The Texas Department of Mental Health and Mental Retardation (TDMHMR) proposes new §§411.451 - 411.555, §§411.459 - 411.465, §411.468, §§411.471 - 411.477, §§411.482 - 411.485, §411.488, §411.490, §§411.493 - 411.496, and §§411.499 - 411.500 of new Chapter 411, Subchapter J, governing standards of care and treatment in psychiatric hospitals. The repeal of §§401.581 - 401.583 and §§401.587 - 401.593 of Chapter 401, Subchapter J, governing standards of care and treatment in psychiatric hospitals, which the new sections would replace, are contemporaneously proposed in this issue of the Texas Register .

The proposed new sections ensure the proper care and treatment of prospective patients and patients in private psychiatric hospitals licensed under Texas Health and Safety Code (THSC), Chapter 577, and Texas Department of Health (TDH) rules at Texas Administrative Code (TAC), Title 25, Chapter 134, governing private psychiatric hospitals and crisis stabilization units licensing rules, and in identifiable mental health services units in hospitals licensed under THSC Chapter 241, and TAC, Title 25, Chapter 133, governing hospital licensing rules. The proposed new sections address requirements related to admission, emergency treatment, treatment planning and the services to be provided, discharge, documentation, staff training, and performance improvement.

A substantial portion of the proposed new sections, namely those concerning admission and discharge, are based on state law, primarily the THSC. Other sections, such as those concerning emergency treatment, service requirements and performance improvement are derived from requirements in the Code of Federal Regulations (CFR) and the most recent edition of the Comprehensive Accreditation Manual for Hospitals promulgated by The Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

The proposed new sections were developed in collaboration with the Texas Department of Health (TDH) which licenses private psychiatric hospitals, mental health services units in general and special hospitals, and crisis stabilization units, and is responsible for enforcing TDMHMR rules that apply to these entities. Additionally, TDMHMR sought the advice of individual advocates, the Advisory Committee on Inpatient Mental Health Services, a statutorily authorized committee of representatives of the psychiatric hospital industry, the Texas Hospital Association, the Texas Society of Psychiatric Physicians, the coalition for Nurses in Advanced Practice, Advocacy Incorporated, and the Citizen's Commission on Human Rights. The stakeholders provided input to ensure the new sections are commensurate with TDMHMR's commitment to have standards of care be effective and practical in application. For purposes of this preamble, the term "hospital" refers to both a private psychiatric hospital and a mental health services unit in general and special hospitals licensed by TDH.

The proposed new sections reflect the decision rendered in Texas Attorney General Opinion GA-0066 that a physician must personally conduct the admission examination of a patient required by THSC, §572.0025(f)(1), and may not delegate this duty to a non-physician. In addition, the new sections address relevant portions of House Bills 21, 2679, and 2292 (78th Legislature). House Bill 21 amended THSC, §572.001(a), and permits the parent, managing conservator, or guardian of a person younger than 18 years of age who is not and has not been married to request the admission of the person to a hospital. Also, for a person who has been voluntarily admitted by his or her parent, managing conservator, or guardian, House Bill 21 amends THSC, §572.003, to include subsection (e) which requires TDMHMR to establish the intervals at which a physician must evaluate the person to determine the person's need for continued inpatient treatment. In addition, for such a person, House Bill 21 amends THSC, §572.004, to include subsection (i) which requires a hospital to, on receipt of a written request for discharge from the person, notify the person's parent, managing conservator, or guardian of the request. House Bill 2679 amends THSC, Chapter 573, to include §573.003, which permits a guardian of the person of an adult to transport the adult to a hospital, without the assistance of a peace officer, for preliminary examination under emergency detention. House Bill 2292 amends THSC, §572.0025(f), to permit a physician to use audiovisual or other telecommunications technology to conduct the admission examination for a voluntary patient.

The proposed new sections reference Chapter 415, Subchapter F, related to Interventions in Mental Health Programs, which is proposed in this issue of the Texas Register .

The proposed new sections contain general provisions that describe a hospital's responsibility in developing written policies and procedures and enforcing staff members' compliance with those policies and procedures. In addition, the proposed new sections set forth the admission criteria for hospitals to follow in determining who can be admitted for inpatient mental health treatment, including for clarification purposes, the additional admission criteria for persons under 18 years of age. Further, the proposed new sections describe those processes and procedures required by the THSC for admission on a voluntary basis, by emergency detention, a protective custody order, a court order for inpatient mental health services, and certain orders issued under the Texas Code of Criminal Procedure and the Texas Family Code. The proposed new sections also require a hospital to assign and implement a level of monitoring to a patient upon admission of that patient to ensure any need for protection of the patient is addressed immediately.

To promote an efficient and coordinated system of ensuring proper responses to emergency medical conditions, the proposed new sections require a hospital to develop and implement a written plan describing the actions a hospital will take to evaluate and stabilize potential emergency medical conditions of patients, prospective patients and, based on 42 CFR §489.24(b), individuals who may arrive on a hospital's property requesting examination or treatment. Further, the proposed new sections set forth a hospital's responsibility to maintain a written record of evaluations for emergency medical conditions. This requirement is derived from 42 CFR §489.20. To enhance a hospital's effective response to individuals suffering cardiac arrest, the proposed new sections also require a hospital to have an automated external defibrillator.

In order to ensure the expedient treatment of patients, the proposed new sections set forth time frames for development of a written treatment plan, the frequency of treatment plan reviews and requirements for consolidation of all treatment into one treatment plan. Further, so patients are aware at all times of the treatment they are receiving in the hospital, the hospital must inform a patient of the initial content of the treatment plan and subsequent revisions to the plan. Also, the proposed new sections establish standards of care and treatment for patients diagnosed with co-occurring psychiatric and substance use disorders (COPSD) to ensure the effective and coordinated provision of services to individuals who require specialized support or treatment due to COPSD.

To ensure accountability for the provision of medical services, the proposed new sections require the assignment of a treating physician at the time a patient is admitted, timely availability of physicians, that a physical and psychiatric examination be conducted, and that the director of psychiatric services meet specified qualifications. To implement new THSC, §572.003(e) and based on industry standards as set forth in the Texas Society of Psychiatric Physicians "Guidelines of Practice for Inpatient Psychiatric Care," the proposed new sections require a psychiatrist to re-evaluate a patient at least five times a week to insure a patient's current clinical status is adequately assessed and the course of treatment is appropriately monitored and modified.

The proposed new sections address nursing services, including the minimum qualifications for the director of psychiatric nursing (DPN). These qualifications are derived, in part, from TDH's rules at TAC, Title 25, §133.41, concerning hospital functions and services, and serve to ensure that the DPN has the requisite education and experience to oversee the nursing services provided at a hospital. The proposed new sections also set forth the requirements regarding time frames for conducting the initial comprehensive nursing assessment and the reassessments thereafter. The department believes that the proposed timeframe for conducting the initial nursing assessment and the time frame for conducting reassessments establish an adequate standard for ensuring that a patient's initial and changing needs are identified and addressed.

The new sections also require the development and implementation of a nurse staffing plan, the establishment of an advisory committee for nurse staffing, implementation of a process to report concerns regarding the staffing plan to such a committee, orientation of nursing staff, and the development and implementation of a policy regarding the use of mandatory overtime. These requirements were based on requirements included in TDH's rules at TAC, Title 25, §133.41, concerning hospital functions and services. These requirements serve to ensure that there are adequate numbers of qualified and informed nurses and unlicensed assistive personnel to provide care to patients. In addition, these requirements ensure that hospitals are not compromising the quality of nursing care provided to patients by requiring an excessive amount of overtime. The proposed new sections also describe requirements regarding verification of nursing staff licensure.

The new subchapter sets forth qualifications for the Director of Social Services to ensure that the director has the requisite education and experience to oversee the social services provided at a hospital. Further, the new sections set forth requirements for a staff member conducting a social services assessment or a therapeutic activities assessment in order to ensure that an appropriate determination of a patient's need for those services is made. Further, the proposed new sections contain provisions for protecting a patient through environmental modifications, identifying and implementing levels of monitoring for each patient, and decision-making based on a patient's needs and vulnerabilities.

The proposed new sections describe the discharge planning activities for hospitals to follow when discharging a patient. In addition the new sections set forth who is involved in the discharge planning and describe the discharge planning activities and content of the discharge summary. Further, the proposed new sections describe those processes and procedures required by the THSC for discharge notices, discharge of a voluntary patient and discharge of an involuntary patient. The proposed new sections also set forth requirements for the content of the medical record and progress notes based on JCAHO requirements and 42 CFR §482.61.

The proposed new sections describe the training for staff members required by THSC, §572.0025 and the training regarding abuse and neglect and patient rights currently required by other state rules. In addition, the proposed new rules set forth requirements for training staff about the confidentiality of patient information. Further, the proposed new sections require training on responding to cardiac emergencies, including the use of an automated external defibrillator. The proposed new sections also set forth requirements for age specific training for staff providing treatment to or working with patients under the age of 18, geriatric patients and patients diagnosed with COPSD. In addition, the proposed new sections describe training requirements for staff regarding patient safety, infection control, reporting complaints about the nurse staffing plan, and the hospital's mandatory overtime policy. These training requirements serve to ensure staff members will be knowledgeable about relevant issues that affect the adequacy of patient care and will master the competencies necessary to provide quality services. The proposed new sections also set forth requirements for documentation of staff member training.

The rule describes the processes and procedures for a hospital to follow in developing and maintaining an on-going quality assessment and performance improvement program. The requirements are based on JCAHO requirements and 42 CFR §482.21, and describe program content, role of the governing body, staff member participation, and program activities. The proposed new sections also describe how a hospital will identify, report and investigate sentinel events in order to improve patient care and safety and implement improvements effective in reducing their reoccurrence. The new subchapter contains provisions for a hospital to develop and implement a written plan to evaluate the effectiveness of plans of correction the hospital submits to external review entities.

Cindy Brown, chief financial officer, has determined that for each year of the first five year period the proposed sections are in effect, enforcing or administering the sections does not have foreseeable implications relating to costs or revenues of state or local governments.

There is a probable economic cost to persons that are required to comply with the new rule, specifically, hospitals, that are not currently in compliance with THSC §572.0025(f)(1). As interpreted by Texas Attorney General Opinion #0066-GA, THSC §572.0025(f)(1) requires that a physician personally conduct the admission examination of a patient for whom a request for voluntary admission to the hospital has been made, thereby prohibiting the physician from delegating the examination to a non-physician. For hospitals that are not in compliance with this statute there will be additional costs of ensuring that a physician conducts the admission examination. Additionally, the proposed new rule requires each hospital to have an automated external defibrillator as part of its emergency equipment. For hospitals that do not already have an automated external defibrillator, the cost to purchase one may range from $1,700 to $2,000 per defibrillator. Further, the proposed new sections require a hospital to develop and document an emergency medical response plan, develop a nurse staffing plan, establish an advisory committee for nursing staff, develop, implement and maintain an ongoing quality assessment and performance improvement plan, and report and investigate sentinel events. For hospitals that are not currently conducting these activities, there may be increased costs related to time and staff to do so. Also, the new subchapter requires a hospital to conduct staff training not currently required by state law or rule. Implementing such training may result in increased costs related to time and staff for a hospital.

There may be an adverse economic effect on small businesses or micro-businesses required to comply with the new rule as described in the previous paragraph.

Sam Shore, director of Behavioral Health Services has determined for each year of the first five years the proposed new sections are in effect, the public benefit expected is the adoption of new and more current rules governing the care and treatment of prospective patients and patients in private psychiatric hospitals licensed under THSC, Chapter 577 and in identifiable mental health services units of general or special hospitals licensed under THSC, Chapter 241.

It is not anticipated the proposed new sections will affect a local economy.

Comments concerning the proposed new sections must be submitted in writing to Linda Logan, director, Policy Development, Texas Department of Mental Health and Mental Retardation, by mail to 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 9:30 a.m., Friday August 15, 2003, in the department's Central Office Auditorium in 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 Linda Brown, at least 72 hours prior to the hearing at (512) 206-4747 or at the TDY phone number of Texas Relay, 1/800-735-2988.

1. GENERAL REQUIREMENTS

25 TAC §§411.451 - 411.455

These sections are proposed under the 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 or persons with mental illness; and THSC, §577.010(a), which provides the board with the authority to adopt rules and standards for the proper care and treatment of patients in a private psychiatric hospital required to obtain a license under THSC, Chapter 577.

The proposed new sections affect THSC, §532.015(a), §571.006, and §577.010(a).

§411.451.Purpose.

The purpose of this subchapter is to describe standards to ensure the proper care and treatment of prospective patients and patients in private psychiatric hospitals licensed under Texas Health and Safety Code, Chapter 577, and Chapter 134 of this title (relating to Private Psychiatric Hospitals and Crisis Stabilization Units Licensing Rules), and in identifiable mental health services units in hospitals licensed under Texas Health and Safety Code, Chapter 241, and Chapter 133 of this title (relating to Hospital Licensing Rules).

§411.452.Application.

This subchapter applies to:

(1) private psychiatric hospitals licensed under Texas Health and Safety Code, Chapter 577 and Chapter 134 of this title (relating to Private Psychiatric Hospitals and Crisis Stabilization Units Licensing Rules); and

(2) identifiable mental health services units in hospitals licensed under Texas Health and Safety Code, Chapter 241, and Chapter 133 of this title (relating to Hospital Licensing Rules).

§411.453.Definitions.

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

(1) Administrator--The individual, appointed by a governing body, who has authority to represent the hospital and, as delegated by the governing body, has responsibility for operating the hospital in accordance with the hospital's written policies and procedures.

(2) Administrator's designee--An individual designated in a hospital's written policies and procedures to act for a specified purpose on behalf of the administrator.

(3) Admission--The acceptance of an individual to a hospital's custody and care for inpatient mental health treatment based on:

(A) a physician's order issued in accordance with §411.461(d)(2)(B) of this title (relating to Voluntary Admission);

(B) a physician's order issued in accordance with §411.462(c)(3) of this title (relating to Emergency Detention);

(D) an order for temporary inpatient mental health services issued in accordance with Texas Health and Safety Code, §574.034;

(E) an order for extended inpatient mental health services issued in accordance with Texas Health and Safety Code, §574.035;

(F) an order for commitment issued in accordance with the Texas Code of Criminal Procedure, Article 46.02, Section 5; or

(G) an order for placement in accordance with Texas Family Code, §55.33(a)(1)(B) or §55.52(a)(1)(B).

(4) Adult--an individual 18 years of age and older or an individual who is under 18 years of age and is or has been married or who has had the disabilities of minority removed for general purposes.

(5) APN or advanced practice nurse--A registered nurse approved by the Texas State Board of Nurse Examiners to practice as an advanced practice nurse, in accordance with Texas Occupations Code, Chapter 301. The term is synonymous with "advanced nurse practitioner."

(6) Business day--Any day except a Saturday, Sunday, or legal holiday.

(7) CFR--The Code of Federal Regulations.

(8) COPSD or co-occurring psychiatric and substance use disorders--A diagnosis of both a mental illness and a substance use disorder.

(9) Council on Social Work Education--The national organization that is primarily responsible for the accreditation of schools of social work in the United States.

(10) Discharge--The release by a hospital of a patient from the custody and care of the hospital.

(11) DSM--The current edition of the Diagnostic Statistical Manual of Mental Disorders published by the American Psychiatric Association.

(12) Emergency medical condition--A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in:

(A) placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) or others in serious jeopardy;

(B) serious impairment to bodily functions;

(D) in the case of a pregnant woman who is having contractions:

(i) that there is inadequate time to effect a safe transfer to another hospital before delivery; or

(ii) that transfer may pose a threat to the health or safety of the woman or the unborn child.

(13) Governing body--The governing authority of a hospital that is responsible for the hospital's organization, management, control and operation, including appointment of the administrator.

(14) Hospital--A private psychiatric hospital licensed under Texas Health and Safety Code, Chapter 577, and Chapter 134 of this title (relating to Private Psychiatric Hospitals and Crisis Stabilization Units Licensing Rules), or an identifiable inpatient mental health services unit in a hospital licensed under Texas Health and Safety Code, Chapter 241, and Chapter 133 of this title (relating to Hospital Licensing Rules).

(15) IDT or interdisciplinary treatment team--A group of individuals who possess the knowledge, skills and expertise to develop and implement a patient's treatment plan and includes:

(A) the patient's treating physician;

(B) a registered nurse;

(D) a staff member trained in accordance with §411.490(a)(6) of this title (relating to Staff Member Training) if the patient is diagnosed with COPSD;

(E) the patient; and

(F) other staff members as clinically appropriate.

(16) Inpatient mental health treatment--Residential treatment provided in a hospital that is designed to allow a patient to function in a less restrictive setting as soon as possible, which includes:

(A) medical services;

(B) nursing services;

(D) therapeutic activities; and

(E) psychological services, if ordered by the treating physician.

(17) Involuntary patient--A patient who is receiving inpatient mental health treatment based on an admission made in accordance with:

(A) §411.462 of this title (relating to Emergency Detention); or

(B) §411.463 of this title (relating to Admission of an Individual Under Protective Custody Order for Court-ordered Inpatient Mental Health Services, or Under Order for Commitment or Order for Placement).

(18) LAR or legally authorized representative--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.

(19) Legal holiday--A holiday listed in Texas Government Code, §662.021 and an officially designated county holiday applicable to a court in which proceedings under the Texas Mental Health Code are held.

(20) Licensed marriage and family therapist--An individual who is licensed as a licensed marriage and family therapist by the Texas State Board of Examiners of Marriage and Family Therapists in accordance with Texas Occupations Code, Chapter 502.

(21) Licensed master social worker--An individual who is licensed as a licensed master social worker by the Texas State Board of Social Work Examiners in accordance with Chapter 505 of the Texas Occupations Code.

(22) Licensed professional counselor--An individual who is licensed as a licensed professional counselor by the Texas State Board of Examiners of Professional Counselors in accordance with Texas Occupations Code, Chapter 503.

(23) Licensed psychologist--An individual who is licensed as a psychologist by the Texas State Board of Examiners of Psychologists in accordance with Texas Occupations Code, Chapter 501.

(24) Licensed social worker--An individual who is licensed as a licensed social worker by the Texas State Board of Social Work Examiners in accordance with Texas Occupations Code, Chapter 505.

(25) LVN or licensed vocational nurse--An individual who is licensed as a licensed vocational nurse by the Texas Board of Vocational Nurse Examiners in accordance with Texas Occupations Code, Chapter 302.

(26) Mandatory overtime--The time, other than on-call time, a nursing staff member is required to work at a hospital beyond the hours or days that were scheduled for the staff member at least one week in advance. Neither the length of the nursing staff member's shift nor the number of shifts the nursing staff member works is the determinative factor in deciding whether time is mandatory overtime.

(27) Medical services--Services provided or delegated by a physician acting within the scope of his or her practice, as described in Texas Occupations Code, Chapter 155.

(28) Mental illness--An illness, disease, or condition (other than a sole diagnosis of epilepsy, senility, substance use disorder, mental retardation, autism, or pervasive developmental disorder) that:

(A) substantially impairs an individual's thought, perception of reality, emotional process, or judgment; or

(B) grossly impairs an individual's behavior as demonstrated by recent disturbed behavior.

(29) Minor--An individual under 18 years of age who is not and has not been married or who has not had the disabilities of minority removed for general purposes.

(30) Monitoring--One or more staff members observing a patient on a continual basis or at pre-determined intervals and intervening when necessary to protect the patient from harming self or others.

(31) National League for Nursing--The national organization that is primarily responsible for the accreditation of nursing education programs in the United States.

(32) Neurological screening--A screening examination to assess an individual's neurological functioning which shall include assessment of the following:

(A) cranial nerves II through XII, excluding taste assessment;

(B) proprioception and cerebellar function, including the Romberg test, and the performance of rapid, rhythmic, alternating movements; and

(C) sensory function, including superficial pain and touch at a distal point of each extremity, and vibration and position sense bilaterally at the great toe; and deep tendon reflexes, excluding plantar reflex and test for ankle clonus.

(33) Nosocomial infection--A hospital-acquired infection of a patient.

(34) Nursing services--Services provided or delegated by a registered nurse acting within the scope of his or her practice, as described in Texas Occupations Code, Chapter 301.

(35) Nursing staff--Staff members of a hospital who are registered nurses, licensed vocational nurses or unlicensed assistive personnel.

(36) Occupational therapist--An individual who is licensed as an occupational therapist by the Texas Board of Occupational Therapy Examiners in accordance with Texas Occupations Code, Chapter 454.

(37) PASP or pre-admission screening professional--A staff member whose responsibilities include conducting a pre-admission screening and who is:

(A) a physician;

(B) a physician assistant;

(D) a licensed psychologist;

(E) a psychological associate;

(F) a licensed social worker;

(G) a licensed professional counselor; or

(H) a licensed marriage and family therapist.

(38) Patient--An individual who has been admitted to a hospital and has not been discharged.

(39) Physician--An individual who is:

(A) licensed as a physician by the Texas State Board of Medical Examiners in accordance with Texas Occupations Code, Chapter 155; or

(B) authorized to perform medical acts under an institutional permit at a Texas postgraduate training program approved by the Accreditation Council on Graduate Medical Education, the American Osteopathic Association, or the Texas State Board of Medical Examiners.

(40) Physician assistant--An individual who is licensed as a physician assistant by the Texas State Board of Physician Assistant Examiners in accordance with Texas Occupations Code, Chapter 204.

(41) Pre-admission screening--The clinical process used to gather information from a prospective patient, including a medical history, any history of substance use, and the problem for which the prospective patient is seeking treatment, to determine if a physician should conduct an admission examination.

(42) Prospective patient--An individual:

(A) for whom a request for voluntary admission has been made, in accordance with §411.461(a) of this title (relating to Voluntary Admission); or

(B) who has been accepted by a hospital for a preliminary examination, in accordance with §411.462(a) of this title (relating to Emergency Detention).

(43) Psychiatrist--A physician who is:

(A) certified in psychiatry by the American Board of Psychiatry and Neurology; or

(B) eligible to take the examination necessary to be certified in psychiatry by the American Board of Psychiatry and Neurology; or

(C) currently in training in a psychiatric residency training program and is supervised by a physician who meets the criteria in subparagraph (A) or (B) of this paragraph.

(44) Psychological associate--An individual who is licensed as a psychological associate by the Texas State Board of Examiners of Psychologists in accordance with Texas Occupations Code, Chapter 501.

(45) Psychological services--Services provided by a psychologist or psychological associate acting within the scope of his or her practice, as described in Texas Occupations Code, Chapter 501.

(46) Psychologist--An individual who is licensed as a psychologist by the Texas State Board of Examiners of Psychologists in accordance with Texas Occupations Code, Chapter 501.

(47) RN or registered nurse--An individual who is licensed as a registered nurse by the Texas State Board of Nurse Examiners in accordance with Texas Occupations Code, Chapter 301.

(48) Sentinel event--Any of the following occurrences that is unexpected and involves a patient:

(A) the death of an individual;

(B) the serious physical injury of an individual;

(D) circumstances that present the imminent risk of death, serious physical injury, or serious psychological injury of an individual.

(49) Social services--Services provided by:

(A) a licensed master social worker or licensed social worker acting within the scope of his or her practice, as described in Texas Occupations Code, Chapter 505; or

(B) a licensed professional counselor acting within the scope of his or her practice, as described in Texas Occupations Code, Chapter 503.

(50) Stabilize--To provide such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a hospital or, if the emergency medical condition for a woman is that she is in labor, that the woman has delivered the child and the placenta.

(51) Staff members--Any and all personnel of a hospital including full-time and part-time employees, contractors, students, volunteers, and professionals granted privileges by the hospital.

(52) Substance use disorder--The use of one or more drugs, including alcohol, which significantly and negatively impacts one or more major areas of life functioning and which currently meets the criteria for substance abuse or substance dependence as described in the DSM.

(53) TAC--The Texas Administrative Code.

(54) Therapeutic activities--Structured activities designed to develop, restore or maintain a patient's optimal level of physical and psychosocial functioning limited to:

(A) recreational therapy provided by a therapeutic recreation specialist;

(B) physical therapy, speech therapy, or occupational therapy, provided by a licensed staff member acting within the scope of the staff member's practice;

(D) music therapy provided by a staff member who is certified as an MT-BC by the Certification Board for Music Therapists; or

(E) psychosocial or leisure activities provided by qualified staff members.

(55) Therapeutic recreation specialist--An individual who is certified as a therapeutic recreation specialist by the Texas Consortium for Therapeutic Recreation/Activities Certification or a certified therapeutic recreation specialist by the National Council for Therapeutic Recreation Certification.

(56) Treating physician--A physician who coordinates and oversees the implementation of a patient's treatment plan.

(57) Unit--A discrete and identifiable area of a hospital that includes patients' rooms or other patient living areas and is separated from another similar area:

(A) by a locked door;

(B) by a floor; or

(58) UAP or unlicensed assistive personnel--An individual, not licensed as a health care provider, who provides certain health related tasks or functions in a complementary or assistive role to a registered nurse in providing direct patient care or carrying out common nursing functions.

(59) Voluntary patient--A patient who is receiving inpatient mental health treatment based on an admission made in accordance with:

(A) §411.461 of this title (relating to Voluntary Admission); or

(B) §411.465 of this title (relating to Voluntary Treatment Following Involuntary Admission).

§411.454.General Provisions.

(a) Written policies and procedures. A hospital shall develop written policies and procedures that ensure compliance with this subchapter.

(b) Compliance by staff. All staff members shall comply with this subchapter and the policies and procedures of the hospital required by subsection (a) of this section.

(c) Responsibility of hospital. A hospital shall be responsible for a staff member's compliance with this subchapter and the policies and procedures required by subsection (a) of this section.

(d) Enforcement of polices and procedures. A hospital shall take appropriate measures, which may include disciplinary action, to ensure a staff member's compliance with this subchapter and the policies and procedures required by subsection (a) of this section.

(e) Implementation of physician orders. A hospital shall implement all orders issued by a physician for a patient.

(f) Compliance with rules. A hospital shall comply with the following departmental rules:

(1) Chapter 404, Subchapter E of this title (relating to Rights of Persons Receiving Mental Health Services);

(2) Chapter 405, Subchapter E of this title (relating to Electroconvulsive Therapy (ECT));

(3) Chapter 415, Subchapter F of this title (relating to Interventions in Mental Health Programs); and

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

(g) Compliance with Treatment Facilities Marketing Practices Act. A hospital shall comply with Texas Health and Safety Code, Chapter 164, unless the hospital is an exemption described in Texas Health and Safety Code, §164.004.

§411.455.Individuals with a Sole Diagnosis of a Substance Use Disorder.

A hospital shall comply with 40 TAC Chapter 148 (relating to Facility Licensure) in admitting, treating, and discharging an individual with a sole diagnosis of a substance use disorder.

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 July 14, 2003.

TRD-200304236

Rodolfo Arredondo

Chairman, TDMHMR Board

Texas Department of Mental Health and Mental Retardation

Earliest possible date of adoption: August 24, 2003

For further information, please call: (512) 206-4581

2. ADMISSION

25 TAC §§411.459 - 411.465

The proposed new sections affect THSC, §532.015(a), §571.006, and §577.010(a).

§411.459.Admission Criteria.

A hospital shall develop and implement written admission criteria that:

(1) are uniformly applied to all prospective patients;

(2) permit the admission of:

(A) a prospective patient only if he or she has a mental illness of sufficient severity to be responsive to inpatient mental health treatment; and

(B) a prospective patient under the age of 18 only if he or she meets the additional criteria described in §411.460 of this title (relating to Additional Admission Criteria for Individuals Under 18 Years of Age); and

(3) prevent the admission of a prospective patient who:

(A) requires specialized care not available at the hospital; or

(B) has a physical medical condition that is unstable and could reasonably be expected to require inpatient treatment for the condition.

§411.460.Additional Admission Criteria for Individuals Under 18 Years of Age.

An individual under the age of 18 may be admitted to a hospital only if:

(1) the individual has an AXIS I diagnosis listed in the DSM;

(2) services in a setting less restrictive than a hospital:

(A) have been ineffective or are inappropriate, as determined and documented by a physician, APN, psychologist, licensed master social worker, licensed professional counselor, or licensed marriage and family therapist; or

(B) are unavailable in the individual's community; and

(3) the individual meets at least one of the following criteria:

(A) the individual is presently a danger to self as demonstrated by at least one of the following:

(i) a recent suicide attempt or active suicidal threats with a plan to carry out harm to self, and an absence of appropriate supervision or structure to prevent self-harm;

(ii) recent self-mutilative behavior or threats of such behavior with a likelihood of acting on the threat;

(iii) active hallucinations or delusions likely to lead to serious self-harm;

(iv) debilitating psychomotor agitation or retardation resulting in a significant inability to participate in meeting the individual's basic needs; or

(v) significant inability to comply with a prescribed medical health regime because of a mental illness and such inability to comply is life-threatening to the individual;

(B) the individual is a danger to others as demonstrated by at least one of the following:

(i) recent life-threatening action or active homicidal threats with a likelihood of acting on the threat;

(ii) recent serious assaultive behavior or sadistic behavior or active threats of same with the likelihood of acting on the threat;

(iii) severely disruptive behaviors and other behaviors which may put individuals at risk of physical, psychological or sexual abuse; or

(iv) active hallucinations or delusions likely to lead to serious harm to others; or

(i) the individual has acute psychosis;

(ii) the individual has chronic psychosis and there is significant risk of clinical deterioration in the condition of the individual if the individual is not hospitalized;

(iii) the individual has a severe eating disorder;

(iv) the individual has a substance use disorder; or

(v) evaluation and treatment of the individual cannot be carried out safely or effectively in other settings because of the behavior of others, including physical, psychological, or sexual abuse.

§411.461.Voluntary Admission.

(a) Request for voluntary admission.

(1) In accordance with Texas Health and Safety Code, §572.001(a) and (c), a request for voluntary admission of a prospective patient may only be made by:

(A) the prospective patient, if:

(i) he or she is 16 years of age or older; or

(ii) he or she is younger than 16 years of age and is or has been married; or

(B) the parent, managing conservator, or guardian of the prospective patient, if the prospective patient is younger than 18 years of age and is not and has not been married, except that a guardian or managing conservator acting as an employee or agent of the state or a political subdivision of the state may request admission of the prospective patient only with the prospective patient's consent.

(2) In accordance with Texas Health and Safety Code, §572.001(b) and (e), a request for admission shall:

(A) be in writing and signed by the individual making the request; and

(B) include a statement that the individual making the request:

(i) agrees that the prospective patient will remain in the hospital; and

(ii) consents to diagnosis, observation, care and treatment of the prospective patient until the earlier of one of the following occurrences:

(I) the discharge of the prospective patient; or

(II) the prospective patient is entitled to leave the hospital, in accordance with Texas Health and Safety Code, §572.004, after a request for discharge is made.

(3) The consent given under paragraph (2)(B)(ii) of this subsection does not waive a patient's rights described in the rules listed under §411.454(f) of this title (relating to General Provisions).

(b) Capacity to consent. If a prospective patient does not have the capacity to consent to diagnosis, observation, care and treatment, as determined by a physician, then the hospital may not admit the prospective patient on a voluntary basis. When appropriate, the hospital may initiate an emergency detention proceeding in accordance with Texas Health and Safety Code, Chapter 573, or file an application for court-ordered inpatient mental health services in accordance with Texas Health and Safety Code, Chapter 574.

(1) Prior to voluntary admission of a prospective patient, a PASP shall conduct a pre-admission screening of the prospective patient.

(2) If the PASP determines that the prospective patient does not need an admission examination, the hospital may not admit the prospective patient and shall refer the prospective patient to alternative services. If the PASP determines that the prospective patient needs an admission examination, a physician shall conduct an admission examination of the prospective patient.

(3) If the pre-admission screening is conducted by a physician, the physician may conduct the pre-admission screening as part of the admission examination referenced in subsection (d)(2)(A) of this section.

(d) Requirements for voluntary admission. A hospital may voluntarily admit a prospective patient only if:

(1) a request for admission is made is accordance with subsection (a) of this section;

(2) a physician has:

(A) in accordance with Texas Health and Safety Code, §572.0025(f)(1), conducted, within 72 hours prior to admission, or has consulted with a physician who has conducted, within 72 hours prior to admission, an admission examination in accordance with subsection (f) of this section; and

(B) issued an order admitting the prospective patient;

(3) the prospective patient meets the hospital's admission criteria; and

(4) in accordance with Texas Health and Safety Code, §572.0025(f)(2), the administrator or administrator's designee has signed a written statement agreeing to admit the prospective patient.

(e) Intake. In accordance with Texas Health and Safety Code §572.0025(b), a hospital shall, prior to voluntary admission of a prospective patient, conduct an intake process, that includes:

(1) obtaining relevant information about the prospective patient, including information about finances, insurance benefits and advance directives; and

(2) explaining, orally and in writing, the prospective patient's rights described in Chapter 404, Subchapter E of this title (concerning Rights of Persons Receiving Mental Health Services), including:

(A) the hospital's services and treatment as they relate to the prospective patient; and

(B) the existence, purpose, telephone number, and address of the protection and advocacy system established in Texas, which is Advocacy, Inc., as required by Texas Health and Safety Code, §576.008.

(f) Admission examination.

(1) The admission examination referenced in subsection (d)(2)(A) of this section shall be conducted by a physician and include a physical and psychiatric examination conducted in the physical presence of the patient or by using audiovisual telecommunications.

(2) The physical examination may consist of an assessment for medical stability.

(3) The physician may not delegate conducting the admission examination to a non- physician.

(g) Documentation of admission order. In accordance with Texas Health and Safety Code §572.0025(f)(1), the order described in subsection (d)(2)(B) of this section shall be:

(1) issued in writing and signed by the issuing physician; or

(2) issued orally or electronically if, within 24 hours after its issuance, the hospital has a written order signed by the issuing physician.

§411.462.Emergency Detention.

(a) Acceptance for preliminary examination. In accordance with Texas Health and Safety Code, §573.022, a hospital may accept for a preliminary examination:

(1) an individual who has been apprehended and transported to a hospital by a peace officer in accordance with Texas Health and Safety Code, §573.001 or §573.012; or

(2) an individual who is 18 years of age or older and who has been transported to the hospital by the individual's guardian of the person in accordance with Texas Health and Safety Code, §573.003.

(b) Preliminary examination.

(1) A physician shall conduct a preliminary examination of the individual as soon as possible but not more than 24 hours after the individual was apprehended by the peace officer or arrived at the hospital after being transported by his or her guardian for emergency detention.

(2) The preliminary examination shall include:

(A) an assessment for medical stability; and

(B) a psychiatric examination to determine if the individual meets the criteria described in subsection (c)(1) of this section.

(1) in accordance with Texas Health and Safety Code, §573.022(a)(2), a physician determines from the preliminary examination that:

(A) the prospective patient has a mental illness;

(B) the prospective patient evidences a substantial risk of serious harm to self or others;

(D) emergency detention is the least restrictive means by which the necessary detention may be accomplished;

(2) in accordance with Texas Health and Safety Code, §573.022(a)(3), a physician makes a written statement:

(A) documenting the determination described in paragraph (1) of this subsection; and

(B) describing:

(i) the nature of the prospective patient's mental illness;

(ii) the risk of harm the individual evidences, demonstrated either by the prospective patient's behavior or by evidence of severe emotional distress and deterioration in the prospective patient's mental condition to the extent that the prospective patient cannot remain at liberty; and

(iii) the detailed information on which the physician based the determination described in paragraph (1) of this subsection;

(3) based on the determination described in paragraph (1) of this subsection, the physician issues an order admitting the prospective patient for emergency detention; and

(4) the prospective patient meets the hospital's admission criteria, as required by §411.459 of this title (relating to Admission Criteria).

(d) Release.

(1) A hospital shall release a prospective patient accepted for a preliminary examination if:

(A) a preliminary examination of the prospective patient has not been conducted within the time frame described in subsection (b)(1) of this section; or

(B) in accordance with Texas Health and Safety Code, §573.023(a), the prospective patient is not admitted for emergency detention in accordance with subsection (c) of this section on completion of the preliminary examination.

(2) In accordance with Texas Health and Safety Code, §576.007, before releasing a prospective patient who is 18 years of age or older, a hospital shall make a reasonable effort to notify the prospective patient's family of the release if the prospective patient grants permission for the notification.

(3) Before releasing a patient who is younger than 16 years of age and who is not or has not been married, a hospital shall notify the patient's LAR or the LAR's designee of the release.

(4) Upon release, the hospital may release a minor younger than 16 years of age only to the minor's LAR or the LAR's designee.

(e) Intake. A hospital shall conduct an intake process as soon as possible, but not later than 24 hours after the time a patient is admitted for emergency detention.

(1) The intake process shall include but is not limited to:

(A) obtaining, as much as possible, relevant information about the patient, including information about finances, insurance benefits and advance directives; and

(B) explaining, orally and in writing, the patient's rights described in Chapter 404, Subchapter E of this title (concerning Rights of Persons Receiving Mental Health Services), including:

(i) the hospital's services and treatment as they relate to the patient; and

(ii) the existence, purpose, telephone number, and address of the protection and advocacy system established in Texas, which is Advocacy, Inc., as required by Texas Health and Safety Code, §576.008.

(2) The hospital shall determine whether the patient comprehends the information provided in accordance with paragraph (1)(B) of this subsection. If the hospital determines that the patient comprehends the information, the hospital shall document in the patient's medical record the reasons for such determination. If the hospital determines that the patient does not comprehend the information, the hospital shall:

(A) repeat the explanation to the patient at reasonable intervals until the patient demonstrates comprehension of the information or is discharged, whichever occurs first; and

(B) document in the patient's medical record the patient's response to each explanation and whether the patient demonstrated comprehension of the information.

§411.463.Admission of an Individual under Protective Custody Order, for Court-ordered Inpatient Mental Health Services, or under Order for Commitment or Order for Placement.

(a) Requirements for admission under court order. A hospital may admit an individual:

(1) under a protective custody order only if a court has issued a protective custody order in accordance with Texas Health and Safety Code, §574.022;

(2) for court-ordered inpatient mental health services only if a court has issued:

(A) an order for temporary inpatient mental health services in accordance with Texas Health and Safety Code, §574.034; or

(B) an order for extended inpatient mental health services in accordance with Texas Health and Safety Code, §574.035;

(3) under an order for commitment issued in accordance with the Texas Code of Criminal Procedure, Article 46.02, Section 5; or

(4) under an order for placement issued in accordance with Texas Family Code, §55.33(a)(1)(B) or §55.52(a)(1)(B).

(b) Intake. A hospital shall conduct an intake process as soon as possible, but not later than 24 hours after the time a patient is admitted under one of the orders described in subsection (a) of this section.

(1) The intake process shall include but is not limited to:

(A) obtaining, as much as possible, relevant information about the patient, including information about finances, insurance benefits and advance directives; and

(B) explaining, orally and in writing, the patient's rights described in Chapter 404, Subchapter E of this title (concerning Rights of Persons Receiving Mental Health Services), including:

(i) the hospital's services and treatment as they relate to the patient; and

(ii) the existence, purpose, telephone number, and address of the protection and advocacy system established in Texas, which is Advocacy, Inc., as required by Texas Health and Safety Code, §576.008.

(A) repeat the explanation to the patient at reasonable intervals until the patient demonstrates comprehension of the information or is discharged, whichever occurs first; and

(B) document in the patient's medical record the patient's response to each explanation and whether the patient demonstrated comprehension of the information.

§411.464.Monitoring Upon Admission.

At the time a patient is admitted, a hospital shall assign and implement one of the levels of monitoring identified by the hospital in accordance with §411.477(b) of this title (relating to Protection of a Patient), based on the patient's needs.

§411.465.Voluntary Treatment Following Involuntary Admission.

A hospital may provide inpatient mental health treatment to an involuntary patient after the patient is eligible for discharge as described in §411.485 of this title (relating to Discharge of an Involuntary Patient), if prior to the provision of such treatment:

(1) the hospital obtains written consent for voluntary inpatient mental health treatment that meets the requirements of a request for voluntary admission, as described in §411.461(a) of this title (relating to Voluntary Admission); and

(2) the patient's treating physician:

(A) examines the patient; and

(B) based on that examination, issues an order for voluntary inpatient mental health treatment that meets the requirements of §411.461(g) of this title (relating to Voluntary Admission).

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 July 14, 2003.

TRD-200304237

Rodolfo Arredondo

Chairman, TDMHMR Board

Texas Department of Mental Health and Mental Retardation

Earliest possible date of adoption: August 24, 2003

For further information, please call: (512) 206-4581

3. EMERGENCY TREATMENT

25 TAC §411.468

This section is proposed under the 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 or persons with mental illness; and THSC, §577.010(a), which provides the board with the authority to adopt rules and standards for the proper care and treatment of patients in a private psychiatric hospital required to obtain a license under THSC, Chapter 577.

The proposed new section affects THSC, §532.015(a), §571.006, and §577.010(a).

§411.468.Responding to an Emergency Medical Condition of a Patient, Prospective Patient, or Individual who Arrives on Hospital Property Requesting Examination or Treatment.

(a) Planning responses to emergency medical conditions. A hospital shall:

(1) identify potential emergency medical conditions of:

(A) a patient;

(B) a prospective patient; and

(C) an individual who arrives on hospital property, as defined in 42 CFR §489.24(b), requesting examination or treatment for a medical condition; and

(2) develop a written plan describing the specific and appropriate action to be taken by the hospital to evaluate for and stabilize each identified potential emergency medical condition, which shall include:

(A) the administration of first aid and basic life support when clinically indicated; and

(B) the use of the supplies and equipment described in subsection (f)(2) of this section.

(b) Written record of evaluations. The hospital shall keep a written record of all evaluations of individuals who arrive on hospital property, as defined in 42 CFR §489.24(b), requesting examination or treatment for a medical condition. The written record shall include the following information:

(1) demographic data regarding the individual evaluated, including the name, age and sex of the individual;

(2) a description of the individual's complaint or symptoms;

(3) whether the hospital determined that the individual had an emergency medical condition and, if so, a description of the condition;

(4) whether the hospital treated or refused to treat the individual;

(5) whether the individual refused or consented to treatment or transfer;

(6) whether the hospital stabilized the emergency medical condition;

(7) whether the hospital admitted or released the individual; and

(8) whether the hospital transferred the individual and, if so, the individual's destination, time of transfer and mode of transportation.

(1) A hospital shall determine an appropriate time period in which a physician will be physically present at a hospital to respond to an emergency medical condition after being contacted by a staff member, in accordance with the plan required by subsection (a)(2) of this section.

(2) At least one physician shall, within the time period determined in accordance with paragraph (1) of this subsection, be physically present at the hospital to respond to an emergency medical condition.

(d) Response to emergency medical conditions. If a hospital determines that a patient, prospective patient, or an individual who arrives on hospital property requesting examination or treatment for a medical condition has an emergency medical condition, the hospital shall:

(1) take action to stabilize the emergency medical condition in accordance with the plan required by subsection (a)(2) of this section; and

(2) if appropriate, transfer the individual in accordance with the following, as applicable:

(A) §134.43 of this title (relating to Patient Transfer Policy), or a transfer agreement made in accordance with §134.61 of this title (relating to Patient Transfer Agreements); or

(B) §133.44 of this title (relating to Hospital Patient Transfer Policy), or a transfer agreement made in accordance with §133.61 of this title (relating to Hospital Patient Transfer Agreements).

(e) Qualified staff members. The hospital shall have an adequate number of staff members who are qualified and available to evaluate for and respond to emergency medical conditions in accordance with the plan required by subsection (a)(2) of this section.

(f) Supplies and equipment.

(1) The hospital shall have an adequate amount of appropriate supplies and equipment immediately available and fully operational at the hospital to respond to emergency medical conditions in accordance with the plan required by subsection (a)(2) of this section.

(2) The emergency supplies and equipment required by paragraph (1) of this subsection shall include, at a minimum:

(A) oxygen;

(B) a suction machine;

(D) an automated external defibrillator.

(3) If an identifiable inpatient mental health services unit in a hospital licensed under Texas Health and Safety Code, Chapter 241, and Chapter 133 of this title (relating to Hospital Licensing Rules) has immediate access to a automated external defibrillator located in another area, the identifiable inpatient mental health services unit is not required to comply with paragraph (2)(D) of this subsection.

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 July 14, 2003.

TRD-200304238

Rodolfo Arredondo

Chairman, TDMHMR Board

Texas Department of Mental Health and Mental Retardation

Earliest possible date of adoption: August 24, 2003

For further information, please call: (512) 206-4581

4. SERVICE REQUIREMENTS

25 TAC §§411.471 - 411.477

The proposed new sections affect THSC, §532.015(a), §571.006, and §577.010(a).

§411.471.Inpatient Mental Health Treatment and Treatment Planning.

(a) Inpatient mental health treatment. A hospital shall provide inpatient mental health treatment to a patient under the direction of a physician and in accordance with the patient's treatment plan and this division.

(b) Treatment plan content within 24 hours. A hospital shall develop and implement a written treatment plan within 24 hours after the patient's admission.

(1) The treatment plan shall include:

(A) a list of all substantiated diagnoses for the patient with notation as to which diagnoses will be treated at the hospital including:

(i) at least one mental illness diagnosis;

(ii) any substance use disorder diagnoses; and

(iii) any physical medical conditions; and

(B) a description of all treatment interventions intended to address the patient's condition including:

(i) the classes of medications prescribed and target symptoms listed for each class;

(ii) one of the levels of monitoring identified in accordance with §411.477(b) of this title (relating to Protection of a Patient); and

(iii) nursing interventions.

(2) The content of the treatment plan described in paragraph (1) of this subsection shall be based on:

(A) findings of the physical examination described in §411.472(e)(1)(A) of this title (relating to Medical Services) or findings of the physical examination described in §411.472(e)(1)(B) of this title (relating to Medical Services);

(B) the psychiatric evaluation described in §411.472(f) of this title (relating to Medical Services); and

(1) Within 72 hours of the patient's admission the hospital shall:

(A) establish an IDT for a patient; and

(B) add the following to the patient's treatment plan:

(i) a list of the problems that are to be addressed during the patient's hospitalization, including, if the patient is diagnosed with COPSD, the problems related to the patient's COPSD;

(ii) a description of the goals of the patient relating to the problems listed;

(iii) a description of the treatment for the patient as follows:

(I) the treatment designed to meet goals of the patient, including:

(-a-) measures taken to protect the patient as described in §411.477(a) of this title (relating to Protection of a Patient); and

(-b-) if the patient is diagnosed with COPSD, the treatment that will address the problems related to the patient's COPSD;

(II) the specific treatment modalities for each treatment by type and frequency; and

(III) the IDT member responsible for providing or ensuring the provision of each treatment;

(iv) if the patient is diagnosed with COPSD, a description of how the interrelationship of the patient's mental illness and substance use disorder affect the patient's recovery;

(v) a description of the clinical criteria for the patient to be discharged; and

(vi) a description of the recommended services and supports needed by the patient after discharge required by §411.482(a)(3)(A) of this title (relating to Discharge Planning).

(2) The content of the treatment plan described in paragraph (1)(B) of this subsection shall be based on:

(A) the findings, evaluation, and assessment described in subsection (b)(2) of this section;

(B) the assessments described in §411.474(d) of this title (relating to Social Services), §411.475(b) of this title (relating to Therapeutic Activities), and §411.476(b) of this title (relating to Psychological Services); and

(3) After the additions described in paragraph (1)(B) of this subsection are made to the treatment plan, the treatment plan shall be signed by all members of the IDT.

(d) Treatment plan review and revisions. The treatment plan shall be:

(1) reviewed and its effectiveness evaluated:

(A) at least every 72 hours after being implemented;

(B) any time there is a change in the patient's condition based on findings from the re-evaluations described in §411.472(g) of this title (relating to Medical Services), findings from the reassessments described in §411.473(f) of this title (relating to Nursing Services), or findings from any reassessments conducted by other members of the IDT; and

(2) revised, if necessary, based on findings from the re-evaluations described in §411.472(g) of this title (relating to Medical Services), findings from the reassessments described in §411.473(f) of this title (relating to Nursing Services), findings from any reassessments conducted by other members of the IDT, or information regarding recommended services and supports needed by the patient after discharge.

(e) Consent to initial content, additions, and revisions to treatment plan. A hospital shall, prior to the implementation of the treatment plan and of any additions or revisions thereto:

(1) inform the patient of the initial content, additions, or revisions to the treatment plan, as applicable; and

(2) obtain a written consent of the patient to the initial content, additions, or revisions, as applicable, or document the reasons such consent could not be obtained.

§411.472.Medical Services.

(a) Medical services in treatment plan. A hospital shall provide medical services to a patient in accordance with a treatment plan developed in accordance with §411.471 of this title (relating to Inpatient Mental Health Treatment and Treatment Planning).

(b) Director of psychiatric services. A hospital shall have a director of psychiatric services who directs, monitors, and evaluates the psychiatric services provided.

(c) Qualifications of director of psychiatric services. In accordance with Texas Health and Safety Code, §577.008, the director of psychiatric services shall be a physician who:

(1) is certified in psychiatry by the American Board of Psychiatry and Neurology or by the American Osteopathic Board of Psychiatry and Neurology; or

(2) has three years of experience as a physician in psychiatry in a "mental hospital" as defined in Texas Health and Safety Code, §571.003.

(d) Treating physician. A hospital shall assign a treating physician to a patient and document such assignment in the patient's medical record at the time the patient is admitted.

(e) Physical examination.

(1) A physician shall:

(A) review written findings of a physical examination of the patient conducted by another physician no more than seven days prior to the patient's admission; or

(B) conduct a physical examination of the patient.

(2) The physical examinations described in paragraph (1) of this subsection shall include a neurological screening and, if indicated, a comprehensive neurological examination.

(f) Psychiatric evaluation. A psychiatrist shall conduct an initial psychiatric evaluation of a patient. The results of the initial evaluation shall include:

(1) a description of the patient's medical history;

(2) a determination of the patient's mental status;

(3) a description of the onset of the patient's mental illness and any substance use disorder and the circumstances leading to admission;

(4) an estimation of the patient's intellectual functioning, memory functioning and orientation;

(5) a description of the patient's strengths and disabilities; and

(6) the diagnoses of the patient's mental illness and if applicable, any substance use disorders.

(g) Re-evaluation. A psychiatrist shall re-evaluate a patient based on the patient's needs but at least five times a week after the initial psychiatric evaluation described in subsection (f) of this section is conducted.

(h) Provision of medical services. A hospital shall provide:

(1) medical services to a patient in response to an emergency medical condition in accordance with the plan required by §411.468 of this title (relating to Responding to an Emergency Medical Condition of a Patient, Prospective Patient or Individual who Arrives on Hospital Property Requesting Examination or Treatment); and

(2) other medical services, as needed by the patient, or transfer the patient to a health care entity that can provide the medical services in accordance with the following, as applicable:

(A) §134.43 of this title (relating to Patient Transfer Policy), or a transfer agreement made in accordance with §134.61 of this title (relating to Patient Transfer Agreements); or

(B) §133.44 of this title (relating to Hospital Patient Transfer Policy), or a transfer agreement made in accordance with §133.61 of this title (relating to Hospital Patient Transfer Agreements).

(i) Availability of physicians. At least one physician shall, at all times:

(1) be physically present at the hospital to provide medical services to a patient; or

(2) be available to staff members by telephone or radio or audiovisual telecommunication to provide medical consultation.

§411.473.Nursing Services.

(a) Nursing services in treatment plan. A hospital shall provide nursing services to a patient in accordance with a treatment plan developed in accordance with §411.471 of this title (relating to Inpatient Mental Health Treatment and Treatment Planning).

(b) Organization of nursing staff. The hospital shall have a written description of the organizational hierarchy and responsibilities of the nursing staff.

(1) has administrative authority over the nursing staff;

(2) directs, monitors, and evaluates the nursing services provided;

(3) for a hospital licensed under Texas Health and Safety Code, Chapter 577, and Chapter 134 of this title (relating to Private Psychiatric Hospitals and Crisis Stabilization Units Licensing Rules), reports directly to the administrator; and

(4) for an identifiable mental health services unit in a hospital licensed under Texas Health and Safety Code, Chapter 241, and Chapter 133 of this title (relating to Hospital Licensing Rules), reports directly to the chief nursing officer as described in §133.41 of this title (relating to Hospital Functions and Services) or reports directly to an RN who reports directly to the chief nursing officer.

(d) Qualifications of DPN. The DPN shall be:

(1) an RN with a master's degree in psychiatric-mental health from a nursing education program accredited by the National League for Nursing;

(2) an RN with a bachelor's degree in nursing: and

(A) have three years experience as a full-time employee or contractor (or its equivalent as a part-time employee or contractor) as an RN in a hospital;

(B) be progressing under a written plan to obtain a master's degree in psychiatric-mental health from a nursing education program accredited by the National League for Nursing or a master's degree in a health-related field from an accredited college or university and

(C) receive eight hours per month of clinical consultation from an RN with a master's degree in psychiatric-mental health from a nursing education program accredited by the National League for Nursing or a master's degree in a health-related field from an accredited college or university; or

(3) an RN with a master's degree in a health-related field from an accredited college or university and have three years experience as a full-time employee or contractor (or its equivalent as a part-time employee or contractor) as an RN in a hospital.

(e) Assessment. An RN shall conduct and complete an initial comprehensive nursing assessment of a patient within eight hours of the patient's admission.

(f) Reassessment. An RN shall reassess a patient, based on the patient's needs, but at least every 12 hours after the initial comprehensive nursing assessment required by subsection (e) of this section is conducted.

(g) Staffing plan.

(1) The DPN shall develop and implement a written staffing plan that:

(A) describes the number of RNs, LVNs, and UAPs on each unit for each shift;

(B) provides for at least one RN to be physically present and on-duty at all times on each unit when a patient is present on the unit;

(C) if the hospital has only one unit, at least two members of the nursing staff to be physically present and on-duty at all times on the unit when a patient is present on the unit; and

(D) provides for an adequate number of registered nurses on each unit to supervise all UAPs.

(2) The staffing plan described in paragraph (1) of this subsection shall be based on the following factors:

(A) the number of patients;

(B) the characteristics of the patients, including the intensity of the patient's emotional, mental, and medical needs;

(D) the architecture of the unit, including geographic dispersion of patients, arrangement of the unit and surveillance and communication technology;

(E) the expertise of the nursing staff;

(F) the nursing staff's familiarity with the patients;

(G) nursing staff continuity and cohesion;

(H) the amount of time required by the nursing staff to perform administrative activities; and

(I) recommendations of the advisory committee regarding the adequacy of the staffing plan made in accordance with §411.496(b)(3) of this title (relating to Advisory Committee for Nurse Staffing).

(3) The DPN shall document his or her determinations made about each factor described in paragraph (2) of this subsection.

(4) A hospital shall retain the staffing plan and the documentation required by paragraph (3) of this subsection for two years after such documentation is created.

(5) The DPN shall revise the staffing plan, as necessary, when the factors described in paragraph (2) of this subsection change.

(6) The DPN shall report to the advisory committee established in accordance with §411.496 of this title (relating to Advisory Committee for Nurse Staffing) any variance between the number of staff members specified in the staffing plan and the actual number of staff members on duty.

(h) Process for reporting concerns regarding staffing plan.

(1) A hospital shall develop and implement a process for RNs and LVNs to report concerns regarding the adequacy of the staffing plan to the advisory committee established in accordance with §411.496 of this title (relating to Advisory Committee for Nurse Staffing).

(2) A hospital shall not retaliate against a nurse for reporting a concern to the advisory committee.

(i) Orientation of nursing staff.

(1) A hospital shall provide orientation to a nursing staff member when the staff member is initially assigned to a unit on either a temporary or long-term basis. The orientation shall include a review of:

(A) the location of equipment and supplies on the unit;

(B) the staff member's responsibilities on the unit;

(D) relevant schedules of staff members and patients; and

(E) procedures for contacting the staff member's supervisor.

(2) A hospital shall document the provision of orientation to nursing staff.

(j) Verification of licensure. A hospital shall verify that a member of the nursing staff, for whom a license is required, has a valid license at the time the staff member assumes responsibilities at the hospital and maintains the license throughout the staff member's employment or association with the hospital.

(k) Mandatory overtime. A hospital shall develop and implement a policy regarding the use of mandatory overtime by the nursing staff. The policy shall require:

(1) documentation of the justification for the use of mandatory overtime;

(2) monitoring and evaluation of the use of mandatory overtime; and

(3) development of a plan to reduce or eliminate the use of mandatory overtime.

§411.474.Social Services.

(a) Social services in treatment plan. A hospital shall provide social services to a patient in accordance with a treatment plan developed in accordance with §411.471 of this title (relating to Inpatient Mental Health Treatment and Treatment Planning).

(b) Director of social services. A hospital shall have a director of social services who directs, monitors, and evaluates the social services provided.

(1) be a licensed master social worker; or

(2) be a licensed social worker who is enrolled in a graduate program accredited by the Council on Social Work Education, receiving eight hours per month of clinical consultation from a licensed master social worker with three years of experience in the provision of psychiatric social work, and summarizing, in writing, the content of each consultation with the licensed master social worker including clinical issues discussed and recommendations made by the licensed master social worker regarding such issues.

(d) Assessment.

(1) A licensed master social worker, a licensed social worker, or a licensed professional counselor, shall conduct a social services assessment of a patient.

(2) If a licensed social worker or a licensed professional counselor conducts the social services assessment:

(A) the licensed social worker or a licensed professional counselor shall be supervised by a licensed master social worker; and

(B) the results of the assessment shall be signed by the licensed master social worker evidencing approval of such results.

§411.475.Therapeutic Activities.

(a) Therapeutic activities in treatment plan. A hospital shall provide therapeutic activities to a patient in accordance with a treatment plan developed in accordance with §411.471 of this title (relating to Inpatient Mental Health Treatment and Treatment Planning).

(b) Assessment.

(1) An occupational therapist, a therapeutic recreation specialist, or a staff member under the supervision of an occupational therapist or a therapeutic recreation specialist shall conduct a therapeutic activities assessment of a patient.

(2) The assessment shall include an evaluation of the patient in the following domains:

(3) If a staff member under the supervision of an occupational therapist or a therapeutic recreation conducts the therapeutic activities assessment, the results of the assessment shall be signed by the occupational therapist or a therapeutic recreation evidencing approval of such results.

(c) Qualified staff members. A hospital shall have qualified staff members who are available to provide the therapeutic activities necessary to address the problems identified by a patient's therapeutic activities assessment.

§411.476.Psychological Services.

(a) Psychological services in treatment plan. If ordered by a patient's treating physician, a hospital shall provide psychological services to a patient in accordance with a treatment plan developed in accordance with §411.471 of this title (relating to Inpatient Mental Health Treatment and Treatment Planning).

(b) Assessment. If ordered by a patient's treating physician, a licensed psychologist shall conduct a psychological assessment of the patient.

§411.477.Protection of a Patient.

(a) Modifying the environment and monitoring the patient. A hospital shall protect a patient by taking the following measures:

(1) modifying the hospital environment based on the patient's needs including:

(A) providing furnishings that do not present safety hazards to the patient;

(B) securing or removing objects that are hazardous to the patient; and

(2) monitoring the patient at the level of monitoring most recently specified in the patient's medical record; and

(3) making roommate assignments and other decisions affecting the interaction of the patient with other patients, based on patient needs and vulnerabilities.

(b) Levels of monitoring. A hospital shall:

(1) identify, in writing, the levels of monitoring of patients; and

(2) define each of the levels of monitoring, in writing, including a description of the responsibilities of staff members for each level of monitoring identified.

(c) Separation of patients under 18 years of age. In accordance with Texas Health and Safety Code, §321.002, a hospital shall keep patients who are under the age of 18 separate from patients who are over the age of 18.

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 July 14, 2003.

TRD-200304239

Rodolfo Arredondo

Chairman, TDMHMR Board

Texas Department of Mental Health and Mental Retardation

Earliest possible date of adoption: August 24, 2003

For further information, please call: (512) 206-4581

5. DISCHARGE

25 TAC §§411.482 - 411.485

The proposed new sections affect THSC, §532.015(a), §571.006, and §577.010(a).

§411.482.Discharge Planning.

(a) Involvement of staff, patient, and LAR in planning activities.

(1) Following the admission of a patient to a hospital, the hospital shall conduct discharge planning for the patient.

(2) Discharge planning shall involve the IDT, the patient, the patient's LAR, and any other individual authorized by the patient or LAR.

(3) Discharge planning shall include, at a minimum, the following activities:

(A) the patient's IDT recommending services and supports needed by the patient after discharge, including the placement after discharge;

(B) qualified staff members arranging for the services and supports recommended by the patient's IDT; and

(C) qualified staff members counseling the patient, the patient's LAR, and as appropriate, the patient's caregivers, to prepare them for post-discharge care.

(b) Discharge summary. The patient's treating physician shall prepare a written discharge summary that includes:

(1) a description of the patient's treatment at the hospital and the response to that treatment;

(2) a description of the patient's condition at discharge;

(3) a description of the patient's placement after discharge;

(4) a description of the services and supports the patient will receive after discharge;

(5) a final diagnosis based on all five axes of the DSM;

(6) in accordance with Texas Health and Safety Code, §574.081(c), a description of the amount of medication the patient will need until the patient is evaluated by a physician; and

(7) in accordance with Texas Health and Safety Code, §574.081(c) and (h), the name of the individual or entity responsible for providing and paying for the medication referenced in paragraph (6) of this subsection, which is not required to be the hospital.

(c) Documentation of refusal. If it is not feasible for any of the activities listed in subsection (a)(3) to be performed because the patient, the patient's LAR, or the patient's caregivers refuse to participate in the discharge planning, the circumstances of the refusal shall be documented in the patient's medical record.

§411.483.Discharge Notices and Release of Minors.

(a) Discharge notice to family or LAR.

(1) In accordance with Texas Health and Safety Code, §576.007, before discharging a patient who is 18 years of age or older, a hospital shall make a reasonable effort to notify the patient's family of the discharge if the patient grants permission for the notification.

(2) Before discharging a patient who is 16 or 17 years of age, or younger than 16 years of age and is or has been married, a hospital shall make a reasonable effort to notify the patient's family of the discharge if the patient grants permission for the notification.

(3) Before discharging a patient who is younger than 16 years of age and who is not or has not been married, a hospital shall notify the patient's LAR or the LAR's designee of the discharge.

(b) Release of minors. Except as required by §411.485(e) of this title, (relating to Discharge of an Involuntary Patient) upon discharge, the hospital may release a minor younger than 16 years of age only to the minor's LAR or the LAR's designee.

(c) Notice of protection and advocacy system. Upon discharge, the hospital must provide the patient with written notification of the existence, purpose, telephone number, and address of the protection and advocacy system established in Texas, which is Advocacy, Inc., as required by Texas Health and Safety Code, §576.008.

§411.484.Discharge of a Voluntary Patient Requesting Discharge.

(a) Request for discharge. If a hospital is informed that a voluntary patient desires to leave the hospital or a voluntary patient or the patient's LAR requests that the patient be discharged, the hospital shall, in accordance with Texas Health and Safety Code, §572.004:

(1) inform the patient or the patient's LAR that the request must be in writing and signed, timed, and dated by the requestor; and

(2) if necessary and as soon as possible, assist the patient in creating a written request for discharge and present it to the patient for the patient's signature.

(b) Responding to a written request for discharge. If a written request for discharge from a voluntary patient or the patient's LAR is made known to a hospital, the hospital shall:

(1) within four hours after the request is made known to the hospital, notify the treating physician or, if the treating physician is not available during that time period, notify another physician who is a hospital staff member of the request;

(2) file the request in the patient's medical record; and

(3) if the request is from a patient admitted under §411.461(a)(1)(B) of this title (relating to Voluntary Admission), notify the patient's LAR of the request.

(1) if the physician who is notified in accordance with subsection (b)(1) of this section does not have reasonable cause to believe that the patient may meet the criteria for court-ordered inpatient mental health services or emergency detention, a hospital shall discharge the patient within the four-hour time period described in subsection (b)(1) of this section; or

(2) if the physician who is notified in accordance with subsection (b)(1) of this section has reasonable cause to believe that the patient may meet the criteria for court-ordered inpatient mental health services or emergency detention, the physician shall examine the patient as soon as possible within 24 hours after the request for discharge is made known to the hospital.

(d) Discharge if not examined within 24 hours or if criteria not met.

(1) If a patient, who a physician believes may meet the criteria for court-ordered inpatient mental health services or emergency services, is not examined within 24 hours after the request for discharge is made known to the hospital, the hospital shall discharge the patient.

(2) In accordance with Texas Health and Safety Code, §572.004(d), if the physician conducting the examination described in subsection (c)(2) of this section determines that the patient does not meet the criteria for court-ordered inpatient mental health services or emergency detention, the hospital shall discharge the patient upon completion of the examination.

(e) Discharge or filing application if criteria met. In accordance with Texas Health and Safety Code, §572.004(d), if the physician conducting the examination described in subsection (c)(2) of this section determines that the patient meets the criteria for court-ordered inpatient mental health services or emergency detention, the hospital shall, by 4:00 p.m. on the next business day:

(1) file an application for court-ordered inpatient mental health services or emergency detention and obtain a court order for further detention of the patient; or

(2) discharge the patient.

(f) Notification by physician. In accordance with Texas Health and Safety Code, §572.004(d), if the hospital intends to detain a patient to file an application and obtain a court order for further detention of the patient, a physician shall:

(1) notify the patient of such intention; and

(2) document the reasons for the decision to detain the patient in the patient's medical record.

(g) Withdrawal of request for discharge. In accordance with Texas Health and Safety Code, §572.004(f), a hospital is not required to complete the discharge process described in this section if the patient makes a written statement to withdraw the request for discharge.

§411.485.Discharge of an Involuntary Patient.

(a) Discharge from emergency detention.

(1) Except as provided by §411.465 of this title (relating to Voluntary Treatment Following Involuntary Admission) and in accordance with Texas Health and Safety Code, §573.023(b) and §573.021(b), a hospital shall immediately discharge a patient under emergency detention if either of the following occurs:

(A) the administrator or the administrator's designee determines, based on a physician's determination, that the patient no longer meets the criteria described in subsection §411.462(c)(1) of this title (relating to Emergency Detention); or

(B) except as provided in paragraph (2) of this subsection, 24 hours elapse from the time the patient was presented to the hospital and the hospital has not obtained a court order for further detention of the patient.

(2) In accordance with Texas Health and Safety Code, §573.021(b), if the 24-hour period described in paragraph (1)(B) of this subsection ends on a Saturday, Sunday, or legal holiday, or before 4:00 p.m. on the next business day after the patient was presented to the hospital, the patient may be detained until 4:00 p.m. on such business day.

(3) In accordance with Texas Health and Safety Code, §573.021(b), the 24-hour period described in paragraph (1)(B) of this subsection does not include any time during which the patient is receiving necessary non-psychiatric medical care in the hospital's emergency room or non-psychiatric emergency care in another area of the hospital.

(b) Discharge under protective custody order. Except as provided by §411.465 of this title (relating to Voluntary Treatment Following Involuntary Admission) and in accordance with Texas Health and Safety Code, §574.028, a hospital shall immediately discharge a patient under a protective custody order if any of the following occurs:

(1) the administrator or the administrator's designee determines that, based on a physician's determination, the patient no longer meets the criteria described in Texas Health and Safety Code, §574.022(a);

(2) the administrator or the administrator's designee does not receive notice that the patient's continued detention is authorized after a probable cause hearing held within the time period prescribed by Texas Health and Safety Code, §574.025(b);

(3) a final order for court-ordered inpatient mental health services has not been entered within the time period prescribed by Texas Health and Safety Code, §574.005; or

(4) an order to release the patient is issued in accordance with Texas Health and Safety Code, §574.028(a).

(1) Except as provided by §411.465 of this title (relating to Voluntary Treatment Following Involuntary Admission), and in accordance with Texas Health and Safety Code, §574.085 and §574.086(a), a hospital shall immediately discharge a patient under a temporary or extended order for inpatient mental health services if either of the following occurs:

(A) the order for inpatient mental health services expires; or

(B) the administrator or the administrator's designee determines that, based on a physician's determination, the patient no longer meets the criteria for court-ordered inpatient mental health services.

(2) In accordance with Texas Health and Safety Code, §574.086(b), before discharging a patient in accordance with paragraph (1) of this subsection, the administrator or administrator's designee shall consider whether the patient should receive court-ordered outpatient mental health services in accordance with a modified order described in Texas Health and Safety Code, §574.061.

(d) Discharge under Texas Code of Criminal Procedure order for commitment. A patient admitted under an order for commitment issued in accordance with the Texas Code of Criminal Procedure, Article 46.02, Section 5 shall be discharged in accordance with the Texas Code of Criminal Procedure, Article 46.02, Section 5.

(e) Discharge under Texas Family Code order for placement. A patient admitted under an order for placement issued in accordance with Texas Family Code, §55.33(a)(1)(B) or §55.52(a)(1)(B) shall be discharged in accordance with the Texas Family Code, Chapter 55.

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 July 14, 2003.

TRD-200304240

Rodolfo Arredondo

Chairman, TDMHMR Board

Texas Department of Mental Health and Mental Retardation

Earliest possible date of adoption: August 24, 2003

For further information, please call: (512) 206-4581

6. DOCUMENTATION

25 TAC §411.488

The proposed new section affects THSC, §532.015(a), §571.006, and §577.010(a).

§411.488.Content of Medical Record.

(a) Medical record. A hospital shall maintain a medical record for a patient. The medical record shall include, at a minimum:

(1) documentation of whether the patient is a voluntary patient, on emergency detention, or under a court order, including the physician or court order, as appropriate;

(2) documentation of the reasons the patient, LAR, family members, or other caregivers state that the patient was admitted to the hospital;

(3) the level of monitoring assigned and implemented in accordance with §411.464 of this title (relating to Monitoring Upon Admission);

(4) the patient's written treatment plan;

(5) the name of the patient's treating physician;

(6) the names of the members of the patient's IDT, if required by the patient's length of stay;

(7) written findings of the physical examination described in §411.472(e)(1)(A) of this title (relating to Medical Services) or written findings of the physical examination described in §411.472(e)(1)(B) of this title (relating to Medical Services);

(8) written findings of:

(A) the psychiatric evaluation described in §411.472(f) of this title (relating to Medical Services); and

(B) the assessments described in §411.473(e) of this title (relating to Nursing Services), §411.474(d) of this title (relating to Social Services), §411.475(b) of this title (relating to Therapeutic Activities), and §411.476(b) of this title (relating to Psychological Services); and

(9) a summary of the revisions made to the treatment plan in accordance with §411.471(d)(2) of this title (relating to Inpatient Mental Health Treatment and Treatment Planning);

(10) the progress notes for the patient as described in subsection (b) of this section;

(11) documentation of the monitoring of the patient by the staff members responsible for such monitoring, including observations of the patient at pre-determined intervals; and

(12) the discharge summary as required by §411.482(b)(3)(D) of this title (relating to Discharge Planning).

(b) Progress notes.

(1) A physician, RN, and other members of the patient's IDT shall make written notes of a patient's progress. The progress notes shall contain, at a minimum:

(A) justification for each mental illness diagnosis and any substance use disorder diagnosis;

(B) the rationale for the treatment, services and interventions listed in the patient's treatment plan;

(D) documentation of the patient's progress toward meeting the goals listed in the patient's treatment plan;

(E) documentation of the discharge planning activities required by §411.482(a)(3) of this title (relating to Discharge Planning);

(F) documentation of the findings of a re-evaluation described in §411.472(g) of this title (relating to Medical Services);

(G) documentation of the findings of a reassessment described in §411.473(f) of this title (relating to Nursing Services), including any change in the patient's level of monitoring; and

(H) documentation of the findings of any other reassessment of the patient conducted by a member of the IDT.

(2) Requirements regarding the frequency of making progress notes are as follows:

(A) a physician shall make the documentation required by paragraph (1)(F) of this subsection at the time each reevaluation is conducted

(B) an RN shall make the documentation required by paragraph (1)(G) of this subsection at least once every 12 hours; and

(C) notwithstanding subparagraphs (A) and (B) of this paragraph, members of the IDT shall make a progress note as often as appropriate, including each time the patient's condition changes.

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 July 14, 2003.

TRD-200304241

Rodolfo Arredondo

Chairman, TDMHMR Board

Texas Department of Mental Health and Mental Retardation

Earliest possible date of adoption: August 24, 2003

For further information, please call: (512) 206-4581

7. STAFF DEVELOPMENT

25 TAC §411.490

The proposed new section affects THSC, §532.015(a), §571.006, and §577.010(a).

§411.490.Staff Member Training.

(a) Training of staff members. A hospital shall provide training to a staff member in accordance with the following:

(1) All staff members shall receive training in:

(A) abuse, neglect and exploitation of a patient, and illegal, unprofessional, or unethical conduct in the hospital in accordance with the memorandum of understanding set forth in 40 TAC §148.205 (relating to Training Requirements Relating to Abuse, Neglect and Unprofessional or Unethical Conduct);

(B) dignity and rights of a patient in accordance with Chapter 404, Subchapter E of this title (relating to Rights of Persons Receiving Mental Health Services); and

(C) confidentiality of a patient's information in accordance with Texas Health and Safety Code, Chapter 611 or Texas Health and Safety Code, Chapter 241, Subchapter G, as applicable, 42 CFR Part 2 and, 45 CFR Parts 160 and 164.

(2) A staff member providing treatment to or working with patients shall successfully complete a course, developed by the American Heart Association or the American Red Cross, in recognizing and caring for breathing and cardiac emergencies. The course shall teach the following skills:

(A) activation of the emergency response system (phone 911 or other appropriate response system);

(B) rescue breathing using mouth-to-mouth ventilation, mouth-to-barrier device ventilation (with and without oxygen), and bag-mask ventilation with oxygen for a victim;

(D) use of an automated external defibrillator; and

(E) relief of foreign-body airway obstruction in the responsive and unresponsive victim.

(3) An RN, LVN, and UAP shall receive training in:

(A) monitoring for patient safety in accordance with §411.477 of this title (relating to Protection of a Patient);

(B) infection control in accordance with §134.41(d) of this title (relating to Facility Functions and Services); and

(4) An RN and an LVN shall receive training in the process for reporting concerns regarding the adequacy of the staffing plan as described in §411.473(h) of this title (relating to Nursing Services).

(5) A staff member providing treatment to, working with, or providing consultation about a patient who is under the age of 18 shall receive training in the aspects of growth and development (including physical, emotional, cognitive, educational and social) and the treatment needs of patients in the following age groups:

(A) early childhood (1-5 years of age);

(B) late childhood (6-13 years of age); and

(6) A staff member providing treatment to, working with, or providing consultation about a patient diagnosed with COPSD shall receive training in substance use disorders.

(7) A staff member providing treatment to, working with, or providing consultation about a geriatric patient shall receive training in the social, psychological and physiological changes associated with aging.

(8) In accordance with Texas Health and Safety Code, §572.0025(e), a PASP shall receive at least eight hours of training in conducting a pre-admission screening as described in subsection (b) of this section.

(9) In accordance with Texas Health and Safety Code, §572.0025(e), a staff member whose responsibilities include conducting the hospital's intake process for a patient shall receive at least eight hours of training in the intake process.

(10) A staff member who may administer a voluntary or involuntary intervention shall receive training in and demonstrate competency in performing such interventions in accordance with Chapter 415, Subchapter F of this title (relating to Interventions in Mental Health Programs).

(b) Pre-admission screening training. The pre-admission screening training required by subsection (a)(8) of this section shall provide instruction to staff members regarding assessing, interviewing, and diagnosing an individual with a mental illness and an individual diagnosed with COPSD.

(1) The intake training required by subsection (a)(9) of this section shall provide instruction to staff members regarding:

(A) obtaining relevant information about the patient, including information about finances, insurance benefits and advance directives;

(B) explaining, orally and in writing, the patient's rights described in Chapter 404, Subchapter E of this title (relating to Rights of Persons Receiving Mental Health Services);

(D) informing the patient in writing of the existence, telephone number and address of the protection and advocacy system established in Texas, which is Advocacy, Inc.; and

(E) determining whether the patient comprehends the information provided in accordance with subparagraphs (B),(C) and (D) of this paragraph.

(2) Up to six hours of the training described in subsection (a)(1) of this section may be used toward the training required by subsection (a)(9) of this section

(d) Frequency of training. A hospital shall provide the training described in subsection (a) of this section, periodically, as follows:

(1) A staff member shall receive the training required by subsection (a)(1)(A) of this section at the intervals described in the memorandum of understanding set forth in 40 TAC §148.205 (relating to Training Requirements Relating to Abuse, Neglect and Unprofessional or Unethical Conduct).

(2) A staff member shall receive the training required by subsection (a)(1)(B) of this section:

(A) before assuming responsibilities at the hospital; and

(B) annually throughout the staff member's employment or association with the hospital;

(3) A staff member shall receive the training required by subsections (a)(1)(C) and (a)(3)-(7) of this section:

(A) before assuming his or her responsibilities at the hospital; and

(B) at reasonable intervals throughout the staff member's employment or association with the hospital.

(4) A staff member shall receive the training required by subsection (a)(2) of this section:

(A) before assuming responsibilities at the hospital; and

(B) at least every 24 months throughout the staff member's employment or association with the hospital.

(5) A PASP shall receive the training required by subsection (a)(8) of this section:

(A) prior to the PASP conducting a pre-admission screening; and

(B) annually throughout the PASP's employment or association with the hospital.

(6) A staff member shall receive the training required by subsection (a)(9) of this section:

(A) prior to conducting the intake process; and

(B) annually throughout the staff member's employment or association with the hospital.

(7) A staff member shall receive the training required by subsection (a)(10) of this section at the intervals described in Chapter 415, Subchapter F of this title (relating to Interventions in Mental Health Programs).

(e) Documentation of training.

(1) A hospital shall document that a staff member has successfully completed the training described in subsections (a)-(c) of this section including:

(A) the date of the training;

(B) the length of the training session; and

(2) A hospital shall maintain certification or other evidence issued by the American Heart Association or the American Red Cross that a staff member has successfully completed the training described in subsection (a)(2) of this section.

(f) Performance in accordance with training. A staff member shall perform his or her responsibilities in accordance with the training required by this section.

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 July 14, 2003.

TRD-200304242

Rodolfo Arredondo

Chairman, TDMHMR Board

Texas Department of Mental Health and Mental Retardation

Earliest possible date of adoption: August 24, 2003

For further information, please call: (512) 206-4581

8. PERFORMANCE IMPROVEMENT

25 TAC §§411.493 - 411.496

The proposed new sections affect THSC, §532.015(a), §571.006, and §577.010(a).

§411.493.Quality Assessment and Performance Improvement Program.

(a) Scope and content of program. A hospital shall develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The program shall:

(1) reflect the complexity of the hospital's organization and services;

(2) involve all of the hospital's departments and services;

(3) specify the frequency and detail of data collected; and

(4) focus on high-risk, high-volume, and problem-prone areas in the hospital.

(b) Approval by governing body. The hospital's quality assessment and performance improvement program shall be approved by the governing body.

(c) Staff member participation. The DPN, the director of psychiatric services, and other appropriate staff members shall participate in the development and implementation of the quality assessment and performance improvement program.

(d) Quality assessment and performance improvement program activities.

(1) As part of its quality assessment and performance improvement activities a hospital shall collect and aggregate data to:

(A) monitor the effectiveness and safety of services and the quality of care; and

(B) identify opportunities for improvement and changes that will lead to improvement.

(2) The hospital shall collect and aggregate data for each of the following performance indicators at a minimum:

(A) sentinel events;

(B) allegations of abuse and neglect as defined in §134.46 of this title (relating to Abuse and Neglect Issues);

(C) findings of abuse and neglect made by the Texas Department of Health in accordance with §134.46 of this title (relating to Abuse and Neglect Issues);

(D) patient rights violations;

(E) nosocomial infections;

(F) human cases of communicable diseases and infections that are required to be reported to the Texas Department of Health in accordance with Chapter 97 of this title (relating to Communicable Diseases);

(G) the use of voluntary and involuntary interventions as defined in Chapter 415, Subchapter F of this title (relating to Interventions in Mental Health Programs);

(H) the use of psychoactive medications in responding to a psychiatric emergency as defined in Chapter 405, Subchapter FF of this title (relating to Consent to Treatment with Psychoactive Medication);

(I) the use of electroconvulsive therapy as defined in Chapter 405, Subchapter E of this title (relating to Electroconvulsive Therapy (ECT));

(J) injuries of patients;

(K) medication errors;

(L) adverse drug reactions in patients;

(M) unauthorized departures of patients;

(N) discharges of patients against medical advice;

(O) deaths of patients;

(P) readmission of patients to the hospital within seven days of admission;

(Q) satisfaction of patients, patients' families, and LARs with hospital services; and

(R) complaints and grievances made by patients and patients' families.

(3) The hospital shall analyze the aggregated data using statistical techniques to identify any:

(A) trends in performance;

(B) significant variations from established benchmarks and practice guidelines;

(C) relationship between the data and the adequacy of the staffing plan required by §411.473(g) of this title (relating to Nursing Services); and

(D) areas of performance to be improved.

(4) The hospital shall develop and implement an action plan to improve the hospital's performance in the areas identified in accordance with paragraph (3)(D) of this subsection.

(5) The hospital shall include measurable outcomes for each area identified in the action plan.

(6) The hospital shall evaluate the implementation of the action plan to measure its success and determine if the measurable outcomes have been achieved and sustained.

(7) If the hospital determines that the measurable outcomes have not been achieved and sustained, the hospital shall modify the action plan and re-evaluate its implementation until the outcomes are achieved and sustained.

(e) Evidence of program. The hospital shall maintain and demonstrate evidence of the quality assessment and performance improvement program for review by an external review entity, including the Texas Department of Health, the Centers for Medicare and Medicaid Services, and the Joint Commission on Accreditation of Healthcare Organizations.

§411.494.Reporting and Investigating Sentinel Events.

A hospital shall develop and implement written procedures to identify, report, and investigate sentinel events. The procedures shall include the following:

(1) a description of the process by which a staff member reports a sentinel event, including a requirement that a sentinel event be reported by a staff member within at least 1 hour after a staff member becomes aware of the incident;

(2) a requirement that, within 24 hours of a sentinel event being reported, the administrator designate a committee to investigate the sentinel event that includes a physician, an RN, and any other staff members determined appropriate by the administrator; and

(3) a requirement that, within 45 days of the sentinel event being reported, the committee will determine and document:

(A) the cause(s) of the sentinel event;

(B) whether the cause(s) is random or is a pattern of error in the hospital's processes or systems;

(C) any improvements to the hospital's processes or systems that may reduce the occurrence of similar incidents in the future;

(D) how such improvements will be implemented including a timeline for implementation;

(E) the staff members responsible for such implementation; and

(F) a method to determine whether the improvements identified were effective in reducing the occurrence of similar incidents.

§411.495.Response to External Reviews.

A hospital shall develop and implement a written plan to evaluate the effectiveness of any plan of correction the hospital submits to an external review entity, including the Texas Department of Health, the Centers for Medicare and Medicaid Services, and the Joint Commission on Accreditation of Healthcare Organizations. If the evaluation indicates that the plan of correction has not been effective, the hospital shall modify the plan and re-evaluate it until its effectiveness is demonstrated.

§411.496.Advisory Committee for Nurse Staffing.

(a) Advisory committee members.

(1) A hospital shall establish an advisory committee that meets the requirements of Texas Health and Safety Code, §§161.031-161.033.

(2) At least one-third of the advisory committee shall be RNs who provide direct patient care at least 50% of their work time and at least one of the RNs shall be from either infection control, quality assurance, or risk management.

(3) For an identifiable mental health services unit in a hospital licensed under Texas Health and Safety Code, Chapter 241, and Chapter 133 of this title (relating to Hospital Licensing Rules), the advisory committee may be the advisory committee required by §133.41 of this title (relating to Hospital Function and Services).

(b) Advisory committee responsibilities. The advisory committee shall:

(1) consider input from RNs and LVNs regarding the adequacy of the staffing plan required by §411.473(g) of this title (relating to Nursing Services), including any concerns reported in accordance with the process required by §411.473(h) of this title (relating to Nursing Services);

(2) consider variances between planned and actual numbers of staff members, as indicated by a report to the advisory committee by the DPN made in accordance with §411.473(g)(6) of this title (relating to Nursing Services);

(3) make recommendations regarding the adequacy of the staffing plan required by §411.473(g) of this title (relating to Nursing Services);

(4) evaluate, at least annually, the staffing plan required by §411.473(g) of this title (relating to Nursing Services) including, in part, evaluating the data that has a relationship to the adequacy of the staffing plan as required by §411.493(d)(3)(C) of this title (relating to Quality Assessment and Performance Improvement Program); and

(5) document in the minutes of its meetings the actions required in paragraphs (1)-(4) of this subsection.

(c) Confidentiality of advisory committee records. As provided by Texas Health and Safety Code, §161.032, the records and proceedings of the advisory committee are confidential and not subject to court subpoena, or disclosure under Texas Government Code, Chapter 552.

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 July 14, 2003.

TRD-200304243

Rodolfo Arredondo

Chairman, TDMHMR Board

Texas Department of Mental Health and Mental Retardation

Earliest possible date of adoption: August 24, 2003

For further information, please call: (512) 206-4581

9. REFERENCES AND DISTRIBUTION

25 TAC §411.499, §411.500

The proposed new sections affect THSC, §532.015(a), §571.006, and §577.010(a).

§411.499.References.

The following federal and state statutes and rules are referenced in this subchapter:

(1) Texas Health and Safety Code:

(A) Chapters 97, 133, 134, 164, 241, 572, 573, 574, 577, and 611;

(B) Chapter 241 Subchapter G, and

(2) Texas Family Code, Chapter 55;

(3) Texas Government Code:

(A) Chapter 552, and

(B) §662.021;

(4) Texas Occupations Code, Chapters 155, 204, 301, 302, 454, 501, 502, 503, and 505;

(5) Texas Code of Criminal Procedure, Article 46.02;

(6) Code of Federal Regulations:

(A) 42 Part 2 and 45 Parts 160 and 164; and

(B) 42 §489.24(b);

(7) TAC, Chapter 148, and section, §148.205;

(8) Chapter 404, Subchapter E of this title (relating to Rights of Persons Receiving Mental Health Services);

(9) Chapter 405, Subchapter E of this title (relating to Electroconvulsive Therapy (ECT));

(10) Chapter 415, Subchapter F of this title (relating to Interventions in Mental Health Programs); and

(11) Chapter 405, Subchapter FF of this title (relating to Consent to Treatment with Psychoactive Medication);

§411.500.Distribution.

(a) This subchapter will be distributed to:

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

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

(3) psychiatric hospitals.

(b) Each psychiatric hospital will ensure distribution of this subchapter to all appropriate staff.

(c) The provisions of this subchapter will be distributed to the Texas Board of Health and appropriate staff at the Texas Department of Health.

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 July 14, 2003.

TRD-200304244

Rodolfo Arredondo

Chairman, TDMHMR Board

Texas Department of Mental Health and Mental Retardation

Earliest possible date of adoption: August 24, 2003

For further information, please call: (512) 206-4581

Subchapter M. STANDARDS OF CARE AND TREATMENT IN CRISIS STABILIZATION UNITS

The Texas Department of Mental Health and Mental Retardation (TDMHMR) proposes new §§411.601 - 411.604, §§411.608 - 411.613, §411.617, §§411.621 - 411.624, §§411.628 - 411.633, §411.637, §411.641, §§411.645 - 411.646, and §§411.649 - 411.650, of new Chapter 411, Subchapter M, governing standards of care and treatment in crisis stabilization units (CSU). The repeal of §§401.641 - 401.647 and §§401.649 - 401.652 of Chapter 401, Subchapter K, governing licensure of crisis stabilization units, which the new sections would replace, are contemporaneously proposed in this issue of the Texas Register .

The proposed new sections ensure the proper care and treatment of prospective patients and patients in CSUs licensed under Chapter 577, of the Texas Health and Safety Code (THSC), and Texas Department of Health (TDH) rules at Texas Administrative Code (TAC), Title 25, Chapter 134, governing private psychiatric hospitals and CSU licensing rules. The new sections address requirements related to admission, emergency treatment, treatment planning and services provided, discharge, transfer, documentation, staff training, and performance improvement.

A substantial portion of the proposed new sections, namely those concerning admission and discharge, are based on state law, primarily the THSC. Other sections, such as those concerning service requirements and performance improvement are derived from requirements in the Code of Federal Regulations (CFR) or the most recent edition of the Comprehensive Accreditation Manual for Hospitals promulgated by The Joint Commission on Accreditation of Healthcare Organizations (JCAHO). As required by THSC, §577.010(c), these proposed new sections are less stringent than rules governing private psychiatric hospitals proposed in this issue of the Texas Register .

The proposed new sections were developed in collaboration with The Texas Department of Health (TDH) which licenses private psychiatric hospitals, mental health services units in general and special hospitals, and crisis stabilization units and is responsible for enforcing TDMHMR rules that apply to these entities. Additionally, TDMHMR sought the advice of a variety of stakeholders including staff from the MHMR Authority of Harris County and Spindletop MHMR Services, community centers that operate CSUs, individual advocates, the Advisory Committee on Inpatient Mental Health Services (a statutorily authorized committee of representatives of the psychiatric hospital industry) and Advocacy, Incorporated.

In addition the new sections address relevant portions of House Bills 2679, and 2292 (78th Legislature). House Bill 2679, amends THSC, Chapter 573, to include §573.003, and permits a guardian of the person of an adult to transport the adult to a hospital, without the assistance of a peace officer, for preliminary examination under emergency detention. House Bill 2292 amends THSC, §572.0025(f), to permit a physician to use audiovisual or other telecommunications technology to conduct the admission examination for a voluntary patient.

The proposed new sections reference Chapter 415, Subchapter F, related to Interventions in Mental Health Programs, which is proposed in this issue of the Texas Register .

The proposed new sections contain general provisions that describe a CSU's responsibility in developing written policies and procedures and enforcing staff members' compliance with those policies and procedures. In addition, the proposed new sections set forth the admission criteria for CSUs to follow in determining who may be admitted for inpatient mental health treatment. Included as part of the admission criteria is a prohibition against the admission of persons who are under the age of 18 who aren't or haven't been married and persons who are under an order for temporary or extended inpatient mental health services. The department believes that minors and persons under a court commitment are more appropriately served in a setting such as a psychiatric hospital, where there are more specialized service options and additional staff resources available than required for a CSU. Further, the proposed new sections describe those processes and procedures required by the THSC for admission on a voluntary basis, by emergency detention, or a protective custody order for inpatient mental health services. The proposed new sections also require a CSU to assign and implement a level of monitoring to a patient upon admission of that patient which ensures any need for protection of the patient is addressed immediately.

To promote an efficient and coordinated system of ensuring proper responses to emergency medical conditions, the proposed new sections require a CSU to develop and implement a written plan describing the actions a CSU will take to stabilize common emergency medical conditions of patients and prospective patients. In addition, the proposed new sections require CSUs to determine appropriate time periods in which a physician will be physically present to respond to an emergency medical condition. Also, in order to ensure a continuity of treatment for a person transferred from the CSU to a general hospital because of an emergency medical condition, the proposed new sections require a CSU to provide certain information about the transferred person to the hospital. Further, the proposed new sections require a CSU to have a written agreement with a general hospital that ensures the hospital will accept persons transferred from the CSU because of an emergency medical condition. To enhance a CSU's effective response to individuals suffering cardiac arrest, the proposed new sections also require a CSU to have an automated external defibrillator

To ensure accountability for the provision of medical services, the proposed new sections require the assignment of a treating physician at the time a patient is admitted, timely availability of physicians, that a physical and psychiatric examination be conducted, and that the director of psychiatric services meet specified qualifications. To ensure a patient's current clinical status is adequately assessed and the course of treatment is appropriately monitored and modified, the proposed new sections require a psychiatrist to re-evaluate a patient at least two times a week.

The proposed new sections address nursing services, including the minimum qualifications for the chief nursing supervisor which serve to ensure that the chief nursing supervisor has the requisite education to oversee the nursing services provided at a CSU. The new sections also set forth the requirements regarding time frames for conducting the initial comprehensive nursing assessment and evaluations or reassessments conducted thereafter. The department believes that the proposed timeframe for conducting the initial nursing assessment and the time frame for conducting subsequent evaluations or reassessments establish an adequate standard for ensuring that a patient's initial and changing needs are identified and addressed.

The new sections also require the development and implementation of a nurse staffing plan. This requirement serves to ensure there are adequate numbers of qualified nurses and unlicensed assistive personnel to provide care to patients. The proposed new sections also describe requirements regarding verification of nursing staff licensure.

The new subchapter sets forth a process for protecting a patient through environmental modifications, identifying and implementing levels of monitoring for each patient, and decision-making based on a patient's needs and vulnerabilities.

The rule describes the discharge planning activities for hospitals to follow when discharging a patient. In addition the new sections set forth who is involved in the discharge planning and describe the discharge planning activities and content of the discharge summary. Further, the proposed new sections describe those processes and procedures required by the THSC for discharge notices, discharge of a voluntary patient and discharge of an involuntary patient.

The proposed new sections also describe procedures for transferring a patient to a psychiatric hospital or other health care facility. Specifically, the new sections require that a CSU facilitate transfer of a patient to a psychiatric hospital if the patient is a serious danger to self or others, if during a 24-hour period the patient is placed in excessive restraint or seclusion, or if the patient becomes subject to an order for inpatient mental health services. The reason for this requirement is that patients presenting these high levels of need are more appropriately served in a psychiatric hospital where there are more specialized service options and additional staff resources available than required for a CSU.

The new subchapter prohibits a voluntary patient from remaining in the CSU longer than 14 days in keeping with a CSU's design to provide short-term residential treatment to reduce acute symptoms of mental illness of a patient.

The proposed new sections also set forth requirements for the content of the medical record and progress notes based on JCAHO requirements and 42 CFR §482.61.

The proposed new sections describe the training for staff members required by THSC, §572.0025 and the training regarding abuse and neglect and patient rights currently required by other state rules. In addition, the proposed new rules set forth requirements for training staff about the confidentiality of patient information. Further, the proposed new sections require training on responding to cardiac emergencies, including the use of an automated external defibrillator. The proposed new sections also set forth requirements for staff providing treatment to or working with geriatric patients. In addition, the proposed new sections describe training requirements for staff regarding patient safety, and infection control. These training requirements serve to ensure staff members will be knowledgeable about relevant issues that affect the adequacy of patient care and will master the competencies necessary to provide quality services. The proposed new sections also set forth requirements for documentation of staff member training.

The proposed new sections also describe how a CSU will identify, report and investigate sentinel events in order to improve patient care and safety and implement improvements effective in reducing their reoccurrence. The new subchapter also contains provisions for a CSU to develop and implement a written plan to evaluate the effectiveness of plans of correction the CSU submits to external review entities.

Cindy Brown, chief financial officer, has determined that for each year of the first five year period that the proposed sections are in effect, enforcing or administering the sections does not have foreseeable implications relating to costs or revenues of state governments or revenues of local governments. There may be some impact to costs of local governments (i.e. community centers operating CSUs) as described in the following paragraph.

There is a probable economic cost to persons required to comply with the new rule, specifically, community centers operating CSUs, that are not currently in compliance with THSC §572.0025(f)(1). As interpreted by Texas Attorney General Opinion #0066-GA, THSC §572.0025(f)(1) requires that a physician personally conduct the admission examination of a patient for whom a request for voluntary admission to the CSU has been made, thereby prohibiting the physician from delegating the examination to a non-physician. For CSUs that are not in compliance with this statute there will be additional costs of ensuring that a physician conducts the admission examination. Additionally, the proposed new rule requires each CSU to have an automated external defibrillator as part of its emergency equipment. For CSUs that do not already have an automated external defibrillator, the cost to purchase one may range from $1,700 to $2,000 per defibrillator. Further, the proposed new sections require a CSU to develop and document an emergency medical response plan, develop a nurse staffing plan, and report and investigate sentinel events. For CSUs that are not currently conducting these activities, there may be increased costs related to time and staff to do so. Also, the new subchapter requires a CSU to conduct staff training not currently required by state law or rule. Implementing such training may result in increased costs related to time and staff for a CSU.

It is not anticipated the proposed new sections will have an adverse economic effect on small businesses or micro-businesses because they do not place additional requirements on those businesses than those in the rules proposed for repeal.

Sam Shore, director of Behavioral Health Services has determined for each year of the first five years the proposed new sections are in effect, the public benefit expected is the adoption of new and more current rules governing the care and treatment of prospective patients and patients in CSUs licensed under THSC, Chapter 577 and 25 TAC Chapter 134.

It is not anticipated the proposed new sections will affect a local economy.

1. GENERAL REQUIREMENTS

25 TAC §§411.601 - 411.604

These sections are proposed under the 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 or persons with mental illness; and THSC, §577.010(a), which provides the board with the authority to adopt rules and standards for the proper care and treatment of patients in a mental health facility required to obtain a license under THSC, Chapter 577.

The proposed new sections affect THSC, §532.015, §571.006, and §577.010.

§411.601.Purpose.

The purpose of this subchapter is to describe standards to ensure the proper care and treatment of prospective patients and patients in crisis stabilization units licensed under Chapter 577, of the Texas Health and Safety Code, and Chapter 134 of this title (relating to Private Psychiatric Hospitals and Crisis Stabilization Units Licensing Rules).

§411.602.Application.

This subchapter applies to crisis stabilization units licensed under Chapter 577, of the Texas Health and Safety Code, and Chapter 134 of this title (relating to Private Psychiatric Hospitals and Crisis Stabilization Units Licensing Rules).

§411.603.Definitions.

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

(1) Administrator--The individual, appointed by a governing body, who has authority to represent the CSU and, as delegated by the governing body, has responsibility for operating the CSU in accordance with the CSU's written policies and procedures.

(2) Administrator's designee--An individual designated in a CSU's written policies and procedures to act for a specified purpose on behalf of the administrator.

(3) Admission--The acceptance of an individual to a CSU's custody and care for crisis stabilization services, based on:

(A) a physician's order issued in accordance with §411.609(d)(2)(B) of this title (relating to Voluntary Admission);

(B) a physician's order issued in accordance with §411.610(c)(3) of this title (relating to Emergency Detention); or

(4) Business day--Any day except a Saturday, Sunday, or legal holiday.

(5) CSU or crisis stabilization unit--A crisis stabilization unit licensed under Chapter 577, of the Texas Health and Safety Code and Chapter 134 of this title (relating to Private Psychiatric Hospitals and Crisis Stabilization Units Licensing Rules).

(6) Crisis stabilization services--Short-term residential treatment designed to reduce acute symptoms of mental illness of a patient and prevent admission of the patient to a psychiatric hospital. Such treatment shall include but is not limited to medical services and nursing services.

(7) Discharge--The release by a CSU of a patient from the custody and care of the CSU.

(8) Emergency medical condition--A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in:

(A) placing the health of the individual or others in serious jeopardy;

(B) serious impairment to bodily functions;

(D) in the case of a pregnant woman who is having contractions:

(i) that there is inadequate time to effect a safe transfer to a hospital before delivery; or

(ii) that transfer may pose a threat to the health or safety of the woman or the unborn child.

(9) General hospital--A general hospital licensed under Chapter 241, of the Texas Health and Safety Code and Chapter 133 of this title (relating to Hospital Licensing Rules).

(10) Governing body--The governing authority of a CSU that is responsible for the CSU's organization, management, control and operation, including appointment of the administrator.

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

(12) Legal holiday--A holiday listed in the Texas Government Code, §662.021 and an officially designated county holiday applicable to a court in which proceedings under the Texas Mental Health Code are held.

(13) LVN or licensed vocational nurse--An individual who is licensed as a licensed vocational nurse by the Texas Board of Vocational Nurse Examiners in accordance with Texas Occupations Code, Chapter 302.

(14) Medical services--Services provided or delegated by a physician acting within the scope of his or her practice, as described in Texas Occupations Code, Chapter 155.

(15) Mental illness--An illness, disease, or condition (other than a sole diagnosis of epilepsy, senility, substance use disorder, mental retardation, autism, or pervasive developmental disorder) that:

(A) substantially impairs an individual's thought, perception of reality, emotional process, or judgment; or

(B) grossly impairs an individual's behavior as demonstrated by recent disturbed behavior.

(16) Monitoring--One or more staff members observing a patient on a continual basis or at pre-determined intervals and intervening when necessary to protect the patient from harming self or others.

(17) Nursing services--Services provided or delegated by a registered nurse acting within the scope of his or her practice, as described in Texas Occupations Code, Chapter 301.

(18) Nursing staff--Staff members of a CSU who are registered nurses, licensed vocational nurses or unlicensed assistive personnel.

(19) PASP or pre-admission screening professional--A staff member whose responsibilities include conducting a pre-admission screening and who meets the definition of "QMHP-CS or qualified mental health professional-community services" set forth in §412.303 of this title (relating to Definitions).

(20) Patient--An individual who has been admitted to a CSU and has not been discharged.

(21) Physician--An individual who is:

(A) licensed as a physician by the Texas State Board of Medical Examiners in accordance with Texas Occupations Code, Chapter 155; or

(22) Pre-admission screening--The clinical process used to gather information from a prospective patient, including a medical history, any history of substance use, and the problem for which the prospective patient is seeking treatment, to determine if a physician should conduct an admission examination.

(23) Prospective patient--An individual:

(A) for whom a request for voluntary admission has been made, in accordance with §411.609(a) of this title (relating to Voluntary Admission); or

(B) who has been accepted by a CSU for a preliminary examination, in accordance with §411.610(a) of this title (relating to Emergency Detention).

(24) Psychiatric hospital--A state mental health facility, a private psychiatric hospital licensed under Texas Health and Safety Code, Chapter 577, and Chapter 134 of this title (relating to Private Psychiatric Hospitals and Crisis Stabilization Units Licensing Rules), or an identifiable mental health services unit in a hospital licensed under Texas Health and Safety Code, Chapter 241, and Chapter 133 of this title (relating to Hospital Licensing Rules).

(25) Psychiatrist--A physician who is:

(A) certified in psychiatry by the American Board of Psychiatry and Neurology;

(B) eligible to take the examination necessary to be certified in psychiatry by the American Board of Psychiatry and Neurology; or

(C) currently in training in a psychiatric residency training program and is supervised by a physician who meets the criteria in subparagraph (A) or (B) of this paragraph.

(26) Psychosocial rehabilitative services--services which assist a patient in regaining and maintaining daily living skills required to function effectively in the community.

(27) RN or registered nurse--An individual who is licensed as a registered nurse by the Texas Board of Nurse Examiners in accordance with Texas Occupations Code, Chapter 301.

(28) Restraint--The use of any manual method, or physical or mechanical device, material or equipment attached to or adjacent to the patient's body that the patient cannot easily remove that restricts freedom of movement or normal access to the patient's body including a mechanical restraint, a personal restraint or a drug used as a restraint.

(29) Seclusion--The involuntary confinement of a patient away from other patients for any period of time in a hazard-free room or other area from which egress is prevented.

(30) Sentinel event--Any of the following occurrences that is unexpected and involves a patient:

(A) the death of an individual;

(B) the serious physical injury of an individual;

(D) circumstances that present the imminent risk of death, serious physical injury, or serious psychological injury of an individual.

(31) Stabilize--To provide such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a CSU or, if the emergency medical condition for a woman is that she is in labor, that the woman has delivered the child and the placenta.

(32) Staff members--Any and all personnel of a CSU including full-time and part-time employees, contractors, students, volunteers, and professionals granted privileges by the CSU.

(33) State mental health facility--A state hospital or state center with a mental health residential component.

(34) Substance use disorder--The use of one or more drugs, including alcohol, which significantly and negatively impacts one or more major areas of life functioning and which currently meets the criteria for substance abuse or substance dependence as described in the current edition of the Diagnostic Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association.

(35) TAC--The Texas Administrative Code.

(36) Transfer--The discharge of a patient from the CSU and the simultaneous movement of the patient to:

(A) a psychiatric hospital in accordance with §411.630(a) of this title (relating to Transfer Because of Dangerous Behavior, Restraint or Seclusion, Commitment Orders, or Medical Condition);

(B) a general hospital in accordance with §411.617(c) of this title (relating to Responding to an Emergency Medical Condition of a Prospective Patient or a Patient) or §411.630(b) of this title (relating to Transfer Because of Dangerous Behavior, Restraint or Seclusion, Commitment Orders, or Medical Condition);

(C) a health care entity in accordance with §411.630(b) of this title (relating to Transfer Because of Dangerous Behavior, Restraint or Seclusion, Commitment Orders, or Medical Condition); or

(D) a health care entity in accordance with §411.622(h)(4) of this title (relating to Medical Services).

(37) Treating physician--A physician who coordinates and oversees the implementation of a patient's comprehensive treatment plan.

(38) Unit--A discrete and identifiable area of a CSU that includes patients' rooms or other patient living areas and is separated from another similar area:

(A) by a locked door;

(B) by a floor; or

(39) UAP or unlicensed assistive personnel--An individual, not licensed as a health care provider, who provides certain health related tasks or functions in a complementary or assistive role to an RN in providing direct patient care or carrying out common nursing functions.

(40) Voluntary patient--A patient who is receiving crisis stabilization services based on an admission in accordance with:

(A) §411.609 of this title (relating to Voluntary Admission); or

(B) who is receiving crisis stabilization services in accordance with §411.613 of this title (relating to Voluntary Treatment Following Involuntary Admission).

§411.604.General Provisions.

(a) Written policies and procedures. A CSU shall develop written policies and procedures that ensure compliance with this subchapter.

(b) Compliance by staff. All staff members shall comply with this subchapter and the policies and procedures of the CSU required by subsection (a) of this section.

(c) Responsibility of CSU. A CSU shall be responsible for a staff member's compliance with this subchapter and the policies and procedures of the CSU required by subsection (a) of this section.

(d) Enforcement of polices and procedures. A CSU shall take appropriate measures, which may include disciplinary action, to ensure a staff member's compliance with this subchapter and the policies and procedures of the CSU required by subsection (a) of this section.

(e) Implementation of physician orders. A CSU shall implement all orders issued by a physician for a patient.

(f) Compliance with rules. A CSU shall comply with the following departmental rules:

(1) Chapter 404, Subchapter E of this title (relating to Rights of Persons Receiving Mental Health Services);

(2) Chapter 405, Subchapter E of this title (relating to Electroconvulsive Therapy);

(3) Chapter 415, Subchapter F of this title (relating to Interventions in Mental Health Programs); and

(4) Chapter 405, Subchapter FF of this title (relating to Consent to Treatment with 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 July 14, 2003.

TRD-200304226

Rodolfo Arredondo

Chairman, TDMHMR Board

Texas Department of Mental Health and Mental Retardation

Earliest possible date of adoption: August 24, 2003

For further information, please call: (512) 206-4581

2. ADMISSION

25 TAC §§411.608 - 411.613

The proposed new sections affect THSC, §532.015, §571.006, and §577.010.

§411.608.Admission Criteria.

A CSU shall develop and implement written admission criteria that:

(1) are uniformly applied to all prospective patients;

(2) permit the admission of a prospective patient only if:

(A) the prospective patient has a mental illness;

(B) the services provided in the CSU may reduce the prospective patient's acute symptoms and may prevent psychiatric hospitalization of the prospective patient; and

(C) the level of monitoring of the prospective patient in the CSU or restrictions of the environment of the CSU is adequate to prevent the prospective patient from causing serious harm to the prospective patient or others; and

(3) prevent the admission of a prospective patient who:

(A) is under the age of 18 unless he or she is or has been married;

(B) is the subject of an order for temporary inpatient mental health services issued in accordance with Texas Health and Safety Code, §574.034;

(C) is the subject of an order for extended inpatient mental health services issued in accordance with Texas Health and Safety Code, §574.035;

(D) requires specialized care not available at the CSU; or

(E) has a physical medical condition that is unstable and could reasonably be expected to require inpatient treatment for the condition.

§411.609.Voluntary Admission.

(a) Request for voluntary admission.

(1) A request for voluntary admission of a prospective patient may only be made by the prospective patient.

(2) In accordance with Texas Health and Safety Code, §572.001(b) and (e), a request for admission shall:

(A) be in writing and signed by the prospective patient; and

(B) include a statement that:

(i) the prospective patient agrees to remain in the CSU; and

(ii) consents to diagnosis, observation, care and treatment until the earlier of one of the following occurrences:

(I) the discharge of the prospective patient; or

(II) the prospective patient is entitled to leave the CSU, in accordance with Texas Health and Safety Code, §572.004, after a request for discharge is made.

(3) The consent given under paragraph (2)(B)(ii) of this subsection does not waive a patient's rights described in the rules listed under §411.604(f) of this title (relating to General Provisions).

(b) Capacity to consent. If a prospective patient does not have the capacity to consent to diagnosis, observation, care and treatment, as determined by a physician, the CSU may not admit the prospective patient on a voluntary basis. When appropriate, the CSU may initiate an emergency detention proceeding in accordance with Texas Health and Safety Code, Chapter 573, or file an application for court-ordered Inpatient Mental Health Services in accordance with Texas Health and Safety Code, Chapter 574.

(1) Prior to voluntary admission of a prospective patient, a PASP shall conduct a pre-admission screening of the prospective patient.

(2) If the PASP determines that the prospective patient does not need an admission examination, the CSU may not admit the prospective patient and shall refer the prospective patient to alternative services, if appropriate. If the PASP determines that the prospective patient needs an admission examination, a physician shall conduct an admission examination of the prospective patient.

(d) Requirements for voluntary admission. A CSU may voluntarily admit a prospective patient only if:

(1) a request for admission is made is accordance with subsection (a) of this section;

(2) a physician has:

(B) issued an order admitting the prospective patient;

(3) the prospective patient meets the CSU's admission criteria; and

(4) in accordance with Texas Health and Safety Code, §572.0025(f)(2), the administrator or administrator's designee has signed a written statement agreeing to admit the prospective patient.

(e) Intake. In accordance with Texas Health and Safety Code §572.0025(b), a CSU shall, prior to voluntary admission of a prospective patient, conduct an intake process, that includes:

(1) obtaining, as much as possible, relevant information about the prospective patient, including information about finances, insurance benefits and advance directives; and

(A) the CSU's services and treatment as they relate to the prospective patient; and

(B) the existence, purpose, telephone number, and address of the protection and advocacy system established in Texas, which is Advocacy, Inc., as required by Texas Health and Safety Code, §576.008.

(f) Admission examination.

(2) The physical examination may consist of an assessment for medical stability.

(3) The physician may not delegate conducting the admission examination to a non physician.

(g) Documentation of admission order. In accordance with Texas Health and Safety Code, §572.0025(f)(1), the order described in subsection (d)(2)(B) of this section shall be:

(1) issued in writing and signed by the issuing physician; or

(2) issued orally or electronically if, within 24 hours after its issuance, the CSU has a written order signed by the issuing physician.

§411.610.Emergency Detention

(a) Acceptance for preliminary examination. In accordance with Texas Health and Safety Code, §573.022, a CSU may accept for a preliminary examination:

(1) an individual who has been apprehended and transported to the CSU by a peace officer in accordance with Texas Health and Safety Code, §573.001 or §573.012; or

(2) an individual 18 years of age or older who has been transported to the CSU by the individual's guardian of the person in accordance with Texas Health and Safety Code, §573.003.

(b) Preliminary examination.

(1) A physician shall conduct a preliminary examination of the individual as soon as possible but not more than 24 hours after the individual was apprehended by the peace officer or arrived at the CSU after being transported by his or her guardian for emergency detention.

(2) The preliminary examination shall include:

(A) an assessment for medical stability; and

(B) a psychiatric examination to determine if the individual meets the criteria described in subsection (c)(1) of this section.

(1) in accordance with Texas Health and Safety Code, §573.022(a)(2), a physician determines from the preliminary examination that:

(A) the prospective patient has a mental illness;

(B) the prospective patient evidences a substantial risk of serious harm to himself or others;

(D) emergency detention is the least restrictive means by which the necessary detention may be accomplished;

(2) in accordance with Texas Health and Safety Code, §573.022(a)(3), a physician makes a written statement:

(A) documenting the determination described in paragraph (1) of this subsection; and

(B) describing:

(i) the nature of the prospective patient's mental illness;

(iii) the detailed information on which the physician based the determination described in paragraph (1) of this subsection;

(3) based on the determination described in paragraph (1) of this subsection, the physician issues an order admitting the prospective patient for emergency detention; and

(4) the prospective patient meets the CSU's admission criteria, as required by §411.608 of this title (relating to Admission Criteria).

(d) Release.

(1) A CSU shall release a prospective patient accepted for a preliminary examination if:

(A) a preliminary examination of the prospective patient has not been conducted within the time frame described in subsection (b)(1) of this section; or

(2) In accordance with Texas Health and Safety Code, §576.007, before releasing a prospective patient who is 18 years of age or older, the CSU shall make a reasonable effort to notify the prospective patient's family of the release, if the prospective patient grants permission for the notification.

(e) Intake. A CSU shall conduct an intake process as soon as possible, but not later than 24 hours after the time a patient is admitted for emergency detention.

(1) The intake process shall include but is not limited to:

(A) obtaining, as much as possible, relevant information about the patient, including information about finances, insurance benefits and advance directives; and

(B) explaining, orally and in writing, the patient's rights described in Chapter 404, Subchapter E of this title (concerning Rights of Persons Receiving Mental Health Services), including:

(i) the CSU's services and treatment as they relate to the patient; and

(ii) the existence, purpose, telephone number, and address of the protection and advocacy system established in Texas, which is Advocacy, Inc., as required by Texas Health and Safety Code, §576.008.

(2) The CSU shall determine whether the patient comprehends the information provided in accordance with paragraph (1)(B) of this subsection. If the CSU determines that the patient comprehends the information, the CSU shall document in the patient's medical record the reasons for such determination. If the CSU determines that the patient does not comprehend the information, the CSU shall:

(A) repeat the explanation to the patient at reasonable intervals until the patient demonstrates comprehension of the information or is discharged, whichever occurs first; and

(B) document in the patient's medical record the patient's response to each explanation and whether the patient demonstrated comprehension of the information.

§411.611.Admission Under Protective Custody Order.

(a) Requirements for protective custody. A CSU may admit an individual under a protective custody order only if a court has issued a protective custody order in accordance with Texas Health and Safety Code, §574.022.

(b) Intake. A CSU shall conduct an intake process as soon as possible, but not later than 24 hours after the time a patient is admitted under a protective custody order.

(1) The intake process shall include but is not limited to:

(A) obtaining, as much as possible, relevant information about the patient, including information about finances, insurance benefits and advance directives; and

(B) explaining, orally and in writing, the patient's rights described in Chapter 404, Subchapter E of this title (concerning Rights of Persons Receiving Mental Health Services), including:

(i) the CSU's services and treatment as they relate to the patient; and

(ii) the existence, purpose, telephone number, and address of the protection and advocacy system established in Texas, which is Advocacy, Inc., as required by Texas Health and Safety Code, §576.008.

(A) repeat the explanation to the patient at reasonable intervals until the patient demonstrates comprehension of the information or is discharged, whichever occurs first; and

(B) document in the patient's medical record the patient's response to each explanation and whether the patient demonstrated comprehension of the information.

(c) Intake process not required. If a CSU conducted the intake process for the patient while the patient was admitted for emergency detention and within 24 hours prior to the issuance of the protective custody order, the CSU is not required to comply with subsection (b) of this section.

§411.612.Monitoring Upon Admission.

At the time a patient is admitted, a CSU shall assign and implement one of the levels of monitoring identified by the CSU in accordance with §411.624(b) of this title (relating to Protection of a Patient), based on the patient's needs.

§411.613.Voluntary Treatment Following Involuntary Admission.

A CSU may provide crisis stabilization services to a patient admitted to the CSU in accordance with §411.610 of this title (relating to Emergency Detention) or §411.611 of this title (relating to Admission under Protective Custody Order) after the patient is eligible for discharge as described in §411.633(a)(1) and (b) of this title (relating to Discharge of an Involuntary Patient), if, prior to the provision of such services:

(1) the CSU obtains written consent from the patient for voluntary crisis stabilization services that meets the requirements of a request for voluntary admission, as described in §411.609(a) of this title (relating to Voluntary Admission); and

(2) the patient's treating physician:

(A) examines the patient; and

(B) based on that examination, issues an order for voluntary crisis stabilization services that meets the requirements of §411.609(g) of this title (relating to Voluntary Admission).

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 July 14, 2003.

TRD-200304227

Rodolfo Arredondo

Chairman, TDMHMR Board

Texas Department of Mental Health and Mental Retardation

Earliest possible date of adoption: August 24, 2003

For further information, please call: (512) 206-4581

3. EMERGENCY TREATMENT

25 TAC §411.617

This section is proposed under the 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 or persons with mental illness; and THSC, §577.010(a), which provides the board with the authority to adopt rules and standards for the proper care and treatment of patients in a mental health facility required to obtain a license under THSC, Chapter 577.

The proposed new section affects THSC, §532.015, §571.006, and §577.010.

§411.617.Responding to an Emergency Medical Condition of a Prospective Patient or a Patient.

(a) Planning responses to emergency medical conditions. A CSU shall:

(1) identify common emergency medical conditions of patients and prospective patients likely to be encountered by the CSU; and

(2) develop a written plan, approved in writing by the director of psychiatric services required by §411.622(b) of this title (relating to Medical Services), describing the specific and appropriate action to be taken by the CSU to stabilize each identified common emergency medical condition, which shall include:

(A) the administration of first aid and basic life support when clinically indicated;

(B) the use of the supplies and equipment described in subsection (f) of this section; and

(C) when the action to be taken is facilitating transfer of the patient or prospective patient, a description of the method of transportation and the name and location of the hospital to which a patient or prospective patient will be transferred.

(b) Availability of physicians.

(1) A CSU shall determine an appropriate time period in which a physician will be physically present at a CSU to respond to an emergency medical condition after being contacted by a staff member, in accordance with the plan required by subsection (a)(2) of this section.

(2) At least one physician shall, within the time period determined in accordance with paragraph (1) of this subsection, be physically present at the CSU to respond to an emergency medical condition.

(1) If a CSU determines that a patient or a prospective patient has an emergency medical condition, the CSU shall take action to stabilize the emergency medical condition within the capability of the CSU and in accordance with the plan required by subsection (a)(2) of this section, which may include summoning community emergency services for transfer to a general hospital.

(2) If the patient or prospective patient is transferred to a general hospital from the CSU, an RN shall, as soon as possible:

(A) inform the general hospital to which the transfer is made, by telephone, of:

(i) the general condition and medical diagnoses of the patient or prospective patient;

(ii) the medications administered and treatments given to the patient or prospective patient by the CSU; and

(iii) the prognosis of the patient or prospective patient; and

(B) provide a copy of the patient's or prospective patient's medical records to the general hospital to which the transfer is made.

(d) Transfer agreement. A CSU shall have a written agreement with a general hospital that the hospital will accept, for medical treatment and care, a prospective patient or patient transferred from the CSU in accordance with subsection (c) of this section.

(e) Qualified staff members. The CSU shall have an adequate number of staff members who are qualified and available to respond to emergency medical conditions in accordance with the plan required by subsection (a)(2) of this section.

(f) Supplies and equipment.

(1) The CSU shall have an adequate amount of appropriate supplies and equipment immediately available and fully operational at the CSU to respond to emergency medical conditions in accordance with the plan required by subsection (a)(2) of this section.

(2) The emergency supplies and equipment required by paragraph (1) of this subsection shall include, at a minimum:

(A) oxygen;

(B) a suction machine; and

(D) an automated external defibrillator.

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 July 14, 2003.

TRD-200304228

Rodolfo Arredondo

Chairman, TDMHMR Board

Texas Department of Mental Health and Mental Retardation

Earliest possible date of adoption: August 24, 2003

For further information, please call: (512) 206-4581

4. SERVICE REQUIREMENTS

25 TAC §§411.621 - 411.624

The proposed new sections affect THSC, §532.015, §571.006, and §577.010.

§411.621.Crisis Stabilization Services and Treatment Planning.

(a) Crisis stabilization services. A CSU shall provide a patient crisis stabilization services under the direction of a physician and in accordance with the patient's treatment plan, and this division.

(b) Treatment plan. A CSU shall develop and implement a written treatment plan within 24 hours after the patient's admission.

(1) The treatment plan shall include:

(A) a list of all substantiated diagnoses for the patient with notation as to which diagnoses will be treated at the CSU including:

(i) at least one mental illness diagnosis;

(ii) any substance use disorder diagnoses; and

(iii) any physical medical conditions;

(B) a description of all treatment interventions intended to address the patient's condition, including:

(i) the classes of medications prescribed and target symptoms listed for each class;

(ii) one of the levels of monitoring identified in accordance with §411.624(b) of this title (relating to Protection of a Patient);

(iii) nursing interventions;

(iv) psychosocial rehabilitative services; and

(v) counseling or psychotherapies; and

(2) The content of the treatment plan described in paragraph (1) of this subsection shall be based on:

(A) findings of the physical examination described in §411.622(e)(1)(A) of this title (relating to Medical Services) or findings of the physical examination described in §411.622(e)(1)(B) of this title (relating to Medical Services);

(B) the psychiatric evaluation described in §411.622(f) of this title (relating to Medical Services); and

(3) A CSU shall, prior to the implementation of the treatment plan:

(A) inform the patient of the content of the treatment plan; and

(B) obtain a written consent of the patient to the content or document the reasons such consent could not be obtained.

(1) The treatment plan shall be:

(A) reviewed and its effectiveness evaluated:

(i) at least every 72 hours after being implemented;

(ii) any time there is a change in the patient's condition based on findings from the re-evaluations described in §411.622(g) of this title (relating to Medical Services), or from the evaluations or reassessments described in §411.623(d) of this title (relating to Nursing Services); and

(iii) upon request by the patient or the patient's LAR; and

(B) revised, if necessary, based on findings from the re-evaluations described in §411.622(g) of this title (relating to Medical Services), from the reassessments described in §411.623(d) of this title (relating to Nursing Services), or information regarding recommended services and supports needed by the patient after discharge.

(2) A CSU shall, prior to the implementation of revisions to the treatment plan, inform the patient of any revisions to the treatment plan.

§411.622.Medical Services.

(a) Medical services in treatment plan. A CSU shall provide a patient medical services in accordance with a treatment plan developed in accordance with §411.621(b) of this title (relating to Crisis Stabilization Services and Treatment Planning).

(b) Director of psychiatric services. A CSU shall have a director of psychiatric services who directs, monitors, and evaluates the psychiatric services provided.

(1) is certified in psychiatry by the American Board of Psychiatry and Neurology or by the American Osteopathic Board of Psychiatry and Neurology; or

(2) has three years of experience as a physician in psychiatry in a "mental hospital" as defined in Texas Health and Safety Code, §571.003.

(d) Treating physician. A CSU shall assign a treating physician to a patient and document such assignment in the patient's medical record at the time the patient is admitted.

(e) Physical examination.

(1) A physician shall:

(A) review written findings of a physical examination of the patient conducted by another physician no more than seven days prior to the patient's admission; or

(B) conduct a physical examination of the patient.

(2) The physical examinations described in paragraph (1) of this subsection must include a neurological screening and, if indicated, a comprehensive neurological examination.

(f) Psychiatric evaluation. A psychiatrist shall conduct an initial psychiatric evaluation of a patient. The initial evaluation shall include:

(1) a description of the patient's medical history;

(2) a determination of the patient's mental status;

(3) a description of the onset of the mental illness and any substance use disorder and the circumstances leading to admission;

(4) an estimation of the patient's intellectual functioning, memory functioning and orientation;

(5) a description of the patient's strengths and disabilities in a descriptive, not interpretive fashion; and

(6) the diagnoses of the patient's mental illness, and, if applicable, any substance use disorders.

(g) Re-evaluation. A psychiatrist shall re-evaluate a patient based on the patient's needs but at least two times a week after the initial psychiatric evaluation described in subsection (f) of this section is conducted.

(h) Provision of medical services. A CSU shall, as appropriate under the circumstances:

(1) provide medical services to a patient in response to an emergency medical condition in accordance with the plan required by §411.617(a)(2) of this title (relating to Responding to an Emergency Medical Condition of a Prospective Patient or a Patient);

(2) provide other medical services, as needed by the patient;

(3) refer the patient to an appropriate health care provider; or

(4) transfer the patient to a health care entity that can provide the medical services.

(i) Availability of physicians. At least one physician shall, at all times, be available to staff members to provide medical consultation:

(1) by telephone, radio, or audiovisual telecommunication; or

(2) by being physically present at the CSU.

§411.623.Nursing Services.

(a) Nursing services in treatment plan. A CSU shall provide nursing services to a patient in accordance with a treatment plan developed in accordance with §411.621(b) of this title (relating to Crisis Stabilization Services and Treatment Planning).

(b) Chief nursing supervisor. A CSU shall have a chief nursing supervisor who is an RN and who directs, monitors, and evaluates the nursing services provided.

(c) Assessment. An RN shall conduct and complete an initial comprehensive nursing assessment of a patient within eight hours before or after the patient's admission.

(d) Evaluation or reassessment

(1) An LVN shall evaluate or an RN shall reassess a patient, based on the patient's needs, but at least every eight hours after the initial comprehensive nursing assessment required by subsection (c) of this section is conducted.

(2) If an LVN evaluates the patient every eight hours as permitted by paragraph (1) of this subsection, an RN shall reassess a patient at least every 24 hours after the initial comprehensive nursing assessment required by subsection (c) of this section is conducted.

(e) Staffing plan.

(1) The chief nursing supervisor shall develop and implement a written staffing plan that:

(A) describes the number of RNs, LVNs, and UAPs on each unit for each shift;

(B) provides for at least one LVN or one RN to be physically present and on-duty at all times on each unit when a patient is present on the unit;

(C) if an RN is not physically present and on-duty at all times on each unit when a patient is present on the unit, provides for an RN to be physically present at the CSU within 10 minutes of being contacted by a staff member;

(D) if the CSU has only one unit, at least two members of the nursing staff to be physically present and on-duty at all times on the unit when a patient is present on the unit; and

(E) provides for an adequate number of RNs on each unit to supervise all UAPs.

(2) The staffing plan described in paragraph (1) of this subsection shall be based on, at a minimum, the number of patients and the characteristics of the patients, including patient acuity.

(3) The chief nursing supervisor shall document his or her determinations made about the factors described in paragraph (2) of this subsection.

(4) A CSU shall retain the staffing plan and the documentation required by paragraph (3) of this subsection for two years after such documentation is created.

(5) The chief nursing supervisor shall revise the staffing plan, as necessary, when the factors described in paragraph (2) of this subsection change.

(f) Orientation of nursing staff.

(1) A CSU shall provide orientation to a nursing staff member when the staff member is initially assigned to a unit on either a temporary or long-term basis. The orientation shall include a review of:

(A) the location of equipment and supplies on the unit;

(B) the staff member's responsibilities on the unit;

(D) relevant schedules of staff members and patients; and

(E) procedures for contacting the staff member's supervisor.

(2) A CSU shall document the provision of orientation to nursing staff.

(g) Verification of licensure. A CSU shall verify that a member of the nursing staff, for whom a license is required, has a valid license at the time the staff member assumes responsibilities at the CSU and maintains the license throughout the staff member's employment or association with the CSU.

§411.624.Protection of a Patient.

(a) Modifying the environment and monitoring the patient. A CSU shall protect a patient by taking the following measures:

(1) modifying the CSU environment based on the patient's needs including:

(A) providing furnishings that do not present safety hazards to the patient;

(B) securing or removing objects that are hazardous to the patient; and

(2) monitoring the patient at the level of monitoring most recently specified in the patient's medical record; and

(3) making roommate assignments and other decisions affecting the interaction of the patient with other patients, based on patient needs and vulnerabilities.

(b) Levels of monitoring. A CSU shall:

(1) identify, in writing, the levels of monitoring of a patients; and

(2) define each of the levels of monitoring, in writing, including a description of the responsibilities of staff members for each level of monitoring identified.

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 July 14, 2003.

TRD-200304229

Rodolfo Arredondo

Chairman, TDMHMR Board

Texas Department of Mental Health and Mental Retardation

Earliest possible date of adoption: August 24, 2003

For further information, please call: (512) 206-4581

5. DISCHARGE

25 TAC §§411.628 - 411.633

The proposed new sections affect THSC, §532.015, §571.006, and §577.010.

§411.628.Discharge Planning.

(a) Involvement of staff, patient, and LAR in planning activities.

(1) Following the admission of a patient to a CSU, the CSU shall conduct discharge planning for the patient.

(2) Discharge planning shall involve qualified staff, the patient, the patient's LAR, and any other individual authorized by the patient or LAR.

(3) Discharge planning shall include, at a minimum, the following activities:

(A) qualified staff members recommending services and supports needed by the patient after discharge, including the placement after discharge;

(B) qualified staff members arranging for the recommended services and supports; and

(C) qualified staff members counseling the patient, the patient's LAR, and as appropriate, the patient's caregivers, to prepare them for post-discharge care.

(b) Discharge summary. The patient's treating physician shall prepare a written discharge summary that includes:

(1) a description of the patient's treatment at the CSU and the response to that treatment;

(2) a description of the patient's condition at discharge;

(3) a description of the patient's placement after discharge;

(4) a description of the services and supports the patient will receive after discharge;

(5) a final diagnosis based on all five axes of the DSM;

(6) in accordance with Texas Health and Safety Code §574.081(c), a description of the amount of medication the patient will need until the patient is evaluated by a physician; and

(c) Contact with the local mental health authority. In conducting the discharge planning activities described in subsection (a)(3)(A)-(B), a CSU shall consult with personnel at the local mental health authority who are responsible for ensuring continuity of care for individuals upon discharge from the CSU.

(d) Documentation of refusal. If it is not feasible for any of the activities listed in subsection (a)(3) to be performed because the patient, the patient's LAR, or the patient's caregivers refuse to participate in the discharge planning, the circumstances of the refusal shall be documented in the patient's medical record.

§411.629.Discharge Notices.

(a) Discharge notice to family. In accordance with Texas Health an Safety Code, §576.007, before discharging a patient, a CSU shall make a reasonable effort to notify the patient's family of the discharge if the patient grants permission for the notification.

(b) Notice of protection and advocacy system. Upon discharge, the CSU must provide the patient with written notification of the existence, purpose, telephone number, and address of the protection and advocacy system established in Texas, which is Advocacy, Inc., as required by Texas Health and Safety Code, §576.008.

§411.630.Transfer Because of Dangerous Behavior, Restraint or Seclusion, Commitment Orders, or Medical Condition.

(a) Transfer to psychiatric hospital. A CSU must immediately facilitate transfer of a patient to a psychiatric hospital, which may include contacting law enforcement or obtaining permission from the court that issued the protective custody order to transfer the patient, as appropriate, if:

(1) a physician determines that the patient is likely to cause serious danger to self or others in the CSU;

(2) during a 24 hour period:

(A) the patient is placed in seclusion:

(i) more than twice; or

(ii) for more than a total of four hours; or

(B) a restraint is applied to the patient for more than 60 consecutive minutes; or

(3) the patient becomes the subject of:

(A) an order for temporary inpatient mental health services issued in accordance with Texas Health and Safety Code, §574.034; or

(B) an order for extended inpatient mental health services issued in accordance with Texas Health and Safety Code, §574.035.

(b) Transfer to general hospital or other health care entity. A CSU must immediately facilitate transfer of a patient to a general hospital or another health care entity, as appropriate, if the patient:

(1) requires specialized care not available at the CSU; or

(2) has a physical medical condition that is unstable and could reasonably be expected to require inpatient treatment for the condition.

§411.631.Discharge of a Voluntary Patient.

(a) Request for discharge. If a CSU is informed that a voluntary patient desires to leave the CSU or a voluntary patient or the patient's LAR requests that the patient be discharged, the CSU shall, in accordance with Texas Health and Safety Code, §572.004:

(1) inform the patient or the patient's LAR that the request must be in writing and signed, timed, and dated by the requestor; and

(2) if necessary and as soon as possible, assist the patient in creating a written request for discharge and present it to the patient for the patient's signature.

(b) Responding to a written request for discharge. If a written request for discharge from a voluntary patient or the patient's LAR is made known to a CSU, the CSU shall:

(1) within four hours after the request is made known to the CSU, notify the treating physician or, if the treating physician is not available during that time period, notify another physician who is a CSU staff member of the request; and

(2) file the request in the patient's medical record.

(1) if the physician who is notified in accordance with subsection (b)(1) of this section does not have reasonable cause to believe that the patient may meet the criteria for court-ordered inpatient mental health services or emergency detention, a CSU shall discharge the patient within the four-hour time period described in subsection (b)(1) of this section; or

(d) Discharge if not examined within 24 hours or if criteria not met.

(2) In accordance with Texas Health and Safety Code, §572.004(d), if the physician conducting the examination described in subsection (c)(2) of this section determines that the patient does not meet the criteria for court-ordered inpatient mental health services or emergency detention, the CSU shall discharge the patient upon completion of the examination.

(1) file an application for court-ordered inpatient mental health services or emergency detention and obtain a court order for further detention of the patient; or

(2) discharge the patient.

(f) Notification by physician. In accordance with Texas Health and Safety Code, §572.004(d), if the CSU intends to detain a patient to file an application and obtain a court order for further detention of the patient, a physician shall:

(1) notify the patient of such intention; and

(2) document the reasons for the decision to detain the patient in the patient's medical record.

(g) Withdrawal of request for discharge. In accordance with Texas Health and Safety Code, §572.004(f), a CSU is not required to complete the discharge process described in this section if the patient makes a written statement to withdraw the request for discharge.

§411.632.Maximum Length of Stay for a Voluntary Patient.

A CSU shall discharge a voluntary patient on the 14th day after the patient's admission, unless:

(1) the patient is discharged earlier:

(A) in accordance with §411.631 of this title (relating to Discharge of a Voluntary Patient); or

(B) based on an order by the patient's treating physician; or

(2) the patient is transferred earlier:

(A) in accordance with §411.630 of this title (relating to Transfer Because of Dangerous Behavior, Restraint or Seclusion, Commitment Orders, or Medical Condition);

(B) in accordance with §411.617(c) of this title (relating to Responding to an Emergency Medical Condition of a Prospective Patient or a Patient); or

§411.633.Discharge of an Involuntary Patient.

(a) Discharge from emergency detention.

(1) Except as provided by §411.613 of this title (relating to Voluntary Treatment Following Involuntary Admission) and in accordance with Texas Health and Safety Code, §573.023(b) and §573.021(b), a CSU shall immediately discharge a patient under emergency detention if either of the following occurs:

(A) the administrator or the administrator's designee determines, based on a physician's determination, that the patient no longer meets the criteria described in subsection §411.610(c)(1) of this title (relating to Emergency Detention); or

(B) except as provided in paragraph (2) of this subsection, 24 hours elapse from the time the patient was presented to the CSU and the CSU has not obtained a court order for further detention of the patient.

(2) In accordance with Texas Health and Safety Code, §573.021(b), if the 24-hour period described in paragraph (1)(B) of this subsection ends on a Saturday, Sunday, or legal holiday, or before 4:00 p.m. on the next business day after the patient was presented to the CSU, the patient may be detained until 4:00 p.m. on such business day.

(b) Discharge under protective custody order. Except as provided by §411.613 of this title (relating to Voluntary Treatment Following Involuntary Admission) and in accordance with Texas Health and Safety Code, §574.028, a CSU shall immediately discharge a patient under an order of protective custody if any of the following occurs:

(1) the CSU administrator or designee determines that, based on a physician's determination, the patient no longer meets the criteria described in Texas Health and Safety Code, §574.022(a);

(2) the CSU administrator or designee does not receive notice that the patient's continued detention is authorized after a probable cause hearing held within the time period prescribed by Texas Health and Safety Code, §574.025(b);

(3) a final order for court-ordered inpatient mental health services has not been entered within the time period prescribed by Texas Health and Safety Code, §574.005; or

(4) an order to release the patient is issued in accordance with Texas Health and Safety Code, §574.028(a).

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 July 14, 2003.

TRD-200304230

Rodolfo Arredondo

Chairman, TDMHMR Board

Texas Department of Mental Health and Mental Retardation

Earliest possible date of adoption: August 24, 2003

For further information, please call: (512) 206-4581

6. DOCUMENTATION

25 TAC §411.637

The proposed new section affects THSC, §532.015, §571.006, and §577.010.

§411.637.Content of Medical Record.

(a) Medical record. A CSU shall maintain a medical record for a patient. The medical record shall include, at a minimum:

(1) documentation of whether the patient is a voluntary patient, on emergency detention, or under a protective custody order, including the physician or court order, as appropriate;

(2) documentation of the reasons the patient, LAR, family members, or other caregivers state that the patient was admitted to the CSU;

(3) the level of monitoring assigned and implemented in accordance with §411.612 of this title (relating to Monitoring Upon Admission);

(4) the patient's written treatment plan;

(5) the name of the patient's treating physician;

(6) written findings of the physical examination described in §411.622(e)(1)(A) of this title (relating to Medical Services) or written findings of the physical examination described in §411.622(e)(1)(B) of this title (relating to Medical Services);

(7) written findings of the psychiatric evaluation described in §411.622(f) of this title (relating to Medical Services), the assessment described in §411.623(c) of this title (relating to Nursing Services), and any other assessment of the patient conducted by a staff member;

(8) a summary of the revisions made to the written treatment plan in accordance with §411.621(c) of this title (relating to Crisis Stabilization Services and Treatment Planning);

(9) the progress notes for the patient as described in subsection (b) of this section;

(10) documentation of the monitoring of the patient by the staff members responsible for such monitoring, including observations of the patient at pre-determined intervals; and

(11) the discharge summary as required by §411.628(b) of this title (relating to Discharge Planning).

(b) Progress notes.

(1) A physician, RN, and other staff members shall make written notes of a patient's progress. The progress notes shall contain, at a minimum:

(A) justification for each mental illness diagnosis and any substance use disorder diagnosis;

(B) the rationale for the treatment, services and interventions listed in the patient's treatment plan;

(D) documentation of the discharge planning activities required by §411.628(a)(3) of this title (relating to Discharge Planning);

(E) documentation of the findings of a re-evaluation described in §411.622(g) of this title (relating to Medical Services);

(F) documentation of the findings of an evaluation or a reassessment described in §411.623(d) of this title (relating to Nursing Services), including any change in the patient's level of monitoring; and

(G) documentation of the findings of any other reassessment of the patient conducted by a staff member.

(2) Requirements regarding the frequency of making progress notes are as follows:

(A) a physician shall make the documentation required by paragraph (1)(E) of this subsection at the time each re-evaluation is conducted;

(B) an RN or LVN, as appropriate, shall make the documentation required by paragraph (1)(F) of this subsection at the time each evaluation or reassessment is conducted; and

(C) notwithstanding subparagraphs (A) and (B) of this paragraph, staff members shall make a progress note as often as appropriate, including each time the patient's condition changes.

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 July 14, 2003.

TRD-200304231

Rodolfo Arredondo

Chairman, TDMHMR Board

Texas Department of Mental Health and Mental Retardation

Earliest possible date of adoption: August 24, 2003

For further information, please call: (512) 206-4581

7. STAFF DEVELOPMENT

25 TAC §411.641

The proposed new section affects THSC, §532.015, §571.006, and §577.010.

§411.641.Staff Member Training.

(a) Training of staff members. A CSU shall provide training to a staff member in accordance with the following:

(1) All staff members shall receive training in:

(A) abuse, neglect and exploitation of a patient, and illegal, unprofessional, or unethical conduct in the CSU in accordance with the memorandum of understanding set forth in 40 TAC §148.205 (relating to Training Requirements Relating to Abuse, Neglect and Unprofessional or Unethical Conduct);

(B) dignity and rights of a patient in accordance with Chapter 404, Subchapter E of this title (relating to Rights of Persons Receiving Mental Health Services); and

(C) confidentiality of a patient's information in accordance with Texas Health and Safety Code, Chapter 611 or Texas Health and Safety Code, Chapter 241, Subchapter G , as applicable, the Code of Federal Regulations, Title 42, Part 2, and the Code of Federal Regulations, Title 45, parts 160 and 164.

(A) activation of the emergency response system (phone 911 or other appropriate response system);

(B) rescue breathing using mouth-to-mouth ventilation, mouth-to-barrier device ventilation (with and without oxygen), and bag-mask ventilation with oxygen for a victim;

(D) use of an automated external defibrillator; and

(E) relief of foreign-body airway obstruction in the responsive and unresponsive victim.

(3) An RN, LVN, and UAP shall receive training in:

(A) monitoring for patient safety in accordance with §411.624 of this title (relating to Protection of a Patient); and

(B) infection control in accordance with §134.41(d) of this title (relating to Facility Functions and Services).

(4) A staff member providing treatment to, working with, or providing consultation about a geriatric patient shall receive training in the social, psychological and physiological changes associated with aging.

(5) In accordance with Texas Health and Safety Code, §572.0025(e), a PASP shall receive at least eight hours of training in conducting a pre-admission screening.

(6) In accordance with Texas Health and Safety Code, §572.0025(e), a staff member whose responsibilities include conducting the CSU's intake process shall receive at least eight hours of training in the intake process.

(7) A staff member who may administer a voluntary or involuntary intervention shall receive training in and demonstrate competency in performing such interventions in accordance with Chapter 415, Subchapter F of this title (relating to Interventions in Mental Health Programs).

(b) Intake training.

(1) The intake training required by subsection (a)(6) of this section shall provide instruction to staff members regarding:

(A) obtaining relevant information about the patient, including information about finances, insurance benefits and advance directives;

(B) explaining, orally and in writing, the patient's rights described in Chapter 404, Subchapter E of this title (relating to Rights of Persons Receiving Mental Health Services);

(D) in accordance with Texas Health and Safety Code, §576.008, informing the patient in writing of the existence, telephone number and address of the protection and advocacy system established in Texas, which is Advocacy, Inc.; and

(E) determining whether the patient comprehends the information provided in accordance with subparagraphs (B), (C) and (D) of this paragraph.

(2) Up to six hours of the training described in subsection (a)(1) of this section may be used toward the training required by subsection (a)(6) of this section.

(c) Frequency of training. A CSU shall provide the training described in subsection (a) of this section, periodically, as follows:

(2) A staff member shall receive the training required by subsection (a)(1)(B) of this section:

(A) before assuming responsibilities required by the CSU; and

(B) annually throughout the staff member's employment or association with the CSU.

(3) A staff member shall receive the training required by subsections (a)(1)(C) and (a)(3) and (4) of this section:

(A) before assuming his or her responsibilities at the CSU; and

(B) at reasonable intervals throughout the staff member's employment or association with the CSU.

(4) A staff member shall receive the training required by subsection (a)(2) of this section:

(A) before assuming responsibilities at the CSU; and

(B) at least every 24 months throughout the staff member's employment or association with the CSU.

(5) A PASP shall receive the training required by subsection (a)(5) of this section:

(A) prior to the PASP conducting a pre-admission screening; and

(B) annually throughout the PASP's employment or association with the CSU.

(6) A staff member shall receive the training required by subsection (a)(6) of this section:

(A) prior to conducting the intake process; and

(B) annually throughout the staff member's employment or association with the CSU.

(7) A staff member shall receive the training required by subsection (a)(7) of this section at the intervals described in Chapter 415, Subchapter F of this title (relating to Interventions in Mental Health Programs).

(d) Documentation of training.

(1) A CSU shall document that a staff member has successfully completed the training described in subsections (a) and (b) of this section including:

(A) the date of the training;

(B) the length of the training session; and

(2) A CSU shall maintain certification or other evidence issued by the American Heart Association or the American Red Cross that a staff member has successfully completed the training described in subsection (a)(2) of this section.

(e) Performance in accordance with training. A staff member shall perform his or her responsibilities in accordance with the training required by this section.

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 July 14, 2003.

TRD-200304232

Rodolfo Arredondo

Chairman, TDMHMR Board

Texas Department of Mental Health and Mental Retardation

Earliest possible date of adoption: August 24, 2003

For further information, please call: (512) 206-4581

8. PERFORMANCE IMPROVEMENT

25 TAC §411.645, §411.646

The proposed new sections affect THSC, §532.015, §571.006, and §577.010.

§411.645.Reporting and Investigating Sentinel Events.

A CSU shall develop and implement written procedures to identify, report and investigate sentinel events. The procedures shall include the following:

(1) a description of the process by which a staff member reports a sentinel event, including a requirement that a sentinel event be reported by a staff member within at least one hour after a staff member becomes aware of the incident;

(3) a requirement that, within 45 days of the sentinel event being reported, the committee will determine and document:

(A) the cause(s) of the sentinel event;

(B) whether the cause(s) is random or is a pattern of error in the CSU's processes or systems;

(C) any improvements to the CSU's processes or systems that may reduce the occurrence of similar incidents in the future;

(D) how such improvements will be implemented including a timeline for implementation;

(E) the staff members responsible for such implementation; and

(F) a method to determine whether the improvements identified were effective in reducing the occurrence of similar incidents.

§411.646.Response to External Reviews.

A CSU shall develop and implement a written plan to evaluate the effectiveness of any plan of correction the CSU submits to an external review entity, including the Texas Department of Health, the Centers for Medicare and Medicaid Services, and the Joint Commission on Accreditation of Healthcare Organizations. If the evaluation indicates that the plan of correction has not been effective, the CSU shall modify the plan and re-evaluate it until its effectiveness is demonstrated.

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 July 14, 2003.

TRD-200304233

Rodolfo Arredondo

Chairman, TDMHMR Board

Texas Department of Mental Health and Mental Retardation

Earliest possible date of adoption: August 24, 2003

For further information, please call: (512) 206-4581

9. REFERENCES AND DISTRIBUTION

25 TAC §411.649, §411.650

The proposed new sections affect THSC, §532.015, §571.006, and §577.010.

§411.649.References.

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

(1) Texas Health and Safety Code:

(A) Chapters 133, 134, 164, 241, 572, 573, 574, 577, and 611;

(B) Chapter 241 Subchapter G, and

(2) Texas Government Code, §662.021;

(3) Texas Occupations Code, Chapters 155, 301, and 302;

(4) TAC 40 §148.205;

(5) Code of Federal Regulations Title 42, Part 2, and Title 45, parts 160 and 164

(6) Chapter 404, Subchapter E of this title (relating to Rights of Persons Receiving Mental Health Services);

(7) Chapter 405, Subchapter E of this title (relating to Electroconvulsive Therapy (ECT));

(8) Chapter 415, Subchapter F of this title (relating to Interventions for Mental Health Programs);

(9) Chapter 405, Subchapter FF of this title (relating to Consent to Treatment with Psychoactive Medication), and

(10) Chapter 412, Subchapter G of this title (relating to Mental Health Community Service Standards).

§411.650.Distribution.

(a) This subchapter will be distributed to:

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

(2) management and program staff in TDMHMR's Central Office;

(3) CEOs of all state hospitals and state centers; and

(4) CEOs of all crisis stabilization units.

(b) CEOs are responsible for distributing this subchapter to appropriate staff members.

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 July 14, 2003.

TRD-200304234

Rodolfo Arredondo

Chairman, TDMHMR Board

Texas Department of Mental Health and Mental Retardation

Earliest possible date of adoption: August 24, 2003

For further information, please call: (512) 206-4581

Chapter 412. LOCAL AUTHORITY RESPONSIBILITIES

Subchapter G. MENTAL HEALTH COMMUNITY SERVICES STANDARDS

2. ORGANIZATIONAL STANDARDS

25 TAC §412.308

The Texas Department of Mental Health and Mental Retardation (TDMHMR) proposes an amendment to §412.308, concerning environment of care and safety, of Chapter 412, Subchapter G, concerning mental health community services standards.

The amendment to §412.308 would update the section to delete references to sections being repealed, i.e., references to Chapter 405, Subchapter F, governing voluntary and involuntary behavioral interventions in mental health programs. The amended section would include the citation of new sections governing the same matters in Chapter 415, Subchapter F, governing interventions in mental health programs. The repeals and the new sections governing restraint are contemporaneously proposed with this proposal of an amendment in this issue of the Texas Register .

Cindy Brown, chief financial officer, has determined that for each year of the first five years the proposed amendment is in effect, enforcing or administering the amended section does not have foreseeable implications relating to costs or revenues of state government.

There is no anticipated economic cost to small businesses, micro-businesses, and local governments which are required to comply with the amended section.

Sam Shore, director of Behavioral Health Services, has determined that for each year of the first five years the proposed amendment is in effect, the public benefit will be the promulgation of clear requirements that better ensure the safety and protection of individuals involved in the use of personal restraint and seclusion in community mental health programs. It is not anticipated that there will be any additional economic cost to persons required to comply with the amendment.

It is not anticipated that the proposed amendment will affect a local economy.

Comments concerning the proposed amendment 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.

The amendment 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, §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; and THSC, §576.024, concerning use of physical restraint.

The proposed amendment would affect Texas Health and Safety Code, §534.052, §571.006, §576.024, and §577.010.

§412.308.Environment of Care and Safety.

(a)-(d) (No change.)

(e) Use of restraint and seclusion. The provider is prohibited from using any restraint or seclusion on a consumer except as provided for in paragraphs (1) and (2) of this subsection, in which case the restraint or seclusion must be in accordance with §§415.253-415.255, §415.257, §§415.261-415.274, and §§415.290-415.292 of Chapter 415, Subchapter F of this title (relating to Interventions in Mental Health Programs [ ~~§405.125, §405.127, and §405.132 of Chapter 405, Subchapter F of this title (relating to Voluntary and Involuntary Behavioral Interventions in Mental Health Programs)~~ ].

(1) In an emergency involving a child, adolescent, or adult, personal restraint may be used.

(2) In an emergency involving a child or adolescent in a partial hospitalization program or a day program for acute needs, seclusion may be used.

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 July 14, 2003.

TRD-200304260

Rodolfo Arredondo

Chairman, Texas MHMR Board

Texas Department of Mental Health and Mental Retardation

Earliest possible date of adoption: August 24, 2003

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

Chapter 415. PROVIDER CLINICAL RESPONSIBILITIES

The Texas Department of Mental Health and Mental Retardation (TDMHMR) proposes new §§415.251 - 415.257, 415.261-415.274, 415.285, 415.290-415.292, and 415.299-415.300 of new Chapter 415, Subchapter F, governing interventions in mental health programs. The new sections would provide updated requirements governing restraint, seclusion, clinical timeout, and quiet time, and distinguish restraint and seclusion as they are used in medical, dental, and surgical procedures from their use in emergency situations. The new subchapter would replace Chapter 405, Subchapter F, governing voluntary and involuntary behavioral interventions in mental health programs, which is contemporaneously proposed for repeal in this issue of the Texas Register .

Research has shown that the risk of injury or death to individuals involved in the use of restraint and seclusion is of a degree of significance that merits preventive actions to eliminate or reduce their use and minimize the risk of harm when they must be used. Federal and state governments, professional associations and individual practitioners, patient, family and advocacy groups, accrediting organizations, university researchers, and the media have articulated a heightened sensitivity to the inherent risks these interventions pose and the need for specific precautions in their use. The proposed new subchapter is responsive to this evolving body of knowledge and public concern and bases its provisions on current best evidence and emerging legal and regulatory initiatives.

The new sections ensure protection of the rights and well-being of individuals during the use of interventions of restraint, seclusion, clinical timeout, and quiet time in the following mental health services settings: state hospitals, state centers, and the Waco Center for Youth; psychiatric hospitals; identifiable mental health services units of acute care and specialty hospitals; crisis stabilization units; and providers, as defined in §412.303(30) of this title (relating to Definitions) of TDMHMR rules governing mental health community services standards (Chapter 412, Subchapter G), to the extent applicable as described in §412.308 of this title (relating to Environment of Care and Safety).

The proposed new sections incorporate federal regulations promulgated in 1999 by the Health Care Financing Administration, now known as the Centers for Medicare and Medicaid Services (CMS). A new Medicare condition of participation related to patients' rights was promulgated in the Code of Federal Regulations (CFR), Title 42, §482.13. It set new standards for the use of restraint for acute medical and physical care and for behavior management in an emergency situation. The standard for use of restraint and seclusion for behavior management included stringent requirements concerning the maximum duration of restraint and seclusion, similar to existing requirements of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). It additionally set forth a new requirement for a physician to personally evaluate an individual within one hour of the implementation of an order for restraint or seclusion. It defined "restraint" to include manual restraint, mechanical restraint, and any drug that is not standard treatment for an individual's medical or psychiatric condition that is used for purposes of restraint. The federal regulations also required reporting deaths attributable to restraint or seclusion to the federal government.

In 1999, TDMHMR notified stakeholders of the new federal requirements and then began the development of new restraint and seclusion rules as part of its rules sunset review process. The new sections were developed in collaboration with the Texas Department of Health (TDH). TDH, which licenses psychiatric hospitals, mental health services units in acute care and specialty hospitals, and crisis stabilization units, is responsible for enforcing TDMHMR rules that apply to these entities. Additionally TDMHMR sought the advice of the Advisory Committee on Inpatient Mental Health Services, which is statutorily authorized to advise the Texas Board of Mental Health and Mental Retardation concerning the regulation of private psychiatric hospitals. The committee includes consumers, family members, adult and child psychiatrists, and other hospital providers. Other individual stakeholders also had input into the development of the new sections.

The new subchapter updates the terminology of existing Chapter 405, Subchapter F. The proposed new sections address actions to be taken by staff when an environmental or medical emergency occurs while an individual is in restraint or seclusion. The minimum credentials for staff who initiate, order, and evaluate restraint or seclusion are clarified, as are the prescribed timeframes for the duration of a restraint or seclusion episode. The proposed new sections distinguish between restraint and seclusion and interventions and procedures that are not restraint or seclusion.

In response to statements from the Substance Abuse Mental Health Services Administration (SAMHSA) and the National Association of State Mental Health Program Directors (NASMHPD) President's Council that restraint and seclusion are not considered treatment, TDMHMR is prohibiting the use of restraint and seclusion as part of a behavior therapy program in the proposed new sections. TDMHMR's goal is to minimize the use of restraint and seclusion and to utilize these interventions as a last resort when less restrictive measures have failed. Medicare regulations in CFR §482.13 limit the use of restraint or seclusion in behavioral emergencies and state that an individual has the right to be free from restraint or seclusion which is used as a means of coercion or discipline. The federal regulations do not allow standing or as-needed orders for restraint or seclusion because a physician must order the interventions each time they are used.

The new sections would prohibit the use of restraint boards except for transporting an individual during a behavioral emergency or for medical and dental procedures for which use of a restraint board is the standard and customary practice. Other mechanical restraints are safer than restraint boards when the duration of restraint in a behavioral emergency is expected to be longer than the period of time necessary to transport an individual to a protected location. This policy, which is currently in effect in state-operated mental health facilities, would be extended to private sector inpatient mental health programs consistent with TDMHMR's commitment to uniform standards of care for mental health services in Texas.

In response to recurring questions and requests for technical assistance from staff who are required to transport individuals between care settings and to locations off premises, the proposed new sections provide procedures for initiating restraint in a behavioral emergency that occurs off premises, prior to transportation, and during transportation.

Based on national reports that indicate that many restraint-related deaths could be prevented by close observation and health monitoring of the individual in restraint, and in compliance with CMS and JCAHO requirements, the proposed new sections require that a staff member who is not involved in the physical restraint of an individual monitor the physical health of the individual during a restraint episode. The new sections also provide more detailed requirements for training staff who may be required to participate in restraining or secluding an individual. These provisions build on existing requirements, place greater emphasis on training that prepares staff to prevent or avoid the use of restraint and seclusion, and focus on improved techniques in the use of restraint or seclusion when it cannot be avoided.

Cindy Brown, 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 government.

There is an anticipated economic cost to small businesses, micro-businesses, and local governments which are required to comply with the new subchapter. Psychiatric hospitals in Texas that do not comply with JCAHO standards and providers of community-based mental health programs may incur additional training costs related to materials, time, and staff.

It is not anticipated that the sections will affect a local economy.

Kenny Dudley, director of State Mental Health Facilities, and Sam Shore, director of Behavioral Health Services, have 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 clear requirements that better ensure the safety and protection of individuals involved in the use of voluntary and involuntary interventions in mental health programs. It is not anticipated that there will be any additional economic cost to persons required to comply with the new subchapter.

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 9:30 a.m., Friday, August 15, 2003, 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 Linda Brown at least 72 hours prior to the hearing at (512) 206-4747 or at the TDY phone number of Texas Relay, 1/800-735-2988.

Subchapter F. INTERVENTIONS IN MENTAL HEALTH PROGRAMS

1. GENERAL PROVISIONS

25 TAC §§415.251 - 415.257

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 or 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; 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; and THSC, §576.024, concerning use of physical restraint.

The proposed sections affect Texas Health and Safety Code, §534.052, §567.024, §571.006, §576.024, and §577.010.

§415.251.Purpose.

The purpose of this subchapter is to ensure protection of the rights and well-being of individuals during the use of voluntary and involuntary interventions.

§415.252.Application.

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

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

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

(3) 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;