Certain subsections of Rule 65E-5.100 defining terms are being repealed because they are redundant to statute. The repealed subsections (2), (4), (16), and (17) merely reference definitions found in Sections 394.455(1), 394.4573(1)(b), 394.455(28) ...

DEPARTMENT OF CHILDREN AND FAMILY SERVICES
Mental Health Program

RULE NO.: RULE TITLE:
65E-5.100: Definitions
65E-5.110: Delegation of Authority
65E-5.120: Forms
65E-5.1302: Admissions to State Treatment Facilities
65E-5.1303: Discharge from Receiving and Treatment Facilities
65E-5.1304: Discharge Policies of Receiving and Treatment Facilities
65E-5.1305: Discharge from a State Treatment Facility
65E-5.1703: Emergency Treatment Orders
PURPOSE AND EFFECT: Certain subsections of Rule 65E-5.100 defining terms are being repealed because they are redundant to statute. The repealed subsections (2), (4), (16), and (17) merely reference definitions found in Sections 394.455(1), 394.4573(1)(b), 394.455(28) and 394.455(29), F.S., respectively. Subsection (6), which defines emergency treatment orders (ETOs) is being revised to clarify that ETOs for seclusion and restraint are to be addressed in subsection 65E-5.180(7), F.A.C.; while ETOs for psychotherapeutic medications are to be addressed in Rule 65E-5.1703, F.A.C. The remaining definitions in Rule 65E-5.110, F.A.C., are being renumbered accordingly.
Rule 65E-5.110, F.A.C., is being repealed because it is not mandated by statute and there are no adverse consequences to repeal. The rule requires that delegation of a facility administrator’s authority be done in writing, except routine delegations which must be incorporated in facility policies and procedures. This is a management issue that should be left to the discretion of facilities.
Rule 65E-5.120, F.A.C., is being repealed because it is not mandated by statute and there are no adverse consequences to repeal. The rule merely provides information and does not create requirements. Subsection (3) of Rule 65E-5.1302, F.A.C., is being deleted because it merely restates a requirement found in Section 394.469, F.S.
Rule 65E-5.1303, F.A.C., is being expanded to include the provisions currently found in Rules 65E-5.1304 and 65E-5.1305, F.A.C.; the latter two rules are being repealed. Thus the provisions of these three rules are effectively being consolidated into a single rule, reducing the total number of rules in effect. All of these Rules 65E-5.1303, 65E-5.1304, and 65E-5.1305, F.A.C., relate to the same topic (discharge planning). There are no substantive changes to these rules.
Rule 65E-5.1703, F.A.C., is being amended to clarify that the requirements for an emergency treatment order (ETO) are different from the requirements for seclusion and restraint. The ETO requirements are addressed in Rule 65E-5.1703, F.A.C. The seclusion and restraint requirements are contained in subsection (7) of Rule 65E-5.180, F.A.C., which is not being amended. This change clarifies and simplifies reporting requirements for service providers.
SUBJECT AREA TO BE ADDRESSED: Mental health services.
RULEMAKING AUTHORITY: 394.457(5), 394.46715 FS.
LAW IMPLEMENTED: 394.455, 394.457, 394.4573, 394.459(2), 394.459(3), 394.459(11), 394.4598, 394.460, 394.4625, 394.463(2)(f), 394.4655, 394.467, 394.468, 394.469 FS.
IF REQUESTED IN WRITING AND NOT DEEMED UNNECESSARY BY THE AGENCY HEAD, A RULE DEVELOPMENT WORKSHOP WILL BE NOTICED IN THE NEXT AVAILABLE FLORIDA ADMINISTRATIVE WEEKLY.
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE DEVELOPMENT AND A COPY OF THE PRELIMINARY DRAFT, IF AVAILABLE, IS: Joe Anson, MSW, Baker Act & Marchman Act Policy Director Policy & Planning, Section Substance Abuse & Mental Health Program Office Department of Children & Families, 1317 Winewood Blvd., Bldg 6, #209, Tallahassee, FL 32399, [phone], [e-mail]

THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT IS:

65E-5.100 Definitions.

As used in this chapter the following words and phrases have the following definitions:

(1) No change.

(2) Administrator means a person as defined in Section 394.455(1), F.S.

(2)(3) Assessment means the systematic collection and integrated review of individual-specific data. It is the process by which individual-specific information such as examinations and evaluations are gathered, analyzed, monitored and documented to develop the person’s individualized plan of treatment and to monitor recovery. Assessment specifically includes efforts to identify the person’s key medical and psychological needs, competency to consent to treatment, patterns of a co-occurring mental illness and substance abuse, as well as clinically significant neurological deficits, traumatic brain injury, organicity, physical disability, developmental disability, need for assistive devices, and physical or sexual abuse or trauma.

(4) Case manager means a person as defined in Section 394.4573(1)(b), F.S.

(3)(5) Discharge plan means the plan developed with and by the person which sets forth how the person will meet his or her needs, including living arrangements, transportation, aftercare, physical health, and securing needed psychotherapeutic psychotropic medications for the post-discharge period of up to 21 days.

(4)(6) Emergency treatment order (ETO) means a the written emergency order for psychotherapeutic psychotropic medications, seclusion, and restraints ordered by a physician in response to a person presenting an imminent danger to self or others, and as described in Rule 65E-5.1703, F.A.C.; or a written emergency order for seclusion or restraint, as described in subsection (7) of Rule 65E-5.180, F.A.C., of this rule chapter.

(5)(7) Examination means the integration of the physical examination required under Section 394.459(2), F.S., with other diagnostic activities to determine if the person is medically stable and to rule out abnormalities of thought, mood, or behavior that mimic psychiatric symptoms but are due to non-psychiatric medical causes such as disease, infection, injury, toxicity, or metabolic disturbances. Examination includes the identification of person-specific risk factors for treatment such as elevated blood pressure, organ dysfunction, substance abuse, or trauma.

(6)(8) Health care proxy means a competent adult who has not been expressly designated by an advance directive to make health care decisions for a particular incapacitated individual, but is authorized pursuant to Section 765.401, F.S., to make health care decisions for such individual.

(7)(9) Health care surrogate means any competent adult expressly designated by a principal’s advance directive to make health care decisions on behalf of the principal upon the principal’s incapacity.

(8)(10) Person means an individual of any age, unless statutorily restricted, with a mental illness served in or by a mental health facility or service provider.

(9)(11) Personal Safety Plan is a form used to document information regarding calming strategies that the person identifies as being helpful in avoiding a crisis. The plan also lists triggers that are identified that may signal or lead to agitation or distress.

(10)(12) Pro re nata (PRN) means an individualized order for the care of an individual person which is written after the person has been seen by the practitioner, which order sets parameters for attending staff to implement according to the circumstances set out in the order. A PRN order shall not be used as an emergency treatment order.

(11)(13) Protective medical devices mean a specific category of medical restraint that includes devices, or combinations of devices, to restrict movement for purposes of protection from falls or complications of physical care, such as geri-chairs, posey vests, mittens, belted wheelchairs, sheeting, and bed rails. The requirements for the use and documentation of use of these devices are for specific medical purposes rather than for behavioral control.

(12)(14) Recovery Plan may also be referred to as a “service plan” or “treatment plan.” A recovery plan is a written plan developed by the person and his or her recovery team to facilitate achievement of the person's recovery goals. This plan is based on assessment data, identifying the person’s clinical, rehabilitative and activity service needs, the strategy for meeting those needs, documented treatment goals and objectives, and documented progress in meeting specified goals and objectives.

(13)(15) Recovery Team may also be referred to as “service team” or “treatment team.” A recovery team is an assigned group of individuals with specific responsibilities identified on the recovery plan who support and facilitate a person’s recovery process. Team members may include the person, psychiatrist, guardian/guardian advocate, community case manager, family member, peer specialist and others as determined by the person’s needs and preferences.

(16) Restraint for behavior management purposes is defined in Section 394.455(28)(a), F.S. A drug used as a restraint is defined in Section 394.455(28)(b), F.S. Physically holding a person during a procedure to forcibly administer psychotropic medication is a physical restraint.

(17) Seclusion for behavior management purposes is defined in Section 394.455(29), F.S.

(14)(18) Seclusion and Restraint Oversight Committee is a group of people at an agency or facility that monitors the use of seclusion and restraint at the facility. This committee is intended to assist in the reduction of seclusion and restraint use at the agency or facility. Membership includes, but is not limited to, the facility administrator/designee, medical staff, quality assurance staff, and a peer specialist or advocate, if employed by the facility or otherwise available. If no such person is employed by the facility, an external peer specialist or advocate may be appointed.

(15)(19) Standing order means a broad protocol or delegation of medical authority that is generally applicable to a group of persons, hence not individualized. As limited by this chapter, it prohibits improper delegations of authority to staff that are not authorized by the facility, or not permitted by practice licensing laws, to independently make such medical decisions; such as decisions involving determination of need, medication, routes, dosages for psychotherapeutic psychotropic medication, or use of restraints or seclusion upon a person.

Rulemaking Specific 394.457(5), 394.46715 FS. Law Implemented 394.455, 394.455(1), 394.457, 394.4573(1)(b), 394.459(2), 394.4625, 394.4655, 394.467, 765.101, 765.401 FS. History–New 11-29-98, Amended 4-4-05, 1-8-07, 5-7-08,________.

 

65E-5.110 Delegation of Authority.

Rulemaking Specific Authority 394.457(5), 394.46715 FS. Law Implemented 394, 394.457(5)(a), 394.4655 FS. History–New 11-29-98, Amended 4-4-05, Repealed________.

 

65E-5.120 Forms.

Rulemaking Specific Authority 394.457(5) FS. Law Implemented 394.457(5) FS. History–New 11-29-98, Amended 4-4-05, Repealed ________.

 

65E-5.1302 Admissions to State Treatment Facilities.

(1) through (2) No change.

(3) If a person awaiting transfer to a state treatment facility improves to the degree that he or she no longer meets the criteria for involuntary placement or that such transfer is unnecessary, the receiving facility shall discharge the person as specified in Section 394.469, F.S.

Rulemaking Specific Authority 394.457(5) FS. Law Implemented 394.4573(2), 394.469 FS. History–New 11-29-98, Amended 4-4-05, ________.

 

65E-5.1303 Discharge from Receiving and Treatment Facilities.

(1) Before discharging a person who has been admitted to a facility, the person shall be encouraged to actively participate in treatment and discharge planning activities and shall be notified in writing of his or her right to seek treatment from the professional or agency of the person’s choice and the person shall be assisted in making appropriate discharge plans. The person shall be advised that, pursuant to Section 394.460, F.S., no professional is required to accept persons for psychiatric treatment.

(2) Discharge planning shall include and document consideration of the following:

(a) The person’s transportation resources;

(b) The person’s access to stable living arrangements;

(c) How assistance in securing needed living arrangements or shelter will be provided to individuals who are at risk of re-admission within the next 3 weeks due to homelessness or transient status and prior to discharge shall request a commitment from a shelter provider that assistance will be rendered;

(d) Assistance in obtaining a timely aftercare appointment for needed services, including continuation of prescribed psychotherapeutic psychotropic medications. Aftercare appointments for psychotherapeutic psychotropic medication and case management shall be requested to occur not later than 7 days after the expected date of discharge; if the discharge is delayed, the facility will notify the aftercare provider. The facility shall coordinate with the aftercare service provider and shall document the aftercare planning;

(e) To ensure a person’s safety and provide continuity of essential psychotherapeutic psychotropic medications, such prescribed psychotherapeutic psychotropic medications, prescriptions, or multiple partial prescriptions for psychotherapeutic psychotropic medications, or a combination thereof, shall be provided to a person when discharged to cover the intervening days until the first scheduled psychotherapeutic psychotropic medication aftercare appointment, or for a period of up to 21 calendar days, whichever occurs first. Discharge planning shall address the availability of and access to prescribed psychotherapeutic psychotropic medications in the community;

(f) The person shall be provided education and written information about his or her illness and psychotherapeutic psychotropic medications including other prescribed and over-the-counter medications, the common side-effects of any medications prescribed and any adverse clinically significant drug-to-drug interactions common between that medication and other commonly available prescribed and over-the-counter medications;

(g) The person shall be provided contact and program information about and referral to any community-based peer support services in the community;

(h) The person shall be provided contact and program information about and referral to any needed community resources;

(i) Referral to substance abuse treatment programs, trauma or abuse recovery focused programs, or other self-help groups, if indicated by assessments; and

(j) The person shall be provided information about advance directives, including how to prepare and use the advance directives.

(3) Should a person in a receiving or treatment facility meet the criteria for involuntary outpatient placement rather than involuntary inpatient placement, the facility administrator may initiate such involuntary outpatient placement, pursuant to Section 394.4655, F.S., and Rule 65E-5.285, F.A.C., of this rule chapter.

(4) Receiving and treatment facilities shall have written discharge policies and procedures which shall contain:

(a) Agreements or protocols for transfer and transportation arrangements between facilities;

(b) Protocols for assuring that current medical and legal information, including day of discharge medication administered, is transferred before or with the person to another facility; and

(c) Policy and procedures which address continuity of services and access to necessary psychotherapeutic medications.

(5) When a state mental health treatment facility has established an anticipated discharge date for discharge to the community which is more than seven days in advance of the person’s actual discharge, at least 7 days notice must be given to the community agency which has been assigned case management responsibility for the implementation of the person’s discharge plan. When an impending discharge is known 7 days or less prior to the discharge, the staff of the state mental health treatment facility shall give verbal and written notice of the impending discharge to the community case management agency within 1 working day after the decision to discharge is made. Recommended form CF-MH 7001, Jan. 98, “State Mental Health Facility Discharge Form,” which is incorporated by reference, may be used for this purpose.

(6) On the day of discharge from a state mental health treatment facility, the referring physician, or his or her designee, within state law and approved facility protocols and practice guidelines shall immediately notify the community aftercare provider or entity responsible for dispensing or administering medications. Recommended form CF-MH 7002, “Physician to Physician Transfer,” as referenced in subsection 65E-5.1302(2), F.A.C., may be used for this purpose.

Rulemaking Specific Authority 394.457(5), 394.46715 FS. Law Implemented 394.4573(2), 394.459(11), 394.460, 394.4655, 394.468 FS. History–New 11-29-98, Amended 4-4-05,________.

 

65E-5.1304 Discharge Policies of Receiving and Treatment Facilities.

Rulemaking Specific Authority 394.457(5) FS. Law Implemented 394.459(11) FS. History–New 11-29-98, Amended 4-4-05, Repealed________.

 

65E-5.1305 Discharge from a State Treatment Facility.

Rulemaking Specific Authority 394.457(5) FS. Law Implemented 394.4573, 394.459(11), 394.468 FS. History–New 11-29-98, Amended 4-4-05, Repealed________.

 

65E-5.1703 Emergency Treatment Orders for the Administration of Psychotherapeutic Medications.

(1) An emergency treatment order shall be consistent with the least restrictive treatment interventions, including the emergency administration of psychotherapeutic psychotropic medications or the emergency use of restraints or seclusion. Use of seclusion or restraint in an emergency situation is addressed in subsection 65E-5.180(7), Florida Administrative Code and is not addressed in this rule. This rule pertains only to the use of psychotherapeutic medication in an emergency situation.

(a) The issuance of an emergency treatment order requires a physician’s review of the person’s condition for causal medical factors, such as insufficiency of psychotherapeutic psychotropic medication blood levels, as determined by drawing a blood sample; medication interactions with psychotherapeutic psychotropic or other medications; side effects or adverse reactions to medications; organic, disease or medication based metabolic imbalances or toxicity; or other biologically based or influenced symptoms.

(b) All emergency treatment orders may only be issued written by a physician licensed under the authority of Chapter 458 or 459, F.S.

(c) The physician must review, integrate and address such metabolic imbalances in the issuance of an emergency treatment order.

(d) The use of an emergency treatment order must be consistent with the least restrictive treatment requirements, and for persons must include:,

1. aAbsent more appropriate interventions, an emergency treatment order is for immediate administration of rapid response psychotherapeutic psychotropic medications to a person to expeditiously treat symptoms, that if left untreated, present an immediate danger to the safety of the person or others.

2. Absent more appropriate medical interventions, an emergency treatment order for restraint or seclusion of a person to expeditiously treat symptoms that if left untreated, present an imminent danger to the safety of the person or others.

(d) An emergency treatment order, as used in this chapter, excludes the implementation of individualized behavior management programs as described and authorized in Rule 65E-5.1602, F.A.C., of this rule chapter.

(2) An emergency treatment order for psychotherapeutic psychotropic medication supersedes the person’s right to refuse psychotherapeutic psychotropic medication if based upon the physician’s assessment that the individual is not capable of exercising voluntary control over his or her own symptomatic behavior and that these uncontrolled symptoms and behavior are an imminent danger to the person or to others in the facility. When emergency treatment with psychotherapeutic psychotropic medication is ordered for a minor or an incapacitated or incompetent adult, facility staff shall document attempts to promptly contact the guardian, guardian advocate, or health care surrogate or proxy to obtain express and informed consent for the treatment in advance of administration where possible and if not possible, as soon thereafter as practical.

(3) The physician’s initial order for emergency treatment may be by telephone but such a verbal order must be reduced to writing upon receipt and signed by a physician within 24 hours.

(4) Each emergency treatment order shall only be valid and shall be authority for emergency treatment only for a period not to exceed 24 hours.

(5) The need for each emergency treatment order must be documented in the person’s clinical record in the progress notes and in the section used for physician’s orders and must describe the specific behavior which constitutes a danger to the person or to others in the facility, and the nature and extent of the danger posed.

(6) Upon the initiation of an emergency treatment order the facility shall, within two court working days, petition the court for the appointment of a guardian advocate pursuant to the provisions of Section 394.4598, F.S., to provide express and informed consent, unless the person voluntarily withdraws a revocation of consent or requires only a single emergency treatment order for emergency treatment.

(7) If a second emergency treatment order is issued for the same person within any 7 day period, the petition for the appointment of a guardian advocate pursuant to the provisions of Section 394.4598, F.S., to provide express and informed consent shall be filed with the court within 1 court working day.

(8) While awaiting court action, treatment may be continued without the consent of the person, but only upon the daily written emergency treatment order of a physician who has determined that the person’s behavior each day during the wait for court action continues to present an immediate danger to the safety of the person or others and who documents the nature and extent of the emergency each day of the specific danger posed. Such orders may not be written in advance of the demonstrated need for same.

(9) To assure the safety and rights of the person, and since emergency treatment orders by a physician absent express and informed consent are permitted only in an emergency, any use of psychotherapeutic psychotropic medications other than rapid response psychotherapeutic psychotropic medications requires a detailed and complete justification for the use of such medication. Both the nature and extent of the imminent emergency and any orders for the continuation of that medication must be clearly documented daily as required above.

Rulemaking Specific Authority 394.457(5) FS. Law Implemented 394.459(3), 394.4598, 394.463(2)(f), 458, 459 FS. History–New 11-29-98, Amended 4-4-05,________.