Psychiatric services in hospitals

1. General acute hospitals providing psychiatric services are subject to the psychiatric services in hospitals requirements for specialized hospitals in this section. If, in the course of the inspection of a general acute hospital, the department finds from a review of the psychiatric treatment rendered and the adequacy of the consultation and referral resources that the hospital practice and staffing warrants the establishment of a psychiatric service, the department shall notify the hospital of the need to establish the service in a manner that complies with this section. 2. Primary care hospitals may not provide psychiatric services. 3. Any facility that provides or purports to provide psychiatric inpatient or inpatient and outpatient diagnosis or treatment on other than an emergency basis shall comply with this section. A hospital may not hold itself out to the public as providing psychiatric services unless such psychiatric service has been licensed by the department and meets the requirements for a psychiatric hospital in this section. a. Hospitals accredited by a national accrediting entity in the category of psychiatric services shall submit, upon receipt, all accreditation survey results, recommendations, and plans of correction to the department. b. In hospitals without an approved psychiatric service, psychiatric care to patients with a primary diagnosis of a psychiatric disorder may be rendered on an emergency basis by appropriate members of the medical staff as determined by the hospital. Psychiatric consultation must be available and utilized appropriately as determined by the hospital. c. The organization and responsibilities of the medical staff for psychiatric services must be in accordance with licensure requirements, except as amended and modified: (1) The physician in charge of the psychiatric services must be a psychiatrist who is licensed to practice medicine in North Dakota. (2) The psychiatrists on the staff of the psychiatric hospital or psychiatric services of a general acute hospital must have as minimum qualifications at least three years' approved residency training in psychiatry or equivalent training and experience. If physicians other than psychiatrists are authorized to treat patients in a psychiatric hospital or in a psychiatric service there must be timely evidence of psychiatric consultation after the patient is admitted, and ongoing consultation with a psychiatrist who is a member of the psychiatric staff, as needed. (3) There must be other medical staff in appropriate specialties, available at all times to the psychiatric staff. d. The organization and staffing of the nursing service must be in accordance with the licensure requirements, except as amended and modified: (1) The registered nurse supervising the nursing services of the psychiatric services must have experience and demonstrated competency in psychiatric nursing. (2) The nursing personnel of the psychiatric services in a general acute hospital must be a separate staff who are assigned to the psychiatric services. (3) There must be at least one registered nurse with experience in psychiatric nursing on duty at all times on each psychiatric nursing unit. The number of registered nurses and other nursing personnel must be adequate to provide the individual patient care required to carry out the patient care plan for each patient. e. The following services or consultative resources are required: clinical psychological services, social work services, and occupation and recreational therapy services. These services must be under the direction of a psychiatrist in charge of the psychiatric services in a general acute hospital or the psychiatric diagnosis or treatment units in a psychiatric hospital. The staff used to support these services must be adequate in number and be qualified by professional education, experience, and demonstrated ability. If registration or licensing of personnel is required by statute or regulation, the registration number must be on file and available upon request. f. Personnel development and training for psychiatric services staff must include the following: (1) There must be written evidence of orientation training for all staff and ongoing, planned, and scheduled inservice training for all staff. (2) Ongoing interdisciplinary staff conferences must be held to ensure communication, coordination, and participation of all professional staff and personnel involved in the care of patients. g. Specialized procedures for psychiatric services must be provided for and implemented as follows: (1) A patient may not be subject to the withholding of privileges or to any system of rewards, except as part of a treatment plan. (2) Electroconvulsive therapy, experimental treatments involving any risk to the patient, or aversion therapy may not be prescribed, unless: (a) The patient's treatment team has documented in the patient's record that all reasonable and less intensive treatment modalities have been considered, the treatment represents the most effective therapy for the patient at that time, the patient has been given a full explanation of the nature and duration of the proposed treatment and why the treatment team is recommending the treatment, and the patient has been informed of the right to accept or refuse the proposed treatment and, if the patient consents, has the right to revoke the consent for any reason at any time prior to or between treatments. (b) The treatment was recommended by qualified staff members trained and experienced in the treatment procedure and has been approved by the psychiatrist. (c) The patient has given written informed consent to the specific proposed treatment. In the alternative, oral informed consent is sufficient if that consent is witnessed by two individuals not part of the patient's treatment team. In either case, such consent must be limited to a specified number of maximum treatments over a period of time and must be revocable at any time before or between treatments. Such withdrawal of consent is immediately effective. (d) If a patient's treatment team determines that the patient could benefit from one of those specified treatments but also believes that the patient does not have the capacity to give informed consent to the treatment, appropriate consent consistent with applicable state laws must be obtained before such treatment may be administered to the patient. (3) A patient may not be subject to chemical, physical, or psychological restraints, including seclusion, other than in accordance with the policy and procedures for seclusion and restraint approved by the medical staff and governing body. A copy of the applicable regulations must be made available to patients upon request. (4) A patient may not be the subject of any research, unless conducted in strict compliance with federal regulations on the protection of human subjects. Patients considered for research approved by the hospital must receive and understand a full explanation of the nature of the research, the expected benefit, and the potential risk involved. Copies of the federal regulations must be made available to patients or their advocates involved in, or considering becoming involved in, research. h. If the treatment team determines that continued voluntary inpatient treatment is not indicated, the treatment team shall discharge the patient with an appropriate postdischarge plan. The postdischarge plan must address followup needs, future consultative needs, or in the event of patient regression or deterioration, treatment or admission needs. i. Care of patients for psychiatric services must include the following: (1) Each psychiatric unit shall have available recreational and occupational therapy and other appropriate facilities adequate in size in relation to patient population, number of beds, and program. (2) Restraints and seclusion facilities must be available, and written policies must be established for their use. Mechanical restraints or seclusion may be used only on the written order of a physician. This written order must be valid for specific periods of time. In an emergency, the licensed professional in charge may order restraints. Confirmation of the order by a physician must be secured. Policies and procedures regarding use of restraints and seclusion must be reviewed annually. The patient medical record must indicate justification for the restraint, time applied and released, and other pertinent information. (3) A current policy and procedure manual must be maintained for the psychiatric service. The manual must include procedures for the care and treatment of patients including the care of suicidal and assaultive patients, and the elopement of patients. The manual must identify the relationship with state agencies and community organizations providing psychiatric services. It must also describe plans for the evaluation and disposition of psychiatric emergencies. (4) The design of facilities and the selection of equipment and furnishings must be conducive to the psychiatric program and must minimize hazards to psychiatric patients. j. The psychiatric services shall develop an interdisciplinary team composed of mental health professionals, health professionals, and other individuals who may be relevant to the patient's treatment. At least one member of the team must be a psychiatrist. The team and patient or advocate shall formulate and evaluate an appropriate treatment plan for the patient. (1) The director of the interdisciplinary team shall assure that staff trained and experienced in the use of modalities proposed in the treatment plan participate in its development, implementation, and review. (2) The director of the interdisciplinary team is responsible for: (a) Ensuring that the patient in treatment is encouraged to become increasingly involved in the treatment planning process. (b) Implementing and reviewing the individualized treatment plan and participating in the coordination of service delivery with other service providers. (c) Ensuring that the unique skills and knowledge of each team member are utilized and that specialty consultants are utilized when needed. (3) Although an interdisciplinary team must be under the direction of a psychiatrist, specific treatment modalities may be under the direction of other mental health professionals when they are specifically trained to administer or direct such modalities. k. A comprehensive individualized treatment plan must: (1) Be formulated to the extent feasible with the consultation of the patient. When appropriate to the patient's age, or with the patient's consent, the patient's family, personal guardian, or appropriate other individuals should be consulted about the plan. (2) Be based upon diagnostic evaluation that includes examination of medical, psychological, social, cultural, behavioral, familial, educational, vocational, and developmental aspects of the patient's situation. (3) Set forth treatment objectives and prescribe an integrated program of therapies, activities, experiences, and appropriate education designed to meet these objectives. (4) Result from the collaborative recommendation of the patient's interdisciplinary team. (5) Be maintained and updated with progress notes, and be retained in the patient's medical record. (6) State the basis for the restraints if the plan provides for restraints. The patient medical record must indicate what less restrictive alternatives were considered and why they were not utilized. (7) Be written in terms easily explainable to the lay person. A copy of the current treatment plan must be available for review by the patient in treatment. (8) Note when the most appropriate form of treatment for the individual is not available or is too expensive to be feasible. l. At least once every seven days every patient in treatment must be plan reviewed. A report of the review and findings must be summarized in the patient's medical record and the treatment plan must be updated as necessary. m. Subject to certain limitations authorized by a parent, legal guardian, legal custodian, or a court of law concerning a minor or guardian of an individual who is incapacitated or restrictions by the treating physician or psychiatrist, which in their professional judgment is in the best interest of the patient, each patient has the right to: (1) Receive or refuse treatment for mental and physical ailments and for the prevention of illness or disability. (2) The least restrictive conditions necessary to achieve the purposes of the treatment plan. (3) Be treated with dignity and respect. (4) Be free from unnecessary restraint and isolation. (5) Visitation and telephone communications. (6) Send and receive mail. (7) Keep personal clothing and possessions. (8) Regular opportunities for outdoor physical exercise. (9) Participate in religious worship of choice. (10) Be free from unnecessary medication. (11) Exercise all civil rights, including the right to habeas corpus. (12) Not be subjected to experimental research without the express written consent of the patient or of the patient's guardian. (13) Not be subjected to psychosurgery, electroconvulsive treatment, or aversive reinforcement conditioning, without the express and informed written consent of the patient or the patient's guardian. n. Each hospital must have a clearly defined appeal system through which any patient who wishes to voice objections concerning the patient's treatment must be heard and have objections determined. (1) Each hospital shall monitor the appeal system to see that it works properly and records must be maintained for review by the department in order to investigate any complaint. (2) All patients must be advised of such system and be encouraged to use it when they believe their treatment plan is not necessary or appropriate to their needs. o. Medical record requirements for psychiatric hospitals and psychiatric services of general acute hospitals must include the following: (1) Medical records must stress the psychiatric components of the patient's condition and care including history of findings and treatment rendered for the psychiatric condition for which the patient is hospitalized. (2) A provisional or admitting diagnosis must be made on every patient at the time of admission and include the diagnoses of current diseases as well as the psychiatric diagnoses. (3) Data from all pertinent sources must be included, in addition to data obtained from the patient. (4) A psychiatric evaluation must be performed within forty-eight hours of admission, include a medical history, contain a record of mental status, and note the onset of illness, the circumstances leading to admission, attitudes, behavior, estimate of intellectual functions, memory functioning, orientation, and an inventory of the patient's assets in descriptive, not interpretive, fashion. (5) A complete neurological examination must be recorded at the time of the admission physical examination, when indicated. (6) Social service records, including reports of interviews with patients, family members, and others must provide an assessment of home plans, family attitudes, and community resource contacts, with appropriate recommendations for family or community resource involvement, as well as a social history. (7) Reports of consultations, reports of electroencephalograms, and other pertinent reports of special studies. (8) The patient's comprehensive treatment plan must be recorded, must be based on an inventory of the patient's strengths as well as disabilities, and must include a substantiated diagnosis in the terminology of the most current edition of the American psychiatric association's diagnostic and statistical manual, short-term and long-range goals, and the specific treatment modalities utilized as well as the responsibilities of each member of the treatment team in such a manner that it provides adequate justification and documentation for the diagnoses and for the treatment and rehabilitation activities carried out. (9) The treatment received by the patient must be documented to assure that all active therapeutic efforts such as individual and group psychotherapy, drug therapy, milieu therapy, occupational therapy, recreational therapy, industrial or work therapy, nursing care, and other therapeutic interventions are included. (10) The discharge summary must include a recapitulation of the patient's hospitalization and recommendations from appropriate services concerning followup or aftercare as well as a brief summary of the patient's condition on discharge. (11) Confidentiality of the psychiatric record must be recognized and safeguarded in medical records services of the hospital.