Policies And Procedures For Outpatient Facilities

(1) The facility must have a written policy and procedures manual which includes the following elements: (a) A quality assurance procedure which assesses the quality of care at the facility. This procedure must ensure appropriate treatment has been delivered according to acceptable clinical practice; (b) A written program description which must be available to staff, clients and members of the public. The description must include, but need not to be limited to, the following: 1. Services offered by the facility, availability of staff (including medical) to provide services and hours of operation, 2. Characteristics of the person(s) to be served, 3. Referral process, 4. Admission criteria, 5. Re-admission criteria, 6. Facility rules for client, 7. Referral mechanisms for services outside the agency (both medical and non- medical), 8. Emergency and non-emergency transportation of clients, and 9. Discharge criteria; (c) Policies and procedures which address the methods for managing disruptive behavior; (d) If restrictive procedures are used to manage disruptive behaviors, written policies and procedures must govern their use and must minimally ensure the following: MINIMUM PROGRAM REQUIREMENTS FOR MENTAL CHAPTER 0940-05-14 HEALTH OUTPATIENT FACILITIES 1. Restrictive procedures will be used by the facility only after all less-restrictive alternatives for dealing with the problem behavior have been systematically tried or considered and have been determined to be inappropriate or ineffective, 2. The client must have given written consent to any restrictive measures taken with him/her by the clinical staff, 3. The restrictive procedure(s) must be documented in the Individual Program Plan, be justifiable as part of the plan and meet all requirements that govern the development and review for the plan, 4. Only mental health professionals or mental health personnel may use restrictive procedures and must be adequately trained in their use, and 5. The adaptive or desirable behavior should be taught to the client in conjunction with the implementation of the restrictive procedures; and (e) A policy which states Physical Holding must be implemented in such a way as to minimize any physical harm to the client and may only be used when the client poses an immediate threat under the following conditions: 1. The client poses an immediate danger to self or others, and/or 2. To prevent the client from causing substantial property damage.