65E-12.107. Minimum Standards for Crisis Stabilization Units (CSUs)

In addition to Rules 65E-12.104, 65E-12.105, and 65E-12.106, F.A.C., above, these standards apply to CSU programs.

(1) Emergency Screening. All persons who apply for admission pursuant to Section 394.4625, F.S., or for whom involuntary examination is initiated pursuant to Section 394.463, F.S., shall be assessed by the CSU or by the emergency services unit of the public receiving facility. Each receiving facility shall provide emergency screening services on a 24-hours-a-day, 7-days-a-week basis and shall have policies and procedures for identifying individuals at high risk. No person can be detained for more than 12 hours without being admitted or released. Everyone for whom involuntary examination is initiated pursuant to Section 394.463, F.S., shall receive a face-to-face examination by a physician or clinical psychologist prior to release. The examination shall include a psychiatric evaluation, including a mental status examination, or a psychological status report.

(a) Unit policies and procedures shall be written concerning the detainment of persons who are awaiting an involuntary examination and disposition. These procedures shall address protection from harm, and the prevention of departure from the unit prior to the examination.

(b) Referral. Individuals referred, or to be referred, to a receiving facility under Chapter 394, Part I, F.S., who also require treatment for an acute physical condition shall be delivered and, if appropriate, admitted to an emergency medical or inpatient service for health care until medically cleared and stabilized to meet the CSU’s medical criteria as prescribed in its policies and procedures. Medical clearance shall be documented in the clinical record.

(c) Paying Fees. Individuals who can pay for services and who wish to be admitted to a private hospital facility authorized to provide services under Chapter 394, Part I, F.S., may be referred without prior examination by the receiving facility.

(2) Admission.

(a) All persons admitted to a CSU shall be admitted pursuant to Chapter 394, Part I, F.S., and Chapter 65E-5, F.A.C. Each CSU shall provide admission services on a 24-hours-a-day, 7-days-a-week basis.

(b) Initial Assessment.

1. Upon admission to the CSU an emotional and behavioral assessment as specified in (d) below shall be made based on facility program policy and procedures. This assessment shall be made by a mental health professional, registered nurse, or other unit staff under the supervision of a mental health professional. The consultation of a physician, psychiatrist, or clinical psychologist shall be available to the CSU staff for purposes of assisting in this assessment. Examination and disposition of a person who has been admitted involuntarily shall be in accordance with the provisions of Section 394.463, F.S.

2. All persons admitted to a CSU shall be provided a nursing assessment, begun at time of admission and completed within 24 hours, by a registered nurse as part of the assessment process.

(c) Physical Examination. All persons admitted to a CSU shall be provided a physical examination within 24 hours of admission, based on program policies and procedures. The physical examination shall include a complete medical history and documentation of significant medical problems. It shall contain specific descriptive terms and not the phrase, “within normal limits.” General findings shall be written in the clinical records within 24 hours.

(d) Emotional and Behavioral Assessment. For everyone admitted to a CSU an emotional and behavioral assessment shall be completed within 72 hours and entered into the clinical record. The assessment shall be made by a mental health professional or other unit staff under the supervision of a mental health professional. The assessment shall include the following.

1. A history of previous emotional, behavioral, and substance abuse problems and treatment.

2. A social assessment to include a determination of the need for participation of family members or significant others in the individual’s treatment; the social, peer-group, and environmental setting from which the person comes; family circumstances; current living situation; employment history; social, ethnic, cultural factors; and childhood history.

3. A direct psychiatric evaluation to be completed by a physician or psychiatrist to include a mental status examination which includes behavioral descriptions, including symptoms, not summary conclusions, and concise evaluation of cognitive functioning. A diagnosis, made by the physician or psychiatrist, shall be recorded in the clinical record, with a minimum of Axes I, II, and III, from the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, Washington, DC, American Psychiatric Association, 1987, which is incorporated by reference and may be obtained from the American Psychiatric Association, 1400 K Street, N.W., Washington, DC 20005.

(e) Laboratory Work. Laboratory work and other diagnostic procedures deemed necessary shall be performed as ordered by the physician or psychiatrist.

(3) Medical Care.

(a) The development of medical care policies and procedures shall be the responsibility of the psychiatrist or physician. The policies and procedures for medical care shall include the procedures that may be initiated by a registered nurse in order to alleviate a life threatening situation. Medication or medical treatment shall be administered upon direct order from a physician or psychiatrist, and orders for medications and treatments shall be written and signed by the physician or psychiatrist.

(b) There shall be no standing orders for any medication used primarily for the treatment of mental illness.

(c) Every order given by telephone shall be received and recorded immediately only by a registered nurse with the physician’s or psychiatrist’s name, and signed by the physician or psychiatrist within 24 hours. Such telephone orders shall include a progress note that an order was made by telephone, the content of the order, justification, time and date.

(d) Physical, medical and nursing care standards shall provide for continuity and follow-up of acute medical problems.

(4) Service Implementation Plan. A service implementation plan shall be initiated by the service plan manager with documented input from the person receiving services and signed by the person receiving services, the responsible physician, psychiatrist, or a staff member privileged by policies and procedures within 24 hours of the individual’s admission. The CSU shall develop a service implementation plan that has objectives and action steps written for the person in behavioral terms. The objectives shall be related directly to one or more goals in the person’s comprehensive service plan, if there is one. The plan shall be fully developed within 5 days of admission and must contain short-term treatment objectives stated in behavioral terms relative to the long-term view and goals in the comprehensive service plan, if there is one, an aftercare plan, and a description of the type and frequency of services to be provided in relation to treatment objectives. A copy of the service implementation plan shall be provided to the person receiving services and his guardian as provided for by law.

(5) Required CSU Services.

(a) Each CSU shall provide the following services on a 24-hour-a-day, 7-days-a-week basis:

1. Emergency reception;

2. Evaluation;

3. Observation;

4. Crisis counseling;

5. Therapeutic activities, including recreational, educational, and social, whose intent is to involve the individual in reality-oriented events and interpersonal interactions shall be provided 3-hours-a-day, 7-days-a-week, with participation and non-participation documented in the individual’s clinical record; and

6. Referral to other service components of a mental health agency, a private care facility, or another appropriate care agency.

(b) Routine Activities. Basic routine activities for persons admitted to a CSU shall be delineated in program policies and procedures which shall be available to all personnel. The daily activities 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 individuals or the group change. Basic daily routine shall be coordinated with special requirements of the service implementation plan. A schedule of daily activities shall be posted or otherwise available to all persons receiving services.

(c) Off premises activities by two or more persons being served are not permitted except in cases as documented in the individual’s clinical record pursuant to subsection 65E-12.106(24) of this Rule.

(d) Continuity of Care.

1. Discharge Preparation. Prior to discharge or departure from the CSU, the staff with the consent of the person receiving services shall work with the individual’s support system including family, friends, employers and case manager, as appropriate, to assure that all efforts are made to prepare the individual for returning to a less restrictive setting.

2. Referral Services. All CSUs shall develop and maintain written referral agreements.

(e) Referral to Hospital Inpatient Care. The CSU shall have access to a hospital inpatient unit to assure that individuals being referred are admitted as soon as necessary.

(f) Transportation. The CSU shall provide or have access to transportation to a hospital inpatient unit on an emergency basis when necessary.

(g) Laboratory and Radiology Services.

1. Requirement. The CSU shall provide or contract with licensed laboratory and radiology services commensurate with the needs of the persons receiving services.

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

b. Orders. All laboratory tests and radiology services shall be ordered by a physician or psychiatrist.

c. Records. All laboratory and radiology reports shall be filed in the clinical record.

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

2. Contracts. When the CSU depends on an outside laboratory or radiology clinic 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 CSU director or administrator.

(6) Space. Each person receiving services shall be provided a minimum of 175 square feet of usable client space within the CSU. Bedrooms shall be spacious and attractive, and activity rooms or space shall be provided.

(7) Locked Doors. CSU facilities shall be locked to provide reasonable control over access to and egress from the unit and emergency reception areas. When individuals are moved to other areas, the pathways shall also be locked or have adequate control provisions to prevent elopement. Such controlled passageways shall include access to the emergency reception area, unit proper, off unit doorways, and recreational areas. All unit door locks shall employ a common key for rapid access in emergency situations with quick releasing or single-turn mechanisms.

Specific Authority 394.457(5), 394.879(1), (2) FS. Law Implemented 394.459(2), 394.463, 394.465, 394.875, 394.879(1) FS. History–New 2-27-86, Amended 7-14-92, Formerly 10E-12.107, Amended 9-1-98.