop policies and procedures for reporting seclusion and restraint events into the statewide designated electronic system specific to seclusion and restraints.

(11) Data. Every CSU and SRT shall participate in reporting data as mandated under Section 394.461, F.S.

(12) Health and Safety.

(a) Disaster Preparedness.

1. Each CSU and SRT shall have, or operate under, a safety committee with a safety director or officer who is familiar with the applicable local, state, federal and National Fire Protection Association safety standards. The committee’s functions may be performed by an already existing committee with related interests and responsibilities.

2. Each CSU and SRT shall have, or be a part of, a written internal and external disaster plan, developed with the assistance of qualified fire, safety and other experts.

a. The plan and fire safety manual shall identify the availability of fire protection services and provide for the following:

(I) Use of the fire alarm;

(II) Transmission of the alarm to the fire department;

(III) Response to the alarm;

(IV) Isolation of the fire;

(V) Evacuation of the fire area or facility utilizing posted evacuation routes;

(VI) Preparation of the residents and building for evacuation;

(VII) Fire extinguishment;

(VIII) Descriptive procedures for the operation and maintenance of fire equipment;

(IX) Procedures for staff training and the provision of monthly fire drills rotated so that all shifts have at least one fire drill quarterly;

(X) Documentation of monthly and periodic professional inspections of equipment; and,

(XI) Provision for annual review and revision of the fire safety manual and plan.

b. The plan shall be made available to all facility staff and posted in appropriate areas within the facility.

c. There shall be records indicating the nature of disaster training and orientation programs offered to staff.

(b) Fire Safety. CSUs and SRTs must comply with all federal and local fire safety standards. Local fire codes which are more stringent standards, or add additional requirements, shall take precedent over the minimum requirements set forth in this rule.

(c) Personal Safety. The grounds and all buildings on the grounds shall be maintained in a safe and sanitary condition.

(d) Health and Sanitation.

1. Appropriate health and sanitation inspections shall be obtained before occupying any new physical facility or addition. A report of the most recent inspections must be on file and accessible to authorized individuals.

2. Hot and cold running water under pressure shall be readily available in all washing, bathing and food preparation areas. Hot water in areas used by individuals being served shall be at least 100 degrees Fahrenheit but not exceed 120 degrees Fahrenheit.

3. Garbage, Trash and Rubbish Disposal.

a. All garbage, trash, and rubbish from residential areas shall be collected daily and taken to storage facilities. Garbage shall be removed from storage facilities frequently enough to prevent a potential health hazard or at least twice per week. Wet garbage shall be collected and stored in impervious, leak proof, fly tight containers pending disposal. All containers, storage areas and surrounding premises shall be kept clean and free of vermin.

b. If public or contract garbage collection service is available, the facility shall subscribe to these services unless the volume makes on-site disposal feasible. If garbage and trash are disposed of on premises, the method of disposal shall not create sanitary nuisance conditions. Facilities must comply with the Florida Department of Health’s garbage, trash, and rubbish disposal requirements, as stated in Chapter 62-701, F.A.C.

(13) Food Services.

(a) At least three nutritious meals per day and nutritional snacks, shall be provided each individual receiving services. No more than 14 hours may elapse between the end of an evening meal and the beginning of a morning meal. Special diets shall be provided when an individual requires it. Under no circumstance may food be withheld for disciplinary reasons. Menus shall be reviewed and approved in advance at least quarterly by a Florida registered dietitian.

(b) For food service areas with a capacity of 13 or more individuals, facilities must comply with the Florida Department of Health’s food service requirements, as stated in Chapter 64E-11, F.A.C.

(c) Third Party Food Service. When food service is provided by a third party, the provider must comply with the Florida Department of Health’s food service requirements, as stated in Chapter 64E-11, F.A.C. There shall be a formal contract between the facility and provider containing assurances that the provider will meet all food service and dietary standards imposed by this rule. Sanitation reports and food service establishment inspection reports shall be on file in the facility.

(14) Housekeeping and Maintenance. Every CSU and SRT shall have housekeeping and maintenance standards which meet the following criteria:

(a) Facilities shall be clean, in good repair, and free of hazards such as cracks in floors, walls, or ceilings; warped or loose boards, tile, linoleum, hand rails or railings; broken window panes; and any similar type hazard.

(b) The interior and exterior of the building shall be clean and in good repair. Loose, cracked or peeling wallpaper or paint shall be promptly replaced or repaired to provide a satisfactory finish.

(c) All furniture and furnishings shall be clean and in good repair, and contribute to creating a therapeutic environment.

(d) An adequate supply of linen shall be maintained to provide clean and sanitary conditions for each individual at all times.

(e) Mattresses and pillows shall have fire retardant covers or similar protection for fire safety and sanitation purposes.

(15) Compliance with Statutes and Rules. The program director or administrator shall ensure that the program complies with Chapter 394, F.S., and Chapters 65E-5, 65E-12, and 65E-14, F.A.C.

(16) Register of Individuals and Census. An admission and discharge logbook shall be maintained which lists individuals admitted sequentially by name with identifying information about each including age, race, sex, county of residence, disposition, and the actual location to which the individual was discharged or transferred. A daily census record shall be maintained which includes the name of individuals on the unit and on authorized pass. This may be maintained electronically, but shall be easily accessible to all relevant facility staff and administrators.

(17) Pharmaceutical Services.

(a) Every CSU and SRT must handle, dispense or administer drugs in accordance with the Department of Health’s Rule Chapter 65E-16, F.A.C.

(b) The professional services of a consultant pharmacist shall be used in the delivery of pharmaceutical services. Standards, policies and procedures shall be established by the consultant pharmacist for the control and accountability of all drugs kept at the program.

(c) Medication Orders. All orders for medications shall be issued by a Florida licensed physician or psychiatric nurse.

(18) Emergency Medical Services. Every CSU or SRT shall have written policies and procedures for handling medical emergency cases which may arise subsequent to an individual’s admission. All staff shall be familiar with the policies and procedures.

(a) Emergency Treatment Orders. Policies and procedures shall be written to address the use of emergency treatment orders as specified in Section 394.459, F.S., and Chapter 65E-5, F.A.C. They shall address the following:

1. Emergency treatment orders shall be initiated only upon direct order of a physician or psychiatrist;

2. The clinical justification shall be documented in the clinical record; and,

3. The use of standing, pro re nata (PRN), or routine orders for emergency treatment orders is prohibited.

(b) Cardiopulmonary Resuscitation and Choke Relief. All nurses and direct service staff shall be trained to practice basic cardiopulmonary resuscitation (CPR) and choke relief technique at employment or within 6 months of employment and have a refresher course at least every 2 years. There shall be one person on the premises at all times who is CPR certified and proficient in choke relief techniques. Training shall be documented in the personnel record of the employee. Consent for referral and the disclosure of vital information is not required in life-threatening situations.

(c) Medical Kit and Emergency Information. A physician, psychiatrist, consultant pharmacist, and registered nurse, designated by the program director or administrator, shall select drugs and ancillary equipment to be included in an emergency medical kit. The kit shall be maintained at the program and safeguarded in accordance with laws and regulations pertaining to the specific items included. A list of emergency programs and poison centers shall be maintained near a telephone for easy access by all staff.

(19) Protection of Individuals Receiving Services.

(a) Unauthorized Entry or Exit. Each CSU and SRT shall have policies and procedures regarding unauthorized entry to or exit from the unit.

(b) Control of potentially injurious items.

1. Policies and procedures shall prohibit the transmittal onto or carrying onto the unit sharps, flammables, toxins, weapons, caustic chemicals, rope, or other items potentially injurious to individuals on the unit.

2. Therapeutic activity materials shall also exclude similarly potentially hazardous items such as bats, paddles, mallets, knives, ropes, cords, wire clothes hangers, wire, sharp pointed scissors, luggage straps, and sticks.

3. Housekeeping supplies and chemicals shall, whenever practical, be non-toxic or non-caustic. The unit shall implement procedures to avoid access by individuals receiving services during use or storage.

4. Nursing and medical supplies including drugs, sharps, and breakables shall be safeguarded from access by individuals receiving services through storage, use, and disposal processes.

(c) Use of Restraint or Seclusion. Each CSU and SRT shall develop and maintain detailed policies and procedures for the use of seclusion and restraint. Such policies and procedures shall be readily available to CSU and SRT staff, individuals served, guardians, and others as specified by the individual.

(d) Suicide Precaution.

1. Suicide precaution is for the protection of individuals who have been assessed to be potentially suicidal and require a higher level of supervision.

2. The modification or removal of suicide precautions shall require clinical justification determined by an assessment and shall be specified by the attending physician or psychiatric nurse and documented in the clinical record. A registered nurse, clinical psychologist or other mental health professional may initiate suicide precautions prior to obtaining a psychiaric nurse’s, physician’s or psychiatrist’s order, but in all instances must obtain an order within 1 hour of initiating the precautions. Telephone orders shall be reviewed and signed by a psychiatric nurse or physician within 24 hours of their initiation.

3. Each CSU shall develop policies and procedures for implementing suicide precautions addressing: assessment, staffing, levels of observation and documentation. Policies and procedures shall require constant visual observation of individuals clinically determined to be actively suicidal.

(e) Other high risk behaviors, such as elopement and assaultive behavior, shall be addressed in the CSU and SRT policies and procedures.

(20) Nursing Services.

(a) Medical Prescription. Registered nurses shall ensure that each psychiaric nurse’s, physician’s, or psychiatrist’s orders are followed. When a determination is made that the orders have not been followed or were refused by the individual being served, the psychiaric nurse, physician or psychiatrist shall be notified within 24 hours. The registered nurse or nursing service shall substantiate this action through documentation in the individual’s clinical record.

(b) Nursing Standards. Each CSU and SRT shall develop and maintain a standard manual of nursing services which shall address medications, treatments, diet, personal hygiene care and grooming, clean bed linens and environment, and protection from infection.

(21) Continuity of Care. Upon admission, all individuals receiving services, in both a CSU and SRT shall be assessed for the need of case management services. If determined to need case management services, the individual shall be linked to a case manager in the community.

(22) Children. Every CSU and SRT which serves individuals under 18 years of age shall define, in policies and procedures, the services and supervision to be provided to the children. Minors under the age of 14 years shall not be admitted to a bed in a room or ward with an adult. They may share common areas with an adult only when under direct visual observation by unit staff. This shall be reviewed and documented on a daily basis.

(23) Collocation.

(a) Collocation means the operation of CSU and SRT, or CSU and substance abuse detoxification services from a common nurses’ station without treatment system integration. It may result in the administration of those services by the same organization and the sharing of common services, such as housekeeping, maintenance and professional services. A CSU shall be separated and secured by locked doors from the SRT and detoxification units.

(b) Whenever a CSU is collocated with an SRT or substance abuse detoxification unit there shall be no compromise in CSU standards. In all instances, whenever there is a conflict between CSU rules and SRT, substance abuse rules, the more restrictive rules shall apply.

(c) Individuals receiving CSU, SRT, and detoxification services shall not commingle or share a common space unless individually authorized by a physician’s, psychiatrist’s, or psychiatric nurse’s written order to participate in specific treatment and evaluation activities on other units as specified in the individual’s service plan. Service plan documentation shall include: type of activity, supervision, frequency of activity, and duration of each activity session.

(d) Collocation Staffing Requirements. CSU and SRT, or CSU and detoxification staff may be shared if the individual served-staff ratio is not violated and the health, safety and welfare of the individual is not jeopardized. When services are collocated and staff resources are shared, the staffing pattern shall be the more restrictive as required by this rule, based on the combined total number of beds. When the combined number of beds exceeds 30, nursing and direct service staff shall not be shared.

(24) Passes.

(a) A psychiaric nurse’s or physician’s order shall be written in accordance with unit policies and procedures specifying each occasion that an individual receiving services is permitted off unit and consistent with the service plan.

(b) Each written order shall specify: the clinical basis for the order; the necessity and purpose of the order; the level of supervision while off the unit; the staff designated responsible for the individual receiving services; and the authorized time of departure and return deadline which cannot exceed 24 hours for CSUs and 48 hours for SRTs.

(25) Smoking. Each CSU and SRT shall designate smoking areas or declare the facility non-smoking and shall post signs to so indicate. Areas frequented by smokers and non-smokers shall not be designated a smoking area. The facility shall ensure the operation of adequate smoke evacuation mechanisms to maintain a healthful air quality throughout.

(26) Personal Items. Individuals receiving services in CSUs and SRTs are entitled to wear their own clothing except when this right is restricted for safety. This restriction must be fully justified in the clinical record. Policies and procedures shall be developed which describe the utilization of special clothing, or describe unit restrictions concerning other potentially hazardous personal articles, such as sharps and ingestibles.

(27) Universal Infection Control. Each CSU and SRT shall develop and implement policies and procedures for universal infection control and prevention to protect people from blood and body fluid borne disease. Specific procedures shall include management of individuals who potentially have infectious diseases, such as Hepatitis B, Human Immunodeficiency Virus (HIV), Acquired Immune Deficiency Syndrome (AIDS), or other infectious diseases. These procedures shall include: isolation, specific infection control techniques, availability of proper equipment, proper disposal of potentially infected waste, transfer, and the release of confidential information to select unit medical and direct care staff on a need-to-know basis. Any testing for HIV must be done in accordance with the Department of Health’s requirements as stated in Chapter 64D-2, F.A.C. Policies and procedures shall be regularly updated to include information provided by the department, the Department of Health, and the Center for Disease Control. All biohazardous waste must  be handled and disposed in accordance with the Department of Health’s requirements as stated in Chapter 64E-16, F.A.C.

(28) HIV and AIDS Education Requirements. Each CSU and SRT must meet the Department of Health’s requirements for HIV and AIDS education pursuant to Section 381.0035, F.S., for each employee and individual receiving services and maintain records of such training.

(29) Unit operating policy and procedure manuals shall be organized and maintained for easy access and reference and available to all facility staff at all times. The CSU and SRT shall have a copy of Chapter 394, F.S., Chapters 65E-5 and 65E-12, F.A.C., on the unit available to all staff and individuals receiving services at all times.

(30) CSUs and SRTs shall ensure that the unit’s licensed professionals and other unit staff function together under a set of written reciprocal unit protocols. These protocols shall establish the sequence of activities to be performed, designate authorized or responsible personnel, and establish standards for the accuracy, completion, and comprehensiveness of activities.

Rulemaking Authority 394.457, 394.46715, 394.879(1), 394.907(8) FS. Law Implemented 394.455, 394.457, 394.4572, 394.459, 394.4615, 394.463, 394.77, 394.875, 394.879, 394.907 FS. History–New 2-27-86, Amended 7-14-92, Formerly 10E-12.106, Amended 9-1-98, 10-4-00, 4-8-18.