TITLE 25.HEALTH SERVICES

Part 2. TEXAS DEPARTMENT OF MENTAL HEALTH AND MENTAL RETARDATION

Chapter 405. CLIENT (PATIENT) CARE

Subchapter A. PRESCRIBING OF MEDICATION--MENTAL HEALTH SERVICES

25 TAC §§405.1 - 405.18

(Editor's note: The text of the following sections proposed for repeal will not be published. The sections may be examined in the offices of the Texas Department of Mental Health and Mental Retardation or in the Texas Register office, Room 245, James Earl Rudder Building, 1019 Brazos Street, Austin.)

The Texas Department of Mental Health and Mental Retardation (TDMHMR) proposes the repeal of §§405.1 - 405.18 of Chapter 405, Subchapter A, governing prescribing of medication--mental health services. The repealed subchapter provided requirements for prescribing psychoactive medications for patients receiving services in state mental health programs in Texas. The repealed Chapter 405, Subchapter A, governing prescribing of medication--mental health services will be replaced by new Chapter 415, Subchapter A, governing prescribing of psychoactive medication, which are contemporaneously proposed in this issue of the Texas Register .

The proposed new sections delineate policy and establish uniform operating standards for prescribing psychoactive medication in both campus-based and community programs operated or contracted by the Texas Department of Mental Health and Mental Retardation.

The contemporaneous repeal and adoption of these subchapters would fulfill the requirements of the Texas Government Code, §2001.039, concerning the periodic review of agency rules.

Kevin Nolting, Acting Chief Financial Officer, has determined that for each year of the first five-year period that the proposed repeal is in effect, enforcing or administering the repeal does not have foreseeable implications relating to costs or revenues of state or local governments.

Steven P. Shon, TDMHMR Medical Director, has determined that for each year of the first five years the proposed repeal is in effect, the public benefit will be the promulgation of requirements that ensure a uniform standard of care for individuals receiving medications under the ages of TDMHMR and without reference to service setting. It is anticipated that there would be no additional economic cost to persons required to comply with the proposed repeal because the new sections does not impose requirements that differ substantively from those already required in operations or through contract.

It is anticipated that the proposed repeal will not affect a local economy because the new sections do not significantly alter the requirements already followed in operations or articulated in contract.

It is anticipated that the proposed repeal will not have an adverse economic effect on small businesses or micro-businesses because the new sections do not place requirements on small or micro-businesses.

Comments concerning the proposed repeal may be submitted in writing to Linda Logan, Director, Policy Development, Texas Department of Mental Health and Mental Retardation, P.O. Box 12668, Austin, Texas 78711-2668; by fax to (512) 206-4750; or by e-mail to policy.co@mhmr.state.tx.us within 30 days of publication.

A hearing to accept oral and written testimony from members of the public concerning this and other related proposals has been scheduled for Thursday, 9:00 a.m., June 17, 2004, in the TDMHMR Central Office Auditorium, Building 2, 909 West 45th Street, Austin, Texas. Persons requiring an interpreter for the deaf or hearing impaired should contact the department's Central Office operator at least 72 hours prior to the hearing at TDD (512) 206-5330. Persons requiring other accommodations for a disability should notify Sharayla Jones at least 72 hours prior to the hearing at (512) 206-5283 or at the TDY phone number of Texas Relay, 1-800-735-2988.

The repeal is proposed under Texas Health and Safety Code (THSC), §532.015(a), which provides the Texas Mental Health and Mental Retardation Board with broad rulemaking authority; THSC, §571.006, which provides the board with the authority to adopt rules as necessary for the proper and efficient treatment of persons with mental illness; THSC, §577.010, which provides the board with the authority to adopt rules and standards for the proper care and treatment of patients in community-based crisis stabilization services and crisis residential services; and THSC, §534.052(a), which provides the board with the authority to adopt rules and standards necessary to ensure adequate provision of community-based mental health services through the local mental health authority.

The proposed repeal affects THSC §§534.052, 567.024, 571.006, 574.101 et seq., 576.024, and 577.010.

§405.1.Purpose.

§405.2.Application.

§405.3.Definitions.

§405.4.Foundation.

§405.5.Minimum Standards in All Service Settings for Diagnosis and Documentation of Diagnosis When Initiating Medication.

§405.6.Patient Evaluation and Review in Inpatient and Crisis Stabilization Unit (CSU) Settings.

§405.7.General Guidelines for Prescribing in All Service Settings.

§405.8.General Guidelines for All Service Settings: Records and Monitoring of Prescribing and Administration Procedures.

§405.9.General Guidelines for All Service Settings: Ongoing Evaluation of Patients Taking Prescription Medications (See Also §405.14 of this title (relating to Required Assessments for Patients Receiving Medication in Community-based Services (CBS)).

§405.10.Prescribing Guidelines for All Service Settings: Side Effects and Adverse Effects, Medication Toxicity, Errors in Medication Administration.

§405.11.Special Considerations in All Service Settings: Patients with Dyskinesias, including Tardive Dyskinesia.

§405.12.Additional Considerations in All Service Settings: Special Populations.

§405.13.Minimum Requirements for Auditing the Prescription of Psychotropic Medication for Inpatients in State Hospitals and Related Procedures.

§405.14.Required Assessments for Patients Receiving Medication in Community-based Services (CBS).

§405.15.Dosage of Psychotropic Medications for Patients Receiving Community-based Services.

§405.16.Administration of Medications to Patients Receiving Community-based Services (CBS).

§405.17.Distribution.

§405.18.Review.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State on May 28, 2004.

TRD-200403631

Rodolfo Arredondo

Chairman, Texas MHMR Board

Texas Department of Mental Health and Mental Retardation

Earliest possible date of adoption: July 11, 2004

For further information, please call: (512) 206-4516


Subchapter B. PRESCRIBING OF PSYCHOTROPIC MEDICATION--MENTAL RETARDATION FACILITIES

25 TAC §§405.25 - 405.38

(Editor's note: The text of the following sections proposed for repeal will not be published. The sections may be examined in the offices of the Texas Department of Mental Health and Mental Retardation or in the Texas Register office, Room 245, James Earl Rudder Building, 1019 Brazos Street, Austin.)

The Texas Department of Mental Health and Mental Retardation (TDMHMR) proposes the repeal of §§405.25 - 405.38 of Chapter 405, Subchapter B, governing prescribing of psychotropic medication--mental retardation facilities. The repeal of the sections and adoption of new sections would provide updated requirements for prescribing psychoactive medications for patients receiving services in state mental health programs in Texas. The repealed Chapter 405, Subchapter B, governing prescribing of psychotropic medication--mental retardation facilities would be replaced by new Chapter 415, Subchapter A, governing prescribing of psychoactive medications, which are contemporaneously proposed in this issue of the Texas Register .

The proposed new sections delineate policy and establish uniform operating standards for prescribing psychoactive medication in both campus-based and community programs operated or contracted by the Texas Department of Mental Health and Mental Retardation.

The contemporaneous repeal and adoption of these subchapters would fulfill the requirements of the Texas Government Code, §2001.039, concerning the periodic review of agency rules.

Kevin Nolting, Acting Chief Financial Officer, has determined that for each year of the first five-year period that the proposed repeal is in effect, enforcing or administering the repeal does not have foreseeable implications relating to costs or revenues of state or local governments.

Steven P. Shon, TDMHMR Medical Director, has determined that for each year of the first five years the proposed repeal is in effect, the public benefit will be the promulgation of requirements that ensure a uniform standard of care for individuals receiving medications under the ages of TDMHMR and without reference to service setting. It is anticipated that there would be no additional economic cost to persons required to comply with the proposed repeal because the new sections do not impose requirements that differ substantively from those already required in operations or through contract.

It is anticipated that the proposed repeal will not affect a local economy because the new sections do not significantly alter the requirements already followed in operations or articulated in contract.

It is anticipated that the proposed repeal will not have an adverse economic effect on small businesses or micro-businesses because the new sections do not place requirements on small or micro-businesses.

Comments concerning the proposed repeal may be submitted in writing to Linda Logan, Director, Policy Development, Texas Department of Mental Health and Mental Retardation, P.O. Box 12668, Austin, Texas 78711-2668; by fax to (512) 206-4750; or by e-mail to policy.co@mhmr.state.tx.us within 30 days of publication.

A hearing to accept oral and written testimony from members of the public concerning this and other related proposals has been scheduled for Thursday, June 17, 2004, 9:00 a.m., in the TDMHMR Central Office Auditorium, Building 2, 909 West 45th Street, Austin, Texas. Persons requiring an interpreter for the deaf or hearing impaired should contact the department's Central Office operator at least 72 hours prior to the hearing at TDD (512) 206-5330. Persons requiring other accommodations for a disability should notify Sharayla Jones at least 72 hours prior to the hearing at (512) 206-5283 or at the TDY phone number of Texas Relay, 1-800-735-2988.

The repeal is proposed under Texas Health and Safety Code (THSC), §532.015(a), which provides the Texas Mental Health and Mental Retardation Board with broad rulemaking authority; THSC, §571.006, which provides the board with the authority to adopt rules as necessary for the proper and efficient treatment of persons with mental illness; THSC, §577.010, which provides the board with the authority to adopt rules and standards for the proper care and treatment of patients in community-based crisis stabilization services and crisis residential services; and THSC, §534.052(a), which provides the board with the authority to adopt rules and standards necessary to ensure adequate provision of community-based mental health services through the local mental health authority.

The proposed repeal affects THSC §§534.052, 567.024, 571.006, 574.101 et seq., 576.024, and 577.010.

§405.25.Purpose.

§405.26.Application.

§405.27.Definitions.

§405.28.General Principles.

§405.29.Diagnosis and Documentation of Diagnosis When Initiating Psychotropic Medication.

§405.30.Prescribing Parameters.

§405.31.Emergency Use of Psychotropic Medication.

§405.32.Initiation and Ongoing Evaluation of Medication Response and Clinical Condition.

§405.33.Individuals with Medication-Related Dyskinesia, Including Tardive Dyskinesia.

§405.34.Prescribing of Psychotropic Medication for Special Populations.

§405.35.Prescribing of Psychotropic Medication for New Admissions.

§405.36.Use of Medication Commonly Considered Psychotropic for Nonpsychiatric and Nonbehavioral Conditions.

§405.37.Quality Improvement.

§405.38.Distribution.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State on May 28, 2004.

TRD-200403630

Rodolfo Arredondo

Chairman, Texas MHMR Board

Texas Department of Mental Health and Mental Retardation

Earliest possible date of adoption: July 11, 2004

For further information, please call: (512) 206-4516


Subchapter FF. CONSENT TO TREATMENT WITH PSYCHOACTIVE MEDICATION

25 TAC §§405.801 - 405.809

(Editor's note: The text of the following sections proposed for repeal will not be published. The sections may be examined in the offices of the Texas Department of Mental Health and Mental Retardation or in the Texas Register office, Room 245, James Earl Rudder Building, 1019 Brazos Street, Austin.)

The Texas Department of Mental Health and Mental Retardation (TDMHMR) proposes the repeal of §§405.801 - 405.809 of Chapter 405, Subchapter FF, governing consent to treatment with psychoactive medication. The repealed sections provided requirements for obtaining consent to treatment with psychoactive medications from patients receiving services in inpatient mental health programs in Texas. The repealed subchapter will be replaced by Chapter 414, Subchapter I, governing the same matters, which is contemporaneously proposed in this issue of the Texas Register .

Kevin Nolting, Acting Chief Financial Officer, has determined that for each year of the first five-year period that the proposed repeal is in effect, enforcing or administering the repeal does not have foreseeable implications relating to costs or revenues of state or local governments.

Steven P. Shon, TDMHMR Medical Director, has determined that for each year of the first five years the proposed repeal is in effect, the public benefit will the promulgation of updated requirements for obtaining patient consent to treatment with psychoactive medications. There is no anticipated economic cost to small businesses or micro-businesses which are required to comply with the repeal of this subchapter. It is not anticipated that there will be any additional economic cost to persons required to comply with the proposed repeal. It is not anticipated that the repeal will affect a local economy.

Comments concerning the proposed repeal may be submitted in writing to Linda Logan, Director, Policy Development, Texas Department of Mental Health and Mental Retardation, P.O. Box 12668, Austin, Texas 78711-2668; by fax to (512) 206-4750; or by e-mail to policy.co@mhmr.state.tx.us within 30 days of publication.

A hearing to accept oral and written testimony from members of the public concerning this and other related proposals has been scheduled for Thursday, June 17, 2004, 10:30 a.m. in the TDMHMR Central Office Auditorium, Building 2, 909 West 45th Street, Austin, Texas. Persons requiring an interpreter for the deaf or hearing impaired should contact the department's Central Office operator at least 72 hours prior to the hearing at TDD (512) 206-5330. Persons requiring other accommodations for a disability should notify Sharayla Jones at least 72 hours prior to the hearing at (512) 206-5283 or at the TDY phone number of Texas Relay, 1-800-735-2988.

The repeal is proposed under Texas Health and Safety Code (THSC), §532.015(a), which provides the Texas Mental Health and Mental Retardation Board with broad rulemaking authority; THSC, §571.006, which provides the board with the authority to adopt rules as necessary for the proper and efficient treatment of persons with mental illness; THSC, §577.010, which provides the board with the authority to adopt rules and standards for the proper care and treatment of patients in private mental health facilities, community-based crisis stabilization services, and crisis residential services; and THSC, §534.052(a), which provides the board with the authority to adopt rules and standards necessary to ensure adequate provision of community-based mental health services through the local mental health authority.

The repeal affects THSC, §§241.001 et seq., 534.052, 567.024, 571.006, 574.101 et seq., 576.024, 577.001 et seq., and Texas Probate Code, §770A.

§405.801.Purpose.

§405.802.Application.

§405.803.Definitions.

§405.804.Information Required To Be Given.

§405.805.Documentation of Informed Consent.

§405.806.Patients Admitted under Texas Statutes.

§405.807.Patients Committed under Texas Statutes.

§405.808.Emergencies.

§405.809.Order Authorizing Administration of Psychoactive Medication.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State on May 28, 2004.

TRD-200403628

Rodolfo Arredondo

Chairman, Texas MHMR Board

Texas Department of Mental Health and Mental Retardation

Earliest possible date of adoption: July 11, 2004

For further information, please call: (512) 206-4516


Chapter 414. PROTECTION OF CONSUMERS AND CONSUMER RIGHTS

Subchapter I. CONSENT TO TREATMENT WITH PSYCHOACTIVE MEDICATION--MENTAL HEALTH SERVICES

25 TAC §§414.401 - 414.415

The Texas Department of Mental Health and Mental Retardation (TDMHMR) proposes new §§414.401 - 414.415 of Chapter 414, Subchapter I, governing consent to treatment with psychoactive medication--mental health services. The new sections would provide updated requirements for obtaining consent to treatment with psychoactive medications from patients receiving services in inpatient mental health programs in Texas. The new subchapter would replace Chapter 405, Subchapter FF, governing consent to treatment with psychoactive medication, which is contemporaneously proposed for repeal in this issue of the Texas Register .

The new subchapter would continue most of TDMHMR's existing policies with respect to obtaining consent to treatment with psychoactive medication from patients receiving inpatient services in mental health facilities. Significant changes to the existing policies include the following: The term "psychiatric emergency" would be used in place of "emergency situation." The term "medically appropriate treatment" would not be defined. Informed medication consent would not be obtained by medication class but would be required to be obtained by individual medication. The definition of "psychoactive medication" would be based on the functional effect of medication as opposed to its inclusion in a specified class of medications. The new subchapter requires the treating physician or ancillary personnel to provide the patient with an explanation of the risks, benefits, and related matters for each medication prescribed. If the explanation is provided by ancillary personnel the treating physician must confirmation the explanation within two days. The new subchapter would establish that a list of medication classes will be made available by the Office of the Medical Director, TDMHMR, and will be updated and posted on the TDMHMR web site, www.mhmr.state.tx.us (Office of the Medical Director). The new subchapter describes conditions under which a medication order by the court will designate a specific medication and not a class of medications. The new subchapter clarifies that a brief physical hold is not considered restraint provided that the individual currently exhibits behavior that meet the definition of a psychiatric emergency, the individual is currently under a court order allowing the facility to administer court-approved medication without the consent of the individual; the purpose of administering medication is to provide active treatment to reduce symptoms of a diagnosed mental illness; using medication to reduce specified symptoms of a diagnosed mental illness is standard clinical practice; the specific medication and dosage ordered can be clinically justified as in keeping with standard clinical practice and are appropriate for reduction of specified target symptoms; and the physical hold is terminated as soon as the medication is administered.

The new subchapter would include a section (§414.413, relating to Monitoring Compliance with Policies and Procedures) that requires facilities to document self-monitoring of compliance. Self-monitoring of compliance would include procedures to audit records for compliance, analyze and report audit results to staff responsible for the informed consent process, improve the performance of individual employees, contractors, and agents, and improve overall facility performance. Facilities would be required to collect information related to obtaining consent to treatment with psychoactive medication and the use of psychoactive medication in psychiatric emergencies as requested by the medical director of TDMHMR.

Pursuant to House Bill 2679 of the 78th Texas Legislature, Regular Session, it would be clarified that if an adult under a protective custody order as provided by THSC Chapter 574, Subchapter B, is a ward, the guardian of the person of the ward may consent to the administration of psychoactive medication as prescribed by the ward's treating physician regardless of the ward's expressed preferences regarding treatment with psychoactive medication. Also pursuant to House Bill 2679, the new subchapter would stipulate that psychoactive medications will not be administered to a patient committed to a mental health facility under an order for temporary or extended mental health services if the patient refuses medication except when the patient is a ward who is 18 years of age or older and the guardian of the person of the ward consents to the administration of psychoactive medication regardless of the ward's expressed preferences regarding treatment with psychoactive medication.

Kevin Nolting, Acting Chief Financial Officer, has determined that for each year of the first five-year period that the proposed new sections are in effect, enforcing or administering the sections does not have foreseeable implications relating to costs or revenues of state or local governments.

It is not anticipated that the proposed new sections will have an economic cost to small businesses or micro-businesses which are required to comply with the new sections. It is not anticipated that the sections will affect a local economy.

Steven P. Shon, TDMHMR Medical Director, has determined that for each year of the first five years the proposed new sections are in effect, the public benefit will be the promulgation of updated requirements for obtaining patient consent to treatment with psychoactive medications. It is not anticipated that there will be any additional economic cost to persons required to comply with the new sections because the new sections do not impose additional requirements on persons required to comply.

Comments concerning the proposed new sections may be submitted in writing to Linda Logan, Director, Policy Development, Texas Department of Mental Health and Mental Retardation, P.O. Box 12668, Austin, Texas 78711-2668; by fax to (512) 206-4750; or by e-mail to policy.co@mhmr.state.tx.us within 30 days of publication.

A hearing to accept oral and written testimony from members of the public concerning this and other related proposals has been scheduled for Thursday, June 17, 2004, 9:00 a.m., in the TDMHMR Central Office Auditorium, Building 2, 909 West 45th Street, Austin, Texas. Persons requiring an interpreter for the deaf or hearing impaired should contact the department's Central Office operator at least 72 hours prior to the hearing at TDD (512) 206-5330. Persons requiring other accommodations for a disability should notify Sharayla Jones at least 72 hours prior to the hearing at (512) 206-5283 or at the TDY phone number of Texas Relay, (800) 735-2988.

The new sections are proposed under Texas Health and Safety Code (THSC), §532.015(a), which provides the Texas Mental Health and Mental Retardation Board with broad rulemaking authority; THSC, §571.006, which provides the board with the authority to adopt rules as necessary for the proper and efficient treatment of persons with mental illness; THSC, §577.010, which provides the board with the authority to adopt rules and standards for the proper care and treatment of patients in private mental health facilities, community-based crisis stabilization services, and crisis residential services; and THSC, §534.052(a), which provides the board with the authority to adopt rules and standards necessary to ensure adequate provision of community-based mental health services through the local mental health authority.

The proposed new sections affect THSC, §§241.001 et seq., 534.052, 567.024, 571.006, 574.101 et seq., 576.024, 577.001 et seq., and Texas Probate Code, §770A.

§414.401.Purpose.

The purpose of this subchapter is to provide procedures for obtaining consent for treatment with psychoactive medications from patients receiving voluntary or involuntary mental health services.

§414.402.Application.

This subchapter applies to the following facilities providing inpatient mental health services:

(1) a state hospital or state center operated by the Texas Department of Mental Health or Mental Retardation (TDMHMR);

(2) a psychiatric hospital licensed under Texas Health and Safety Code (THSC), Chapter 577, and Chapter 134 of this title;

(3) an identifiable mental health service unit of a hospital licensed under THSC, Chapter 241, and Chapter 133, Subchapter A of this title;

(4) a crisis stabilization unit (CSU) licensed under THSC, Chapter 577, and Chapter 134 of this title; and

(5) facilities operated by local mental health authorities or under contract to local mental health authorities

§414.403.Definitions.

The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise:

(1) Capacity--A patient's ability to:

(A) understand the nature and consequences of a proposed treatment, including the benefits, risks, and alternatives to the proposed treatment; and

(B) make a decision whether to undergo the proposed treatment.

(2) Imminent--Ready to take place within seconds.

(3) Informed consent--Consent given by a person or the person's legally authorized representative when each of the following conditions have been met:

(A) Comprehension of information. The person giving the consent has been provided the information outlined in §414.404 of this title (relating to Information Required To Be Given) and has the capacity to give consent; and

(B) Voluntariness. The consent has been given voluntarily.

(4) Legally authorized representative (LAR)--A person authorized by law to act on behalf of an individual with regard to a matter described in this subchapter, and may include a parent, guardian, managing conservator of a minor individual, a guardian of an adult individual, or legal representative of a deceased individual.

(5) Medication class--A group of medications with similar actions and indications for use, as outlined in the department's most recent "Classes of Psychoactive Medications Determined by the Texas Department of Mental Health and Mental Retardation." A copy of which may be obtained by contacting TDMHMR, Office of Office of the Medical Director, P.O. Box 12668, Austin, TX 78711-2668, or the TDMHMR website, www.mhmr.state.tx.us.

(6) Mental health facility--A facility that can provide 24-hour residential and psychiatric services and that is:

(A) a TDMHMR mental health facility that is a state hospital or state center operated by the Texas Department of Mental Health or Mental Retardation (TDMHMR);

(B) a psychiatric hospital licensed under Texas Health and Safety Code, Chapter 577, and Chapter 134 of this title;

(C) an identifiable mental health service unit of a hospital licensed under Texas Health and Safety Code, Chapter 241, and Chapter 133, Subchapter A of this title;

(D) a crisis stabilization unit (CSU) licensed under THSC, Chapter 577, and Chapter 134; or

(E) a facility operated by a local mental health authority or under contract to a local mental health authority.

(7) Minor--A person under 18 years of age who is not and has not been married or who has not had his or her disabilities of minority removed for general purposes.

(8) Order for temporary or extended mental health services--A court-ordered commitment to mental health services Texas Health and Safety Code, §574.034 or §574.035.

(9) Psychiatric emergency--A situation in which, in the opinion of the physician, it is immediately necessary to administer medication to ameliorate the signs and symptoms of a patient's mental illness and to prevent:

(A) imminent probable death or substantial bodily harm to the patient because the patient:

(i) is threatening or attempting to commit suicide or serious bodily harm; or

(ii) is behaving in a manner that indicates that the patient is unable to satisfy the patient's need for nourishment, essential medical care, or self-protection; or

(B) imminent physical or emotional harm to others because of threats, attempts, or other acts the patient makes or commits.

(10) Psychoactive medication--Medication whose primary intended therapeutic effect is to treat or ameliorate the signs or symptoms of mental disorder, or to modify mood, affect, perception, or behavior, consistent with THSC, Chapter 574, Subchapter G, §574.101.

(11) Refusal to consent to administration of psychoactive medication (refusal)--Actions which include the following behaviors:

(A) The patient or legally authorized representative communicates orally, through sign language, or in writing that he or she refuses psychoactive medication.

(B) The patient communicates through behavior that he or she refuses psychoactive medication, e.g., refusing to swallow oral medication or refusing to submit to hypodermic injection of psychoactive medication.

(C) The patient pretends to swallow oral psychoactive medications, and the attending physician determines that the pretending behavior is due to an unwillingness to take the medication.

(D) The patient gives either no response or a noncommittal response after he or she has received the standard risk-benefit explanation.

(12) Service Setting--A state mental health facility, state mental retardation facility, a local authority (LA) site, or a service site contracted to one of these entities.

(13) TDMHMR mental health facility--A state hospital or state center operated by the Texas Department of Mental Health and Mental Retardation.

(14) Ward--A person for whom a guardian has been appointed.

§414.404.Information Required To Be Given.

(a) The treating physician, registered nurse (RN), licensed vocational nurse (LVN), physician's assistant (PA), or registered pharmacist (RPh) will explain to the patient and to the patient's legally authorized representative, the information in paragraphs (1) - (10) of this subsection in simple, nontechnical language in the person's primary language, if possible. If the explanation is not provided by the treating he or she must confirm the explanation with the patient and the patient's legally authorized representative, within two working days, not including weekends or legal holidays:

(1) the nature of the patient's mental illness and condition;

(2) the name of the medication and the beneficial effects on the patient's mental illness or condition expected as a result of treatment with that medication;

(3) the probable health and mental health consequences to the patient of not taking the medication, including the occurrence, increase, or reoccurrence of symptoms of mental illness;

(4) the existence of generally accepted alternative forms of treatment, if any, that could reasonably be expected to achieve the same benefits as the medication and why the physician rejects the alternative treatment;

(5) a description of the proposed course of treatment with medication including any necessary evaluations and lab work;

(6) the fact that side effects of varying degrees of severity are a risk of all medication;

(7) the relevant side effects of the medication, including:

(A) any side effects which are known to frequently occur in most persons;

(B) any side effects to which the particular patient may be predisposed; and

(C) the nature and possible occurrence of the potentially irreversible symptoms of tardive dyskinesia;

(8) the need to advise mental health facility staff immediately if any of these side effects occur;

(9) an instruction that the patient may withdraw consent at any time without negative actions on the part of staff; and

(10) the patient's rights under this section.

(b) The patient and his or her LAR must also be provided a summary of this information in writing, along with an offer to answer any questions concerning the treatment. If the LAR is not present, the information must be mailed to the representative (via certified letter) within 24 hours, except on weekdays and legal holidays when the information will be mailed on the next business day.

§414.405.Documentation of Informed Consent.

(a) Informed medication consent must be obtained for each individual medication, not by medication class.

(b) Informed consent for the administration of each psychoactive medication will be evidenced by a completed copy of the department's form, Consent to Treatment with Psychoactive Medication (MHRS 9-7 form (or other format including the same information)) executed by the patient or his or her LAR. A copy of which may be obtained by contacting TDMHMR, Office of Policy Development, P.O. Box 12668, Austin, TX 78711-2668.

(1) Any time the medication regimen is altered in a way that would result in a significant change in the risks or benefits for the patient, an explanation of the change will be provided to the patient and the patient's legally authorized representative. The explanation will include notification of the right to withdraw consent at any time.

(2) A new consent will be obtained if a change to a different medication is prescribed.

(c) If the patient or his or her LAR consents to the administration of psychoactive medication but refuses or is unable to execute the form, a witness to the consent will be obtained. The consent and its witnessing will be documented in the patient's medical record or on the MHRS 9-7 form (or other format including the same information) and placed in the medical record. The witness will confirm this consent by signing the consent form.

(d) If the RN, LVN, PA, or RPh gives the initial explanation of the consent information to the patient, then the treating physician must confirm the explanation and the consent and sign the MHRS 9-7 form (or other format including the same information) within two working days, not including weekends or legal holidays.

(e) A patient's refusal or attempt to refuse to receive psychoactive medication, whether given verbally or by other indications or means, will be documented in the progress notes of the patient's clinical record or on the consent form (MHRS 9-7 form (or other format including the same information)).

(f) An LAR's refusal to consent for the patient's treatment will be documented in the patient's medical record.

(g) All consents will be reviewed with the patient and his or her legally authorized representative at least every 90 days. The review will include a discussion of the information outlined in §414.404 of this title (relating to Information Required To Be Given) as well as a discussion of the patient and his or her legally authorized representative's wishes regarding continuation of the medication.

§414.406.Patients Admitted under Texas Statutes.

(a) Psychoactive medications will not be administered to patients admitted to a mental health facility under the voluntary provisions of the Texas Health and Safety Code (THSC) or detained at a mental health facility under the THSC emergency detention or order of protective custody (OPC) provisions without informed consent from the patient or the patient's legally authorized representative unless the patient is in an psychiatric emergency and medication is administered as provided in §414.410 of this title (relating to Psychiatric Emergencies).

(b) If an adult under a protective custody order as provided by THSC, Chapter 574, Subchapter B, is a ward, the guardian of the person of the ward may consent to the administration of psychoactive medication as prescribed by the ward's treating physician regardless of the ward's expressed preferences regarding treatment with psychoactive medication.

§414.407.Patients Committed to Mental Health Facilities under Provisions of the Texas Health and Safety Code.

Psychoactive medications will not be administered to patients committed to a mental health facility under an order for temporary or extended mental health services if the patient or the patient's legally authorized representative refuses the medication unless:

(1) the patient is in a psychiatric emergency and medication is administered as provided in §414.410 of this title (relating to Psychiatric Emergencies);

(2) the patient does not have a legally authorized representative and the administration of the medication, regardless of the patient's refusal, is authorized by an order as outlined in THSC §§574.101 - 574.110; or

(3) the patient is a ward who is 18 years of age or older and the guardian of the person of the ward consents to the administration of psychoactive medication regardless of the ward's expressed preferences regarding treatment with psychoactive medication.

§414.408.Patients Committed to Mental Health Facilities under Provisions Other than Those Found in the Texas Health and Safety Code (i.e., Code of Criminal Procedure, Family Code).

(a) The decision to administer medication to a patient committed to a TDMHMR mental health facility under provisions other than THSC §574.034 or §574.035 is consistent with the holding in Sell v. United States, 123 S.Ct. 2174 (2003).

(b) Nothing in this section is intended to preclude the administration of psychoactive medication to any patient in a psychiatric emergency as provided for in §414.410 of this title (relating to Psychiatric Emergencies).

§414.409.Involuntary Administration of Medication to Patients Committed to Mental Health Facilities under the Texas Health and Safety Code or by Court Order.

(a) The physician will order medications administered involuntarily under §414.407 of this title (relating to Patients Committed to Mental Health Facilities under Provisions of the Texas Health and Safety Code) or §414.411 of this title (relating to Order Authorizing Administration of Psychoactive Medication) to be given by the method most acceptable to the patient, if clinically appropriate.

(b) When a patient is court ordered to receive medication involuntarily and refuses all routes of administration that are consistent with community standards of practice, e.g., intramuscular injection, an ethics committee of the facility must be consulted for further guidance in the method of administration.

(c) The authority to administer a medication involuntarily to a patient under §414.407 or §414.411 of this title includes the authority to obtain evaluations and laboratory tests necessary to safely administer the medication.

§414.410.Psychiatric Emergencies.

(a) Nothing in this subchapter is intended to preclude the administration of psychoactive medication to any patient in a psychiatric emergency.

(b) If a physician issues an order to administer psychoactive medication to a patient without the patient's consent because of a psychiatric emergency, then the physician will document in the patient's clinical record in specific medical or behavioral terms:

(1) why the order is necessary:

(2) other generally accepted, less intrusive forms of treatment, if any, that the physician has evaluated but rejected; and

(3) the reasons those treatments were rejected.

(c) Treatment of the patient with the psychoactive medication will be provided in the manner, consistent with clinically appropriate medical care, least restrictive of the patient's personal liberty.

(d) A brief physical hold is not considered restraint for purposes of this subchapter provided that:

(1) the individual currently exhibits behavior that meets the definition of psychiatric emergency as defined in this subchapter, or the individual is currently under a court order allowing the facility to administer medication without consent of the individual and the medication ordered is permitted by the court order;

(2) the purpose of administering medication is active treatment to reduce symptoms of a diagnosed mental illness;

(3) using medication to reduce specified symptoms of a diagnosed mental illness is standard clinical practice;

(4) the specific medication and dosage ordered can be clinically justified as in keeping with standard clinical practice and are appropriate for reduction of specified target symptoms; and

(5) the physical hold is terminated as soon as the medication is administered.

(e) When the psychiatric emergency is no longer imminent or present, medication prescribed without consent on an emergency basis must be safely discontinued. If continued use of medication is recommended on a regular basis, the physician must comply with provisions outlined in §414.406 of this title (relating to Patients Admitted Under Texas Statutes), §414.407 of this title (relating to Patients Committed to Mental Health Facilities Under Provisions of the Texas Health and Safety Code), or §414.408 of this title (relating to Patients Committed to Mental Health Facilities under Provisions Other than Those Found in the Texas Health and Safety Code (i.e., Code of Criminal Procedure, Family Code)), as appropriate.

(f) In no case may inappropriate designation of a situation as a psychiatric emergency be used to circumvent the process of obtaining consent or applying to the court for an order authorizing administration of psychoactive medication.

§414.411.Order Authorizing Administration of Psychoactive Medication.

(a) Filing of Petition. A physician who is treating a patient may petition a probate court or a court with probate jurisdiction for an order to authorize the administration of a class or classes of psychoactive medication regardless of the patient's refusal:

(1) if the physician believes that the patient lacks the capacity to make a decision regarding the administration of the psychoactive medication;

(2) if the physician determines that the medication is the proper course of treatment for the patient; and

(3) if the patient is under an order for temporary or extended mental health services under THSC §574.034 or §574.035 and the patient, verbally or by other indication, refuses to take the medication voluntarily.

(b) Hearing on petition. A hearing on a petition for an order to authorize the administration of psychoactive medication regardless of the patient's refusal will be held in accordance with provisions outlined in THSC §§576.104 - 574.106.

(c) Issuance of order.

(1) The court may issue an order authorizing the administration of one or more classes of psychoactive medication only if the court finds by clear and convincing evidence after the hearing that:

(A) the patient lacks the capacity to make a decision regarding the administration of the proposed medication; and

(B) treatment with the proposed medication is in the best interest of the patient.

(2) In making its finding, the court shall consider:

(A) the patient's expressed preferences regarding treatment with psychoactive medication;

(B) the patient's religious beliefs;

(C) the risks and benefits, from the perspective of the patient, of taking psychoactive medication;

(D) the consequences to the patient if the psychoactive medication is not administered;

(E) the prognosis for the patient if the patient is treated with psychoactive medication; and

(F) alternatives to treatment with psychoactive medication.

(3) An order entered under this subsection shall authorize the administration to a patient, regardless of the patient's refusal, of one or more classes of psychoactive medications specified in the petition and consistent with the patient's diagnosis. The order shall permit:

(A) an increase or decrease in a medication's dosage;

(B) reinstitution of medication authorized but discontinued during the period the order is valid; or

(C) the substitution of a medication within the same medication class.

(4) The issuance of an order authorizing administration of psychoactive medication is not a determination or adjudication of mental incompetency and does not limit in any other respect the patient's rights as a citizen or the patient's property rights or legal capacity.

(d) Appeal of order. A patient may appeal an order under this subchapter in the manner provided by THSC §574.070 for appeal of an order requiring court-ordered mental health services. The order authorizing the administration of psychoactive medication remains effective pending the appeal.

(e) Review and expiration of order.

(1) An order authorizing the administration of psychoactive medication expires on the expiration or termination date of the order for temporary or extended mental health services in effect when the order for psychoactive medication is issued.

(2) An order authorizing the administration of medication shall be reviewed by the court on an annual basis.

§414.412.Designation of Medication Classes.

(a) TDMHMR will maintain an updated list of psychoactive medication classes to be used by the court. The list will be revised and distributed at least annually or more frequently as needed and will include the most common psychoactive medications. The list will be available from the Office of the Medical Director, TDMHMR, and on the TDMHMR website, www.mhmr.state.tx.us (Office of the Medical Director).

(b) As provided by §414.411(c)(1) of this title (relating to Order Authorizing Administration of Psychoactive Medication), the court will only approve classes of medications unless the specific medication appears in the other category on the list or is not on the list and:

(1) the medication is being used for a non-FDA approved indication; or

(2) the medication is a recently FDA approved psychiatric medication.

§414.413.Monitoring Compliance with Policies and Procedures.

(a) Each service setting will implement policies and procedures in accordance with this subchapter.

(b) Self-monitoring of compliance will include the following components:

(1) procedures to audit records for compliance;

(2) procedures to analyze and report audit results to staff responsible for the informed consent process; and

(3) procedures to improve the performance of individual employees, contractors, and agents, and to improve overall facility performance.

(c) Each service setting will collect information related to obtaining consent to treatment with psychoactive medication and the use of psychoactive medication in psychiatric emergencies as may be required by the medical director of TDMHMR.

(d) Each service setting will maintain a record of self-monitoring of compliance and may present these records to licensing or oversight authorities when requested.

§414.414.References.

The following statutes are referenced in this subchapter:

(1) the Texas Health and Safety Code;

(2) the Texas Code of Criminal Procedure; and

(3) the Texas Family Code.

§414.415.Distribution.

This subchapter is distributed to:

(1) members of the Texas Mental Health and Mental Retardation Board;

(2) executive, management, and program staff of Central Office;

(3) CEOs and medical directors of all facilities and LAs;

(4) CEOs of psychiatric hospitals and crisis stabilization units;

(5) advocacy organizations;

(6) any person on request.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State on May 28, 2004.

TRD-200403627

Rodolfo Arredondo

Chairman, Texas MHMR Board

Texas Department of Mental Health and Mental Retardation

Earliest possible date of adoption: July 11, 2004

For further information, please call: (512) 206-4516


Chapter 415. PROVIDER CLINICAL RESPONSIBILITIES

Subchapter A. PRESCRIBING OF PSYCHOACTIVE MEDICATION

25 TAC §§415.1 - 415.14

The Texas Department of Mental Health and Mental Retardation (TDMHMR) proposes new §§415.1 - 415.14 of Chapter 415, Subchapter A, governing prescribing of psychoactive medication. The new sections would provide updated requirements for prescribing psychoactive medications for patients receiving services in state mental health and mental retardation programs in Texas. The new subchapter would replace Chapter 405, Subchapters A and B, governing prescribing of medication--mental health services and prescribing of psychotropic medication--mental retardation facilities, which are contemporaneously proposed for repeal in this issue of the Texas Register .

The proposed new sections delineate policy and establish uniform operating standards for prescribing psychoactive medication in both campus-based and community programs operated or contracted by the Texas Department of Mental Health and Mental Retardation.

The contemporaneous repeal and adoption of these subchapters would fulfill the requirements of the Texas Government Code, §2001.039, concerning the periodic review of agency rules.

Kevin Nolting, Acting Chief Financial Officer, has determined that for each year of the first five-year period that the proposed new sections are in effect, enforcing or administering the sections do not have foreseeable implications relating to costs or revenues of state or local government.

Steven P. Shon, TDMHMR Medical Director, has determined that for each year of the first five years the proposed new sections are in effect, the public benefit will be the promulgation of requirements that ensure a uniform standard of care for individuals receiving medications. It is anticipated that there would be no additional economic cost to persons required to comply with the proposed new sections because the sections do not impose requirements that differ substantively from those already required in operations or through contract.

It is anticipated that the proposed new sections will not affect a local economy because the sections do not significantly alter the requirements already followed in operations or articulated in contract.

It is anticipated that the proposed new sections will not have an adverse economic effect on small businesses or micro-businesses because the sections do not place requirements on small or micro-businesses.

Comments concerning the proposed new sections may be submitted in writing to Linda Logan, Director, Policy Development, Texas Department of Mental Health and Mental Retardation, P.O. Box 12668, Austin, Texas 78711-2668; by fax to (512) 206-4750; or by e-mail to policy.co@mhmr.state.tx.us within 30 days of publication.

A hearing to accept oral and written testimony from members of the public concerning this and other related proposals has been scheduled for Thursday, June 17, 2004, 9:00 a.m. in the TDMHMR Central Office Auditorium, Building 2, 909 West 45th Street, Austin, Texas. Persons requiring an interpreter for the deaf or hearing impaired should contact the department's Central Office operator at least 72 hours prior to the hearing at TDD (512) 206-5330. Persons requiring other accommodations for a disability should notify Sharayla Jones at least 72 hours prior to the hearing at (512) 206-5283 or at the TDY phone number of Texas Relay, 1-800-735-2988.

The new sections are proposed under Texas Health and Safety Code (THSC), §532.015(a), which provides the Texas Mental Health and Mental Retardation Board with broad rulemaking authority; THSC, §571.006, which provides the board with the authority to adopt rules as necessary for the proper and efficient treatment of persons with mental illness; THSC, §577.010, which provides the board with the authority to adopt rules and standards for the proper care and treatment of patients in community-based crisis stabilization services and crisis residential services; and THSC, §534.052(a), which provides the board with the authority to adopt rules and standards necessary to ensure adequate provision of community-based mental health services through the local mental health authority.

The proposed new sections affect THSC §§534.052, 567.024, 571.006, 574.101 et seq., 576.024, and 577.010.

§415.1.Purpose.

(a) The purpose of this subchapter is to establish standards for prescribing psychoactive medication to patients served by the state mental health and mental retardation system in Texas.

(b) This subchapter is not a clinical guide to prescribing psychoactive medication and is not the only source of information concerning related issues of appropriate practice.

(c) Accepted guidelines, as defined in §415.3 of this title (relating to Definitions) supplement the use of this subchapter.

§415.2.Application.

(a) The provisions of this subchapter apply to the employees and contractors of:

(1) the facilities of the Texas Department of Mental Health and Mental Retardation (TDMHMR); and

(2) TDMHMR local authorities.

(b) The provisions of this subchapter may not apply to prescribing practice in research projects that have been approved in accordance with TDMHMR's policies and procedures concerning the review and approval of research involving human subjects.

§415.3.Definitions.

The following words and terms, when used in this subchapter, have the following meanings:

(1) Accepted guidelines--Clinical guidelines or algorithms (such as Texas Implementation of Medication Algorithms or TIMA) formally approved in writing by the TDMHMR medical director. In cases in which none are formally approved, current professionally recognized clinical guidelines or accepted standards of care are considered the accepted guidelines.

(2) Child psychiatrist--A physician who is board eligible or board certified in child and adolescent psychiatry or who is currently in training in an approved residency and is supervised by a board eligible or board-certified child and adolescent psychiatrist.

(3) DSM--The current edition of The Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Press.

(4) Legally authorized representative (LAR)--An individual authorized by law to act on behalf of a individual with regard to a matter described in this subchapter, and may be a parent, guardian, or managing conservator of a minor, or the guardian of an adult.

(5) Local authority--The entity designated by TDMHMR to plan, facilitate, coordinate, and ensure the provision of services to persons with mental illness or mental retardation.

(6) Medication error--Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional or consumer.

(7) Physician--A doctor of medicine or osteopathy who holds a current license or institutional permit to practice medicine in Texas.

(8) Plan of care--The written document specifying how comprehensive care of the person with mental illness or mental retardation is to be carried out (sometimes called the "multidisciplinary treatment plan" or "interdisciplinary plan of care").

(9) Polypharmacy--Concurrent use of more than one psychoactive medication having identical or very similar mechanisms of action.

(10) Prescribing professional--A physician or other health care professional who, as authorized by statute, may prescribe under the supervision of a physician.

(11) PRN--As needed (pro re nata).

(12) Psychiatric emergency--A situation in which, in the opinion of the prescribing professional, it is immediately necessary to administer medication to a patient to ameliorate the signs and symptoms of that patient's mental illness and to prevent:

(A) imminent probable death or substantial bodily harm to the patient because the patient

(i) overtly or continually is threatening or attempting to commit suicide or serious bodily harm; or

(ii) is behaving in a manner that indicates that the patient is unable to satisfy the patient's need for nourishment, essential medical care, or self-protection;

(B) imminent physical or emotional harm to others, because of threats, attempts, other acts the patient overtly or continually makes or commits.

(13) Psychiatrist--A physician who is board eligible or board certified in psychiatry or who is currently in training in such a program and is supervised by a board eligible or board certified psychiatrist.

(14) Psychoactive medication--Medication whose primary intended therapeutic effect is to treat or ameliorate the signs and/or symptoms of mental disorder or to modify mood, affect, perception, or behavior.

(15) Service setting--A state mental health facility, state mental retardation facility, a local authority (LA) site, or a service site contracted to one of these entities.

(16) Team--The patient, patient's LAR, and with the patient's consent, the patient's family members, and the group of professionals and direct care workers responsible for the care of the patient, sometimes called the "multidisciplinary team" or "interdisciplinary team."

§415.4.Philosophy.

The standard of care for psychoactive medication use in patients should not vary according to service setting. The variations in treatment should be individualized according to patient needs.

§415.5.General Principles.

(a) All state facilities and LAs will establish and implement written policies and procedures as approved by their medical staff in accordance with this subchapter.

(b) The prescribing professional will practice within the scope of his or her license with supervision as appropriate to that license.

(c) The prescribing of psychoactive medication will be in accordance with accepted guidelines. Use of psychoactive medication that falls outside accepted guidelines may be permissible if the clinical rationale is documented in the patient record.

(d) In no case will psychoactive medication be used for punishment, for convenience of staff, as a substitute for appropriate psychosocial treatments, or in amounts that interfere with a patient's quality of life or plan of care.

(e) The patient's plan of care will reflect any use of psychoactive medication as part of an integrated treatment approach aimed at increasing the patient's functioning and quality of life.

(f) The prescribing professional will document the rationale for initiating, continuing, or discontinuing psychoactive medication in the clinical record.

(g) Medications traditionally considered psychoactive may be prescribed for nonpsychiatric indications if such use is supported by accepted guidelines and the provisions of this subchapter would not apply.

(h) If a service setting must meet other standards (external or otherwise), the more stringent standards will prevail.

(i) The service setting will have policies and procedures governing the scope of practice regarding prescription of psychoactive medications when the prescribing professional is not a psychiatrist. These policies and procedures must require involvement of a psychiatrist and describe the nature, extent, and time frame of this involvement regarding the following:

(1) initiation of any psychoactive medication;

(2) significant changes in the medication regimen other than simple titration or substitution of equivalent medications;

(3) institution of polypharmacy under §415.7(e)(4) of this title (relating to Prescribing Parameters); or

(4) prescription of any regimen that falls outside accepted guidelines, including dosing guidelines.

(j) Each service setting must ensure psychiatric consultation is available at all times.

§415.6.Evaluation and Diagnosis.

(a) Prior to initiating psychoactive medication according to accepted guidelines, the prescribing professional will:

(1) assess and document the medical history including the chief complaint, psychiatric history, substance use history, and medication history along with medication allergies of the patient;

(2) conduct and document a mental status examination of the patient according to accepted guidelines;

(3) assess and document the current physical status and general health of the patient in detail sufficient for safe prescription of the medication contemplated and may include a reference to a physical examination conducted within the past 12 months, a physical examination by the physician, or a referral of the patient for a more thorough examination as appropriate to health status and service setting;

(4) assess and document the need for laboratory screening and other procedures to gather relevant clinical information; and

(5) make and document the psychiatric diagnosis in accordance with the DSM and within the scope of the professional's license.

(b) The prescribing professional will solicit input and discuss with the team the psychoactive medication.

(c) If psychoactive medication known to cause movement disorders is contemplated, an appropriately trained and competent staff will screen the patient for abnormal involuntary movements using a standardized procedure such as the Abnormal Involuntary Movement Scale (AIMS) or Dyskensia Identification System Condensed User Scale (DISCUS), as appropriate, and document the result or the examination prior to initiation of the medication.

(d) In a psychiatric emergency, the assessments and documentation required by this section will take place as soon as is feasible after the emergency. If the patient has already received such assessments during this treatment episode, then the prescribing professional will document only those assessments and decisions that directly relate to the emergency.

§415.7.Prescribing Parameters.

(a) Target signs and symptoms. The prescribing professional will identify and document the target signs and symptoms along with their initial frequency and severity for each medication prescribed prior to its initial use.

(b) Choice of psychoactive medication. The prescribing professional will choose the psychoactive medication in accordance with accepted guidelines.

(c) Laboratory and screenings. The prescribing professional will identify, order, and follow up any laboratory tests, screenings, or other procedures indicated by the proposed psychoactive medication and the physical condition of the patient in accordance with accepted guidelines.

(d) Dose and route of administration. The prescribing professional will choose doses at or below the maximum doses indicated in the TDMHMR Formulary . Higher doses or unusual routes of administration may be used with documentation in the patient record of appropriate supporting clinical rationale.

(e) Polypharmacy. The prescribing professional will not prescribe polypharmacy as a mechanism to avoid single drug dosage recommendations, adequate monotherapy drug trials, or adequate psychosocial treatment or programming. It is acceptable practice when:

(1) overlapping medications are used as part of a change from one medication to another;

(2) currently prescribed medication is not available in the route most appropriate to a psychiatric emergency situation.

(3) accepted guidelines support polypharmacy as an appropriate choice; or

(4) appropriate single drug trials have failed, accepted guidelines provide no guidance, and the current biomedical literature supports polypharmacy as a reasonable next choice:

(A) if the rationale for determining the choice to prescribe polypharmacy is documented to support the situation;

(B) if the prescribing professional is privileged through the medical staff privileging process to prescribe psychoactive medication, he or she may prescribe polypharmacy, or

(C) if the prescribing professional is not a psychiatrist, or in the case of a child patient, not a child psychiatrist, consultation with a psychiatrist or a child psychiatrist as appropriate must be conducted prior to initiating polypharmacy.

(f) Orders not written in person. The service setting will have policies and procedures which govern orders not written in person (such as verbal, telephone, fax, or electronic orders) by the prescribing professional. These will address who may give orders, who may accept them, and how orders will be documented in the patient record. Orders will be authenticated by the prescribing professional within a time frame appropriate to the service setting as set forth in that setting's approved policies and procedures.

(g) PRN orders. The prescribing professional may write PRN orders in accordance with accepted guidelines and Chapter 414, Subchapter I of this title (relating to Consent to Treatment with Psychoactive Medication) or Chapter 405, Subchapter I of this title (relating to Consent to Treatment with Psychoactive Medications--Mental Retardation Facilities) as appropriate. The service setting will have policies and procedures for PRN orders that address:

(1) indications;

(2) appropriate medication classes and dosing, including maximum dose in 24 hours; and

(3) time frames for:

(A) medication administration;

(B) order duration;

(C) assessment of effectiveness;

(D) continued PRN use; and

(E) documentation standards that apply to the order itself and the assessments.

(h) Psychiatric emergency orders. The physician may order a single, immediate administration of a psychoactive medication(s) for a psychiatric emergency. The service setting will have policies and procedures for emergency use of psychoactive medications in accordance with accepted guidelines and Chapter 414, Subchapter I of this title and Chapter 405, Subchapter I of this title as appropriate that address:

(1) indications;

(2) appropriate medication classes and dosing, including maximum dose in 24 hours;

(3) assessment of effectiveness;

(4) patient education as appropriate. The psychiatric emergency itself does not make patient education inappropriate;

(5) review with consideration of changing the current plan of care if a pattern of use of psychiatric emergency orders emerges; and

(6) documentation time frames and standards that address the incident, the use of medications, and the outcome.

(i) Documentation. The prescribing professional will document the rationale for the initiation, continuation, or discontinuation of any psychoactive medication.

§415.8.Emergency Use of Psychoactive Medication.

(a) Emergency psychoactive medications are used to treat the signs and symptoms of mental illness in an acute psychiatric emergency when other interventions are ineffective or inappropriate.

(b) The selection of the medication should take into account the patient's current medication regimen. Using a medication that the patient is currently prescribed is preferable, if clinically indicated.

(c) All required documentation will be entered into the patient's record in a concurrent fashion or as soon as the emergency abates.

§415.9.Consent and Patient Education.

(a) Informed consent for treatment with a psychoactive medication will be obtained in accordance with the provisions of Chapter 414, Subchapter I of this title (relating to Consent to Treatment with Psychoactive Medication--Mental Health Facilities) or Chapter 405, Subchapter I of this title (relating to Consent to Treatment with Psychoactive Medication--Mental Retardation Facilities), as appropriate.

(b) The use of PRN medication requires an appropriate consent process in accordance with the provisions referred to in subsection (a) of this section.

(c) The service setting will provide individual or group medication education if possible and when appropriate to patients, their families, and LARs according to accepted guidelines (e.g., TIMA patient and family education guidelines). If accepted guidelines do not exist, the education will discuss characteristics of the medication, including expected benefits, potential adverse or side effects, dosage, standard alternative treatments, legal rights, and any questions the patient, family, or LAR may have. This education is also provided as necessary to address significant changes in the patient's medication regimen. The service setting will have policies and procedures to address medication education and documentation standards.

§415.10.Medication Monitoring.

(a) All patients receiving psychoactive medication will receive timely ongoing face-to-face evaluation and documentation by the prescribing professional of:

(1) data collected since the last follow-up, including data about the frequency, severity, and timing of target signs and symptoms;

(2) effectiveness of the medication on those target signs and symptoms; and

(3) assessment for side effects and adverse effects.

(b) Using the assessment data and with input from the team, the prescribing professional will continue or alter the medication regimen to maximize the benefit to the patient.

(c) At initiation of a new medication or significant change in medication regimen, medication monitoring will occur as often as medically necessary and for the period of time needed to stabilize the clinical response. Such monitoring will occur at least weekly for one month in hospitals and crisis stabilization units (unless discharged in the interim) and at least monthly in outpatient and residential settings. Rationale for less frequent monitoring will be documented.

(d) Further minimum frequencies of medication monitoring in other patients are:

(1) state hospital inpatient settings--monthly as described in subsections (a) and (b) of this section. Also, every 90 days, the medication monitoring includes review of consent issues and long-term consequences of psychoactive medication;

(2) state school residential settings--monthly review of data with appropriate members of the team and every third month (quarterly) face-to-face evaluation of the patient. Rationale for less frequent monitoring will be documented;

(3) LA programs--medication monitoring appointments will be scheduled quarterly as described in subsections (a) and (b) of this section. Rationale for less frequent monitoring will be documented.

(e) For medications known to cause movement disorders, appropriately trained and competent staff will screen the patient quarterly for abnormal involuntary movements using a standardized procedure such as AIMS, document the results, and arrange for any appropriate follow-up with a psychiatrist or neurologist, if indicated.

(f) Clinically significant adverse effects or side effects will be evaluated by a physician, managed according to accepted guidelines, and addressed in the plan of care.

(g) Laboratory testing or other procedures needed for the continued safe and effective use of medication will be ordered according to accepted guidelines.

(h) In any service setting that operates a pharmacy, the pharmacist will evaluate medication orders and patient medication records in accordance with the Texas Pharmacy Rules and will include a review for dosage range according to the TDMHMR Formulary, polypharmacy, and PRN use. The service setting will have policies and procedures in place for doing this review and the documentation and outcome of any questions arising out of this review.

§415.11.Special Populations.

Special populations will be managed according to accepted guidelines as appropriate to their special needs.

(1) Patients with dyskinesias, including tardive dyskinesia.

(A) A diagnosis of a dyskinesia will be verified by a psychiatrist or neurologist and documented in the patient record along with suspected or known duration and severity.

(B) The patient and, as appropriate, family and LAR as appropriate will receive relevant education about the diagnosis and its implications for psychoactive medication use.

(C) Risks and benefits of continued psychoactive medication use will be assessed and communicated to the patient and, as appropriate, family or LAR. If continued use is recommended, a new consent for medication will be obtained.

(D) If continued use of psychoactive medication is contemplated, then the prescribing professional, if not a psychiatrist or neurologist, must obtain and document consultation from a psychiatrist or neurologist.

(2) Children and adolescents.

(A) Except in an emergency, if the prescribing professional is not a child psychiatrist, then prescribing psychoactive medication which falls outside accepted guidelines requires consultation from a child psychiatrist in addition to any other requirements.

(B) If the prescribing professional is not a child psychiatrist, then use of polypharmacy is governed as indicated in §415.7 of this title (relating to Prescribing Parameters) except subsection (e)(4) of that section, which requires consultation from a child psychiatrist in addition to any other requirements.

(3) Patients with mental retardation.

(A) Although it is recognized that psychiatric diagnosis may be more difficult in this population, all attempts will be made to give a specific psychiatric diagnosis in accordance with the DSM prior to initiating psychoactive medication.

(B) Except in an emergency or acute psychiatric hospitalization, psychoactive medications are prescribed only after behavioral and clinical baselines have been established.

(C) Specific target behaviors or clinical signs and quality of life outcomes must be objectively defined, quantified, and tracked using recognized empirical measurement methods appropriate to the service setting in order to monitor psychoactive medication efficacy.

(4) Patients with substance use disorders.

(A) In recognition of the high incidence of substance use disorder comorbidity with other mental disorders, service settings will consider the possibility of comorbidity during evaluations for medication, initiation of medication, and medication monitoring, and will have policies and procedures which address this possibility.

(B) Provision of medication services to this population will be in accordance with accepted guidelines for patients with these comorbid conditions and will be in collaboration and coordination with other treatments that the patient may be receiving for substance use.

(5) Pregnant or nursing patients.

(A) Except in an emergency, consultation will be sought from an obstetrics consultant (or the physician currently managing the pregnancy) for pregnant patients or from a pediatrician (or the physician currently managing the infant) for nursing patients prior to prescribing.

(B) Informed consent for use of psychoactive medication in this population must specifically document that the risk and benefits of that use on the fetus or infant have been discussed with the patient and, as appropriate, LAR and family.

(C) The prescribing professional will seek to collaborate with the physician or clinic providing prenatal, postnatal, or pediatric care to include providing, with consent, appropriate documentation of diagnoses and plan of care to that service provider.

(6) Geriatric patients. Service settings will have policies and procedures for psychoactive medication use which recognize that this population has special needs when compared to the general adult population.

(7) Other special populations. Prescribing professionals will be aware that other populations exist that may have particular clinical or special risk factors associated with their treatment with psychoactive medications. Consultation with an appropriate specialist or expert will be considered when treating these populations.

§415.12.Quality Improvement.

(a) Each service setting will have in place policies and procedures that address standards and improvement in the quality of provision of psychoactive medication related services.

(b) At a minimum, psychoactive medication use (in aggregate) in each service setting must be reviewed and evaluated at least semiannually and strategies for improvement identified using accepted guidelines.

(c) Required areas of review include:

(1) appropriateness of prescribing (including choice of medication, dose, and route);

(2) documentation;

(3) polypharmacy;

(4) emergency use of psychoactive medication;

(5) PRN use;

(6) medication errors;

(7) adverse drug reactions; and

(8) frequency of medication monitoring.

(d) Aggregate reports of the medication use reviews are reviewed by the medical staff and necessary strategies for improvement approved by them for implementation.

§415.13.References.

The following statutes and TDMHMR rules are referenced in this subchapter:

(1) Chapter 414, Subchapter P of this title (relating to Research in TDMHMR Facilities);

(2) Chapter 414, Subchapter I of this title (relating to Consent to Treatment with Psychoactive Medications--Mental Retardation Facilities); and

(3) Chapter 405, Subchapter I of this title (relating to Consent to Treatment with Psychoactive Medication).

§415.14.Distribution.

This subchapter is distributed to:

(1) all members of the Texas Mental Health and Mental Retardation Board;

(2) executive, management, and program staff of Central Office;

(3) CEOs and medical directors of all facilities and LAs;

(4) advocacy organizations;

(5) any person on request.

This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State on May 28, 2004.

TRD-200403629

Rodolfo Arredondo

Chairman, Texas MHMR Board

Texas Department of Mental Health and Mental Retardation

Earliest possible date of adoption: July 11, 2004

For further information, please call: (512) 206-4516