Regulation text
Subject 82-3-1 ADULT CRISIS STABILIZATION UNITS
Rule 82-3-1-.01 Legal Authority
These regulations have been promulgated to ensure that basic
statutory licensing requirements to operate Adult Crisis Stabilization Units
(CSUs) and any associated Crisis Service Center (CSC) and/or Temporary
Observation (Temp Obs) functions are met and to ensure that organizations
providing this service promote the empowerment and recovery of the individuals
they serve. These rules are adopted and published pursuant to the Official Code
of Georgia Annotated (O.C.G.A) Sec.
37-1-29
. These rules and
regulations supersede any and all prior operational standards related to the
designation or certification of Crisis Stabilization Units.
Rule 82-3-1-.02 Title and Purpose
1.
The purpose of these rules is to establish
general licensing procedures, operational requirements and enforcement
procedures required by the Department of Behavioral Health and Developmental
Disabilities (DBHDD) for CSUs. The issuance of a CSU operating license requires
compliance with these rules and regulations and authorizes the licensee to
establish services to meet the needs of the individuals in a safe, therapeutic
environment and to set forth the minimum requirements for providing short term
residential, psychiatric stabilization and detoxification services.
2.
Compliance with this chapter does not
constitute release from the requirements of other applicable federal, state, or
local laws, codes, rules, regulations and ordinances. This chapter must be
followed where it exceeds other codes and ordinances.
3.
Licensure of the CSU does not constitute
an entitlement to any type or level of funding by DBHDD.
Rule 82-3-1-.03 Definitions
The following words and terms, when used in this chapter,
shall have the following meanings, unless the context clearly indicates
otherwise:
1.
Abuse means any
unjustifiable intentional or grossly negligent act, exploitation or series of
acts, or omission of acts which causes physical or mental injury or endangers
the safety of an individual, including but not limited to, verbal abuse,
assault or battery, failure to provide treatment or care, or sexual harassment
of the individual;
2.
Adult means an
individual who is either eighteen (18) years of age or older or an emancipated
minor;
3.
Advanced Practice Nursing
means practice under a "Nurse Protocol Agreement", which is a written document,
mutually agreed upon and signed by an APRN and a physician, by which the
physician delegates to that APRN the authority to perform certain medical acts
pursuant to O.C.G.A. Sec.
43-34-25
, which may include
without being limited to, the ordering of drugs, medical devices, medical
treatments, diagnostic studies, or in life-threatening situations radiographic
imaging tests;
1.
Advanced Practice
Registered Nurse, (hereinafter referred to as APRN), means a registered
professional nurse licensed under Title 43, Chapter 25 of the Official Code of
Georgia Annotated, who is recognized by the Georgia Board of Nursing as having
met the requirements established by the Georgia Board of Nursing to engage in
advanced nursing practice and who holds a master's degree or other graduate
degree approved by the Georgia Board of Nursing and national board
certification in his or her area of specialty, or a person who is recognized as
an advanced practice registered nurse by the Georgia Board of Nursing on or
before June 30, 2006;
2.
Behavioral
Health Crisis Center (BHCC) is a CSU which includes CSC and Temp Obs functions
and has the capacity to accept individuals in crisis who can present for
screening, assessment and evaluation by the appropriate practitioner and can
receive referral to the next appropriate level of care. A BHCC is licensed as
CSU and all provisions herein apply;
3.
Certificate of Need as defined in O.C.G.A.
Sec.
31-6-2
means an official
determination by the Department of Community Health (DCH), evidenced by
certification issued pursuant to an application, that the action proposed in
the application satisfies and complies with the criteria contained in the
Georgia Code and rules promulgated by DCH;
4.
Certified Addiction Counselor means an
individual who is certified by one of the approved certifying bodies recognized
by the state of Georgia, i.e. the Alcohol and Drug Abuse Certification Board of
Georgia or the Georgia Addiction Counselor's Association;
5.
Charge Nurse means a registered nurse who
has the responsibility for coordination and supervision of nursing services
during the period of a work shift;
6.
Chemical Restraint means an
over-the-counter or prescribed medication or drug that is administered to
manage an individual's behavior in a way that reduces the safety risk to the
individual or to others that has the effect of reducing the individual's
freedom of movement and that is not a standard treatment for the individual's
medical or psychiatric condition;
7.
Chief Executive Officer (CEO) means the
person, by whatever title used, whom the governing body has delegated the
responsibility for the management and operation of the facility including the
implementation of the rules and policies adopted by the governing
body;
8.
Commissioner means the
commissioner of the Department of Behavioral Health and Developmental
Disabilities (DBHDD);
9.
Contraband
means any item or article of property that poses a threat to the security and
safety of the CSU and any associated CSC and/or Temp Obs individuals,
employees, visitors or public, or other items prohibited by CSU or state
law;
10.
Crisis Bed means any bed
operated by the Crisis Stabilization Unit excepting transitional beds as
defined within;
11.
Crisis Service
Center (CSC) provides short-term intervention designed to be time limited,
generally a single episode that stabilizes the individual and moves them to the
appropriate level. CSCs are generally open twenty-four hours, seven day a week
and provide walk-in capacity for assessment, stabilization, and
referral;
12.
Crisis Stabilization
Unit (CSU) means a medically monitored short-term residential program that is
licensed by the Department under these rules and designated by the Department
as an emergency receiving and evaluating facility to provide emergency
disability services that include providing psychiatric stabilization and
detoxification services twenty-four hours a day, seven days a week. If a CSU
operates a CSC and/or Temp Obs area in conjunction with the CSU, these areas
are considered a part of the CSU for the purposes of these Rules and
Regulations, as determined necessary and applicable by DBHDD to meet the needs
of individuals in a safe, therapeutic environment;
13.
Department means the Department of
Behavioral Health and Developmental Disabilities (DBHDD);
14.
Emancipated minor means a person who is at
least sixteen (16) but less than eighteen (18) years of age where the rights of
the minor's parents to the custody, control, services, and earnings of the
minor have been terminated by operation of state law or pursuant to a valid
emancipation order issued by a court of competent jurisdiction;
15.
Emergency Disability Services provided in
a CSU and any associated CSC and/or Temp Obs means services provided to
individuals who meet criteria for admission to an emergency receiving and
evaluating facility on voluntary or involuntary status;
16.
Emergency Receiving Facility means a
facility designated by the Department to receive individuals under emergency
conditions as provided in Part 1 of Article 3 of Chapter 3, and Part 1 of
Article 3 of Chapter 7 of Title 37 of the Official Code of Georgia
Annotated;
17.
Evaluating Facility
means a facility designated by the Department to receive individuals for
evaluations as provided in Part 2 of Article 3 of Chapter 3, and Part 2 of
Article 3 of Chapter 7 of Title 37 of the Official Code of Georgia
Annotated;
18.
Governing Body means
the Board of Trustees, the partnership, the corporation, the association, the
person, group of persons or other legal entity that is legally responsible for
operation of the CSU and any associated CSC and/or Temp Obs
functions;
19.
Individual means any
person applying to, or receiving services in a CSU and any associated CSC
and/or Temp Obs;
20.
Individualized
Recovery Plan (IRP) is the document that is initiated during an individual's
admission to the CSU and is continued when the individual is discharged to the
next level of care. The development of an IRP proceeds from a synthesis of (a)
the reason for admission, (b) the individual's goals and choices, (c) treatment
and recovery needs as identified by multidisciplinary assessments, (d)
interventions, and (e) discharge criteria;
21.
Involuntary Status means admission of an
individual who has a mental illness or an addictive disorder and who meets
clinical criteria for admission, but who is unable or unwilling to provide
informed consent for services pursuant to O.C.G.A. Secs.
37-3-41
,
37-7-41
;
22.
Law Enforcement Hold means that an
individual is in the custody or control of law enforcement and must be
discharged only to the custody of law enforcement;
23.
License means the official authorization
granted by the Department pursuant to any of the provisions of O.C.G.A. Sec.
37-1-29
and these rules to operate
a CSU physically located in Georgia;
24.
Licensed/Certified Clinician in a CSU
setting and its associated CSC and/or Temp Obs means a person who is licensed
or certified, as specified by professional practice acts, as a LCSW, LMSW, LPC,
APC, LMFT, AMFT, PhD, Psychologist or a CACII;
25.
Licensed Practical Nurse (LPN) means any
person who holds a current license to practice nursing pursuant to O.C.G.A.
Sec.
43-26-32
et
seq
;
26.
Licensing
requirements means any provisions of law, rule, regulation, or formal order of
the Department which apply to the CSU with respect to initial or continued
authority to operate;
27.
Manual
Hold (also known as Manual Restraint or Personal Hold) means the application of
physical force, without the use of any device, for the purpose of restricting
the free movement of an individual's body regardless of duration or
timeframe;
28.
Medical Director
means the chief medical officer who is physician with overall responsibility
for treatment of individuals receiving services within the CSU and any
associated CSC and/or Temp Obs or a physician appointed in writing as the
designee of such chief medical officer;
29.
Nursing Administrator means a full time
employee of the CSU who:
a.
Is a registered
professional nurse;
b.
Is
responsible for:
i.
The management of the
nursing staff in the CSU;
ii.
Effective nursing care systems; and
iii.
Ensuring continuous quality improvement
in care.
30.
Nursing staff, as used in these rules,
means the licensed and unlicensed assistive personnel providing direct care
twenty-four hours a day, seven days a week. This includes the registered nurse
in charge, other registered nurses on duty, licensed practical nurses, and
unlicensed assistive personnel in the employ of the CSU and any associated CSC
and/or Temp Obs;
31.
Physician means
a person lawfully licensed in this state to practice medicine and surgery under
the provisions of O.C.G.A. Sec.
43-34-20
et seq.
Physician, as used in these rules, means physician as well as those
practitioners to whom the physician may delegate authority as defined in
Physician Extender below;
32.
Physician's Assistant means a skilled
person who is licensed to a supervising physician and who is qualified by
academic and practical training to provide patient services not necessarily
within the physical presence but under the personal direction or supervision of
the supervising physician pursuant to O.C.G.A. Sec.
43-34-102
et
seq
;
33.
Physician Extender
means an advanced practice registered nurse or a physician's assistant to whom
the physician may delegate authority as defined in O.C.G.A. Secs.
43-34-23
, 43-24-25;
34.
Plan of Correction means a plan for
correcting deficiencies in meeting rules and regulations of the
Department;
35.
Psychiatrist means
any physician certified as a diplomat in psychiatry by the America Board of
Psychiatry and Neurology, or who has completed three (3) years of an approved
residency training program in psychiatry and has had at least two (2) years of
full-time practice in this specialty;
36.
Registered Professional Nurse (RN) means
any person who holds a current license to practice nursing under O.C.G.A. Sec.
43-26-3
et
seq
;
37.
Restraint means
any method, device, material or equipment attached or adjacent to the
individual's body that the individual cannot easily remove and that restricts
freedom of movement or normal access to one's body. This includes use of a
manual restraint; manual hold or personal hold; a physical device; a mechanical
device; use of material that is any physical matter including cloth or fabric,
or use of equipment;
38.
Risk
Mitigation Plan is a document which addresses safety management for CSUs for
which the architectural structure and/or environment of care is not consistent
with the applicable provision;
39.
Seclusion means the involuntary
confinement of an individual alone in a room or area of a room from which the
individual is physically prevented from leaving;
40.
Temporary Observation (Temp Obs) is a
facility-based program that provides a physically secure and medically safe
environment during which an individual in crisis is further assessed,
stabilized and referred to the next appropriate level of care;
41.
Transitional Bed means a bed utilized for
an individual on voluntary status who is transferred by order of a physician
from a crisis bed but who remains within the CSU in a transitional bed during
transition into the community. The designation of a transitional bed is not
limited to a specific bed, but can also reference the individual during his/her
transitional status;
42.
Treatment
means care, diagnostic and therapeutic services, including the administration
of medication, and any other service for an individual as defined in O.C.G.A.
Sec.
37-3-1
;
43.
Treatment Facility means a facility
designated by the Department to receive individuals for involuntary commitment
for treatment ordered by the Probate Court provided in Part 3 of Article 3 of
Chapter 3 and Part 3 of Article 3 of Chapter 7 of Title 37 of the Official Code
of Georgia Annotated;
44.
Treatment
Team means physician, RN, licensed clinician, and related professionals such
as, certified peer specialists, certified addiction counselors, etc;
45.
Unlicensed Assistive Personnel, as used in
these rules, means individuals in the employ of the CSU and any associated CSC
and/or Temp Obs who provide direct care and oversight to individuals served in
the CSU and any associated CSC and/or Temp Obs, including, but not limited to,
vital signs, activities of daily living, safety observations, and other duties
as assigned. Unlicensed assistive personnel may be referred to as psychiatric
assistants; certified nursing assistants, mental health assistants, healthcare
technicians, or other recognized industry terms;
46.
Voluntary Status means admission of an
individual who has a mental illness or an addictive disease who meets clinical
criteria for admission, and who is able to understand and exercise the rights
and powers of an individual on voluntary status pursuant to O.C.G.A. Secs.
37-3-20
,
37-7-20
.
Rule 82-3-1-.04 General Licensing Requirements
1.
A license is required to operate a CSU and
its associated CSC and/or Temp Obs functions:
a.
No person, corporation or other entity
shall offer or provide crisis stabilization services as defined in these rules
unless designated as an emergency receiving and evaluating facility and
licensed by the Department;
b.
An
applicant shall obtain a license prior to admitting individuals;
c.
No license shall be issued by the
Department unless the CSU and any associated CSC and/or Temp Obs functions are
in compliance with these rules.
2.
The CSU shall prominently and
conspicuously display the license in a public area of the licensed premises
that is readily visible to individuals, employees, and visitors. A CSU license
shall not be altered.
3.
A CSU
license shall not be transferred or assigned and each CSU location shall be
separately licensed.
4.
The CSU
shall obtain approval from the Department in writing for any change in bed
capacity. Any change in Temporary Observation capacity shall also require
Departmental approval.
5.
The CSU
shall notify the Department in writing at least thirty (30) days prior to, or
in the event of an emergent change, within seventy-two (72) hours of any of the
following occurrences:
a.
Any construction,
renovation, or modification of the CSU, CSC and/or Temp Obs
buildings;
b.
Date of cessation of
operation of the CSU;
c.
Moving to
a new location;
d.
Change in CSU
name or telephone number;
e.
Change
in ownership; or f. Change in agency CEO, medical director, and/or nurse
administrator of the CSU.
6.
The license shall be returned to the
Department immediately after the notification date When a CSU ceases to
operate, is moved to another location, changes ownership, or the license is
suspended or revoked. Failure to return the CSU license to the Department shall
not mean the CSU is licensed. If the CSU receives notice from the Department
that the license is no longer valid, the CSU shall no longer be considered to
be licensed.
7.
The Department may
deny an agency a license for reasons, including but not limited to:
a.
The applicant fails to provide the
required application or renewal information;
b.
Operation of a CSU which has been
decertified or had its contract cancelled under the Medicare or Medicaid
program in any state; federal Medicare or state Medicaid sanctions or
penalties; federal or state tax liens; unsatisfied final judgments; eviction
involving any property or space used as a CSU; unresolved state Medicaid or
federal Medicare audit; denial, suspension, or revocation of a hospital
license, belonging to the governing body, owner or operator of an applicant,
for a license for any health care facility in any state; a court injunction
prohibiting ownership or operation of a facility;
c.
Violation of any rules, regulations,
local, state and federal laws.
Rule 82-3-1-.05 Application Requirements
1.
An application for a license to provide CSU
and any associated CSC and/or Temp Obs services/functions shall be submitted on
forms made available by the Department in a format acceptable to the
Department. No application shall be acted upon by the Department until the
application is determined complete by the Department with all required
attachments submitted.
2.
The
applicant shall submit the following documents to the Department no later than
ninety (90) calendar days prior to the projected opening date of the CSU and
any associated CSC and/or Temp Obs functions:
a.
An accurate and complete application
form;
b.
A working budget showing
projected revenue and expenses for the first year of operation, including
revenue plan;
c.
Documentation of
working capital:
i.
Funds or a line of credit
sufficient to cover at least 90 days of operating expenses if the applicant is
a corporation, unincorporated organization or association, a sole proprietor or
a partnership;
ii.
Appropriate
revenue if the applicant is a state or local governmental agency, board or
commission.
d.
Documentation of authority to conduct business in the State of
Georgia;
e.
A separate twenty-four
hour staffing plan for each service/function (CSU, CSC and/or Temp Obs) which
includes nurses and physicians;
f.
A floor plan with dimensions and with space and room function
designations;
g.
Number of proposed
CSU beds; and proposed capacity in Temp Obs;
h.
Photocopies of operating agreements with
healthcare providers to provide care that is beyond the scope of the
facility;
i.
A program description
signed by the medical director that includes, consistent with these rules and
Department policy, admission and discharge criteria and procedures, including
reasons for denial of admission, for both voluntary and involuntary individuals
who do not meet admission criteria;
j.
Proposed daily schedule of treatment and
education options throughout twelve waking hours each day, to include treatment
and educational opportunities responsive to the mental health, physical health
and addictive disorder issues represented by individuals receiving
services;
k.
Fire Safety
Documentation:
a.
For new construction,
additions, and renovation projects, written approval by the local Building
authority as well as well as a fire safety report (e.g., Fire Safety Inspection
Report or a Certificate of Occupancy) in the jurisdiction in which the CSU and
any associated CSC and/or Temp Obs is based, must be submitted before a license
is issued;
b.
For buildings already
constructed, a copy of a fire safety report indicating approval by the local
fire authority for the jurisdiction in which the CSU and any associated CSC
and/or Temp Obs is based, dated within the last twelve (12) months of the
projected opening date must be submitted before a license is issued.
l.
Documentation of agency
accreditation as required by Departmental policy.
3.
The Department shall conduct announced or
unannounced on-site reviews of all facilities and services to determine
compliance with the rules and regulations to operate a CSU and any associated
CSC and/or Temp Obs functions, prior to a license being granted.
Rule 82-3-1-.06 Issuance of Initial and Renewal of License
1.
When the Department determines that the
applicant is in compliance with all applicable rules and regulations, the
Department shall issue an initial license to the applicant.
a.
The initial license for a new facility is
valid for the first year of operation. The term of the initial license may not
exceed one (1) year from the date of issuance;
b.
Prior to expiration of the initial license,
the Department shall conduct a review of the CSU and/any associated CSC and/or
Temp Obs functions for compliance with all applicable rules and
regulations;
c.
Pursuant to a
satisfactory review, the Department shall issue a license which shall be valid
for a period of up to two (2) years.
2.
It shall be the responsibility of the CSU
to complete and submit a renewal application for licensure, as required by the
Department, which is postmarked at least ninety (90) calendar days prior to the
expiration date of the current license. If the CSU fails to submit the
completed renewal application, the Department shall provide notice by certified
mail advising that unless the renewal application and licensure review is
satisfactorily completed, the CSU is operating without a valid license and is
subject to sanctions.
Rule 82-3-1-.07 Operational Scope of Services
Each CSU shall have a detailed description of the scope of
services under which the CSU operates that includes, but is not limited
to:
1.
The CSU and any associated CSC
shall describe its capacity to serve both voluntary and involuntary
individuals;
2.
The CSU and any
associated CSC and/or Temp Obs shall clearly state in its policy that it is not
a treatment facility as defined in O.C.G.A. Secs.
37-1-29
,
37-3-1(18)
;
3.
The services offered within the CSU shall
be provided in a community based setting, and shall be described as crisis
residential services rather than inpatient or hospital level of care
service;
4.
The CSU shall not
advertise or hold itself out as a hospital nor shall it bill for hospital or
inpatient services;
5.
The CSU shall
be exempt from any requirement of Georgia's Certificate of Need (CON)
program;
6.
The facility shall
pursue with due diligence operating agreements in writing, with one or more
healthcare providers, to provide care that is beyond its scope:
a.
Operating agreements shall be updated at a
minimum every five (5) years as evidenced by date and signatures on the
agreement document;
b.
The operating
agreement with an inpatient treatment facility shall include the agreement that
the CSU shall transfer the individual to the treatment facility on the existing
involuntary legal document in sufficient time for the treatment facility to
evaluate the individual and petition the court for involuntary treatment as
necessary.
7.
The average
annual length of stay in the crisis beds of the CSU shall not exceed eight (8)
calendar days;
8.
The CSU shall
report census and length of stay data as required to the Department for both
crisis and transitional beds, respectively;
9.
The CSU shall give priority consideration
to serving those individuals without private health care coverage;
10.
Individuals shall be billed in accordance
with Departmental policy on payment for services;
11.
The CSU and any associated CSC and/or Temp
Obs shall not refuse service to receive, evaluate, or stabilize any individual
who meets criteria for services as defined in O.C.G.A. Sec.
37-1-29
and Departmental
Policy;
12.
The CSU shall not
operate solely as a twenty-four hour residential service offering
detoxification.
Rule 82-3-1-.08 Program Description
Each CSU shall have a description of services which shall
clearly state the following:
1.
The CSU
is designed to serve as a first-line community based alternative to
hospitalization, offering psychiatric stabilization and detoxification services
on a short- term basis;
2.
The
target population is adults (eighteen (18) years or older). Individuals may
also have other co-occurring diagnoses;
3.
Emancipated minors may be served when the
need for stabilization can be met when they do not need specialized adolescent
services, and when their life circumstances demonstrate they are more
appropriately served in an adult environment. Admissions to the CSU must be
approved by the medical director;
4.
Psychiatric stabilization and residential
detox services are offered at a clinical intensity level which supports the
level of care in DBHDD contracts and the DBHDD Provider Manual for Community
Behavioral Health Providers;
5.
The
CSU and any associated CSC and/or Temp Obs shall have policies and procedures
for identifying and managing individuals who meet the diagnostic criteria for a
Substance Dependence Disorder;
6.
The CSU and any associated CSC and/or Temp Obs shall have policies and
procedures for providing a planned regimen of twenty-four hour professionally
driven evaluation, care and treatment services for individuals who meet the
diagnostic criteria for a Substance Dependence Disorder. All services offered
within the CSU and any associated CSC and/or Temp Obs shall be provided under
the direction of a physician. Consultation by a psychiatrist shall be available
if the covering physician is not a psychiatrist;
7.
A physician or psychiatrist shall be on
call twenty-four hours a day and shall make rounds seven days a week. The
physician is not required to be on site twenty-four hours a day, however the
physician must respond to staff calls immediately (delay not to exceed one (1)
hour);
8.
The CSU and any
associated CSC and/or Temp Obs shall provide emergency receiving, screening,
and evaluation services twenty-four hours a day, seven days a week and shall
have the ability to admit and discharge seven days a week;
9.
The CSU and any associated CSC and/or Temp
Obs shall have policies and procedures for identifying and managing individuals
at high risk of suicide or intentional self- harm;
10.
The functions performed by staff whose
practice is regulated or licensed by the State of Georgia are within the scope
allowed by state law and professional practice acts;
11.
The CSU shall have a full-time position
classified as a nursing administrator.
12.
The CSU shall have an RN present within
the CSU twenty-four hours a day, seven days a week who is the charge nurse for
the CSU. For every thirty (30) CSU beds there shall be one (1) RN present at
all times;
13.
Staffing for the CSU
shall be established based on the needs of individuals being served as follows:
a.
At all times there shall be at least two
(2) nursing staff present within the CSU including the charge nurse (if the
charge nurse is an APRN, then he/she may not simultaneously serve as the
accessible physician during the same shift);
b.
The ratio of nursing staff to individuals
shall not be less than 1:8 (including the charge)
c.
The ratio of nursing staff to individuals
shall increase on the basis of the clinical care needs of the individual,
including required levels of observation for high risk individuals;
d.
If a nursing staff is assigned a 1:1
support role, then he/she shall not be counted in the 1:8 ratio
above;
e.
Utilization of licensed
practical nurses (LPNs) in CSU shall be to provide technical support to the
registered nurse by performing duties specified in O.C.G.A. Sec.
43-26-3
et
seq.
14.
Program offerings for the CSU shall be designed to meet the biopsychosocial
stabilization needs of each individual, and the therapeutic content of the
program (group therapy/training, individual therapy/training, education
support, etc.) shall be annually approved by a licensed/certified clinician.
This content is captured in a master file which will have the licensed
clinician's approval, signature and date of review;
15.
The CSU and any associated CSC and/or
Temp Obs shall have protocols with respect to stabilization and transfer of
individuals to a different level of care. The treating physician shall make the
determination as to the time and manner of transfer to ensure no further
deterioration of the individual during the transfer between facilities, and
shall specify the benefits expected from the transfer in the individual's
record;
16.
The CSU shall designate
a specific number of beds which may be used as a crisis bed or as a
transitional bed with Department approval;
17.
A physician must write an order for the
individual's change in status from CSU crisis status to transition status. The
CSU must record the date of transfer and the length of stay in the transitional
bed for each episode of care.
Rule 82-3-1-.09 Evaluation and Admissions
1.
The CSU must have written protocols for
screening individuals presenting for evaluation pursuant to O.C.G.A Secs.
37-3-41
and
37-7-41
. If screening results in
an individual not being offered services or admitted to the CSU, the CSU shall
maintain documentation of the rationale for the denial of services and referral
of the individual.
2.
Level of Care
instruments defined in the DBHDD Provider Manual for Community Behavioral
Health Providers will be utilized to determine the required need and resulting
level of care for admission to the CSU.
3.
The CSU shall not admit individuals
presenting with issues listed under "Exclusion Criteria" in the Department's
policy on medical exclusion guidelines and criteria. The CSU staff shall ask
the referral source for information regarding the medical status of the
individual. If there are medical status issues, the CSU physician may request
additional information or waive medical clearance when clinically appropriate
or when medical clearance is not available.
4.
The CSU shall not refuse to receive for
evaluation an individual who presents to the CSU for evaluation and/or
stabilization.
5.
Staff shall
conduct a search of the individual, his or her clothing, and all personal
effects before admission to the unit.
6.
Personal searches of individuals (e.g.
strip searches) are to be performed only for cause and shall be ordered by the
physician. The rationale for the personal search must be clearly documented in
the order. Sequential steps of the search, including documentation of staff
involved by name and title, must be recorded in the progress notes section of
the clinical record. Mandatory removal of clothing or standing orders for
personal searches is not permitted.
7.
An initial screening for risk of suicide
or harm to others shall be conducted for each individual presenting to the CSU,
and its associated CSC and/or Temp Obs for evaluation.
8.
A physician must assess each individual
within twenty-four (24) hours of admission, to the CSU, document the findings
of the assessment(s), and write orders for care.
9.
Orders for care shall include the
clinically appropriate level of observation for the individual.
Rule 82-3-1-.10 Provision of Individualized Care
1.
An Individualized Recovery Plan (IRP)
shall be developed and written within seventy- two (72) hours of admission on
the basis of assessments conducted by the physician, registered nurse and
professional social work or counseling staff. A major goal of each IRP shall be
the individual's stabilization and recovery. For individuals with both
substance abuse and mental health diagnoses, the IRP shall address issues
relative to both diagnoses.
2.
At
a minimum, this IRP shall be developed in collaboration with the individual,
and shall include the following:
a.
A problem
statement or statement of needs to be addressed;
b.
Goals that are consistent with the
individual's needs, realistic, measurable, linked to symptom reduction, and
attainable by the individual during the individual's projected length of
stay;
c.
Objectives, stated in
terms that allow measurement of progress, that build on the individual's
strengths;
d.
Specific treatment
offerings, methods of treatment and staff responsible to deliver the
treatments;
e.
Interventions and
preferred approaches that are responsive to findings of past trauma and
abuse;
f.
Evidence of involvement
by the individual, as documented by his or her signature or refusal/ability to
sign;
g.
Signatures of all staff
participating in the development of the plan.
3.
The IRP shall be reviewed at a minimum
every seventy-two (72) hours by a treatment team to assess the need for the
individual's continued stay in the CSU. The IRP shall be updated as appropriate
when the individual's condition or needs change.
4.
The physician shall, at a minimum:
a.
Conduct the initial assessment of the
individual;
b.
Establish a
diagnosis and write care orders;
c.
Document the rationale for medications prescribed;
d.
Assess the individual's response to care
and services provided; and
e.
Conduct an assessment of the individual at the time of discharge.
5.
Discharge summary information
shall be provided to the individual at the time of discharge that includes:
a.
Criteria describing evidence of
stabilization and discharge planning;
b.
Significant findings relevant to the
individual's recovery (strengths, needs, preferences);
c.
Specific instructions for ongoing
care;
d.
Individualized
recommendations for continued care to include recovery supports, community
services, if indicated; and
e.
Contact information for how to access community services.
Rule 82-3-1-.11 Documentation of Care
The CSU shall maintain a clinical record for each individual,
which may be recorded manually or electronically. The clinical record shall
contain chronological information on all matters relating to the admission,
care and treatment, discharge and legal status of the individual, and shall
include documents relating to the individual. The clinical record shall include
at least the following:
1.
Record of
evaluation for admission and outcome of the evaluation, including the date,
time, name and credentials of the professional conducting the
evaluation;
2.
Legal status
documents for admission and continued stay in the CSU, as detailed in O.C.G.A.
Secs.
37-3-1
et seq.
and
37-7-1
et seq
;
3.
Documentation of guardianship, whenever applicable;
4.
Assessments, to include psychiatric,
physical health, nursing and psychosocial status; physician orders;
5.
Every order given by telephone shall be
received by an RN or LPN and shall be recorded immediately with the ordering
physician's name, and shall be reviewed and signed by a physician within
twenty-four (24) hours. Specific to the ordering of medication, documentation
shall demonstrate evidence that an order was made by telephone, the content of
order, and date of the order;
6.
Documentation by the physician of the individual's response to care, including
rationale for changes in orders or levels of observation;
7.
An IRP which specifies individualized
interventions responsive to the needs of the individual;
8.
Documentation of implementation of
interventions, including the individual's response to the
interventions;
9.
Location and type
of treatment or education provided, including the date and time of treatment or
education, the name and credentials of the professional or other staff
providing the service, and the response of the individual to the treatment or
education;
10.
Evidence of progress
toward stabilization and recovery, or lack thereof;
11.
Documentation of medical testing (if
any), medical findings and medical care needs or interventions
provided;
12.
Documentation of
continued stay justifications;
13.
Documentation at least once per day by an RN as to the status of the
individual;
14.
Documentation of
events or incidents that affect care and treatment, including the individual's
response;
15.
Record of
implementation of emergency safety interventions of last resort (seclusion or
restraint), if implemented;
16.
Name and title of staff providing care and treatment; and
17.
Discharge notes and aftercare plans,
including the individual's status at discharge, ongoing needs, aftercare plan,
and the date, time and method of discharge.
Rule 82-3-1-.12 Protection and Safety of the Individual and of Others
1.
The CSU and any associated CSC and/or Temp
Obs shall have procedures regarding authorized entry and/or exit between and
from the facility services.
2.
The
CSU and any associated CSC and/or Temp Obs shall have policies and procedures
to protect and respect individuals' rights and privacy while conducting
searches.
3.
The CSU and any
associated CSC and/or Temp Obs shall have control of potentially injurious
items, clearly defined in policy to include, but may not be limited to:
a.
Prohibition of flammables, toxins, ropes,
wire clothes hangers, sharp-pointed scissors, luggage straps, belts, knives,
shoestrings, or other potentially injurious items;
b.
Management of housekeeping supplies and
chemicals, including procedures to avoid access by individuals during use or
storage. Whenever practical, supplies and chemicals shall be non-toxic or
non-caustic;
c.
Safeguarding use
and disposal of nursing and medical supplies including drugs, needles and other
"sharps" and breakable items.
4.
Except as otherwise provided byassociated
CSC and/or Temp Obs. The facility shall post notices regarding the prohibition
of w law, weapons shall be prohibited at the CSU and any weapons at all
entrances and shall have written protocols addressing the same.
5.
The CSU and any associated CSC and/or Temp
Obs shall develop and implement policies and practices, consistent with
Departmental policy, that describe interventions to prevent crises and minimize
incidents when they do occur, that are organized in a least to most restrictive
sequence. The written policies and procedures shall:
a.
Emphasize positive approaches to
interventions;
b.
Protect the
health and safety of the individual served at all times;
c.
Specify the methods for documenting the
use of the interventions; the admission assessment shall contain an assessment
of past trauma or abuse, how the individual served would prefer to be
approached should he or she become dangerous to him or herself or to others and
the findings from this initial assessment shall guide the process for
determining interventions.
6.
The CSU shall develop and implement
internal policies and practices for use of seclusion or restraint that are
consistent with federal and state laws, rules, regulations and DBHDD policy:
a.
Seclusion or restraint, as defined in
these regulations, shall be used only as an emergency safety intervention of
last resort to ensure the physical safety of the individual and others, and
shall be used only after less restrictive interventions have been determined to
be ineffective;
b.
Seclusion or
restraint shall not be used as punishment or for the convenience of
staff
c.
Seclusion and restraint
shall not be implemented simultaneously;
d.
All individuals placed in restraints shall
be afforded full privacy away from other individuals receiving
services;
e.
Chemical restraint as
defined by the Code of Federal Regulations shall not be utilized under any
circumstances;
f.
Staff and
individuals shall be debriefed immediately following an episode of seclusion or
restraint, identifying the circumstances leading up to the seclusion or
restraint;
g.
The individual's IRP
shall be updated following the debriefing of what led to a seclusion or
restraint episode, including changes that could be made to prevent the
situation from reoccurring or better support the individual if future issues do
occur.
7.
The CSU and
any associated CSC and/or Temp Obs shall develop policies and procedures for
implementing suicide prevention interventions addressing: screening, crisis
safety plan, assessments, staffing, levels of observation and documentation in
accordance with DBHDD policy.
a.
Policies and
procedures shall require constant visual observations of persons clinically
determined to be actively suicidal;
b.
A person assessed to be potentially
suicidal shall be on a higher level of supervision;
c.
Modifications or removal of suicide
prevention interventions shall require clinical justification determined by an
assessment and shall be specified by the attending physician and documented in
the clinical record;
d.
A
registered professional nurse or other licensed/certified clinician may
initiate suicide prevention interventions prior to obtaining a
physician/psychiatrist's order, but in all instances must obtain an order
within one (1) hour of initiating the intervention;
e.
Staff shall be debriefed immediately
following a suicide attempt, identifying the circumstances leading up to the
suicide attempt;
f.
The
individual's IRP shall be updated following the debriefing of what led to the
suicide attempt, including changes that could be made to prevent the situation
from reoccurring or to better support the individual if future issues do
occur.
8.
Other
high-risk behaviors such as assaultive behavior shall be addressed in the CSU
policies and procedures.
Rule 82-3-1-.13 Pharmacy Services and Management of Medication
1.
All pharmacy operations or services within
the CSU must be licensed and under the direct supervision of a registered
pharmacist or provided by contract with a licensed pharmacy operated by a
registered pharmacist.
2.
The CSU
must ensure access to pharmacy services for prescription medications within
eight (8) hours of the physician's order.
3.
Stat medication not maintained in the CSU
must be available for administration within one (1) hour of the order to give
the medication.
4.
Any request for
exemptions for requirements regarding a pharmacy license must be submitted in
writing to the Georgia State Board of Pharmacy.
5.
The CSU shall establish and implement
policies, procedures and practices that guide the safe and effective use of
medications and shall, at a minimum, address the following:
a.
Medications and medical care orders shall
be written, signed, administered, and implemented upon direct order from a
physician, as defined in O.C.G.A. Secs.
43-34-23
,
43-34-25
;
b.
Medications shall be used solely for the
purposes of providing effective treatment and protecting the safety of the
individual and other persons and shall not be used as punishment or for the
convenience of staff or as chemical restraint;
c.
There shall be no standing orders for any
psychotropic medication;
d.
Medication management policies and procedures shall follow federal and state
laws, rules and regulations, and shall direct the management of medication
ordering, procurement, prescribing, transcribing, dispensing, administration,
documentation, wasting or disposal and security, to include the management of
controlled substances, floor stock, and physician sample medications;
e.
There shall be documented evidence of
oversight by the medical director for the accounting of and dispensing of
sample medications;
f.
The CSU
shall develop a policy on informed consent on medication, including the right
to refuse medication;
g.
The CSU
shall follow the Department's policies and procedures for Informed Consent and
Involuntary Administration of Psychotropic Medication;
h.
There shall be a process to identify,
track and correct deviations in medication prescribing, transcribing,
dispensing, administration, documentation, or drug security of ordering or
procurement of medication that results in a variance;
i.
The CSU shall develop and implement
policies and procedures that describe actions to follow when drug reactions and
other emergencies related to the use of medications occur, and emergency
medical care that may be initiated by a registered nurse in order to alleviate
a life threatening situation; and
j.
The CSU shall conduct daily checks and maintain temperature logs for all
medication room refrigerators. Temperatures for the refrigerator shall be set
between 34°F to 41°F (1°C to 5°C).
Rule 82-3-1-.14 Laboratory Services
1.
Laboratory work and other diagnostic
procedures deemed necessary shall be performed as ordered by the
physician.
2.
Any CSU that
processes laboratory tests on-site shall provide documented evidence of a
current Clinical Laboratory Improvement Amendment waiver.
Rule 82-3-1-.15 Food Services
All CSU food service operations shall comply with current
federal and state laws and rules concerning food service and shall
include:
1.
At least three (3)
nutritious meals per day shall be served;
2.
Nutritional snacks shall be available to
each individual;
3.
No more than
fourteen (14) hours may elapse between the end of an evening meal and the
beginning of a morning meal;
4.
Therapeutic diets shall be provided when ordered by the physician;
5.
Under no circumstances may food be
withheld for disciplinary reasons;
6.
The CSU must have a sufficient designated
area to accommodate meal service.
Individuals may eat or be served in shifts during daily
operations. The eating area may double as a group or activity
area;
7.
If food is prepared
by the CSU, the CSU must have a satisfactory food service permit score,
pursuant to Georgia Department of Human Services, Public Health, Food Service,
290-5-14-.10. If applicable, a copy
of the current food service permit must be on file in the CSU;
8.
The CSU may utilize meal preparation
services from an affiliated or contracted entity with a current food service
permit. There shall be a formal contract between the CSU and the contracted
food entity containing assurances that the contracted food entity will meet all
food service and dietary standards imposed by this rule;
9.
If the CSU elects to have meals prepared
off-site, the CSU will have a modified kitchen that includes a microwave, a
refrigerator, an ice maker and clean-up facilities;
10.
The CSU must maintain a daily temperature
log for the freezer(s) and refrigerator(s).
Temperatures for the refrigerator shall be set between
34°F and 41°F (1°C to 5°C) and the freezer temperature should
be set between 0°F and 10°F (-17°C to -15°C);
11.
Foods, drinks and condiments shall be
dated when opened and discarded when expired;
12.
Each CSU shall maintain a three-day
supply of non-perishable emergency food and water at all times.
Rule 82-3-1-.16 Infection Control and Prevention
The CSU and any associated CSC and/or Temp Obs functions
shall develop and implement policies and procedures for infection control and
prevention that include the following:
1.
Standard precautions are defined and the
use of personal protective equipment when handling blood, body substances,
excretions and secretions are outlined;
2.
Proper hand washing techniques are
outlined;
3.
Proper disposal of
biohazards, such as potentially infected waste and spills- management, needles,
lancets, scissors, tweezers and other sharp instruments is described;
3.
Prevention and treatment of needle
stick/sharp injuries are outlined;
4.
The management of common illnesses such
as, but not limited to Methicillin-Resistant Staphylococcus Aureus
(
MRSA), colds and influenza, gastrointestinal viruses, pediculosis
and tinea pedis, etc. is described;
6.
Specific procedures to manage infectious
diseases including but not limited to tuberculosis, hepatitis B, Human
Immunodeficiency Virus (HIV), Acquired Immune Deficiency Syndrome (AIDS) or
other infectious diseases are described;
7.
Handling and maintenance of individual
care equipment is described;
8.
The
infection control risk assessment and plan is reviewed annually for
effectiveness and revision, if necessary;
9.
The CSU and any associated CSC and/or Temp
Obs shall have written hygienic practices and procedures regarding the
management of linens and minimizing healthcare-associated infections, including
collection, sorting, transport, washing and storage of soiled linens. The
practices shall be based upon a cited expert source (such as the U.S. Centers
for Disease Control and Prevention) and updated annually to ensure the
procedures reflect evolving standard practice. At a minimum, the facility
shall:
a.
Have immediately available a
quantity of clean bed linens and towels, etc., essential for the proper care of
individuals at all times; and
b.
Have collection, sorting, and cleaning procedures which are designed to prevent
contamination of the environment, individuals served, and personnel.
10.
In relation to individuals who
are carriers of an infectious illness, the transfer and the release of
confidential information to select unit medical and nursing staff on a need to
know basis is addressed; and
11.
Hand washing facilities provided in both the kitchen and the bathroom areas
shall include hot and cold running water, soap dispensers, disposable towels
and/or hand blowers.
Rule 82-3-1-.17 Rights and Responsibilities of Individuals
1.
The CSU and any associated CSC and/or Temp
Obs functions shall safeguard the rights of individuals treated pursuant to
applicable state laws and rules and regulations.
2.
The CSU and its associated CSC and/or Temp
Obs functions shall maintain a written statement of rights and responsibilities
for individuals receiving services, as articulated in DBHDD rule and
policy.
3.
During receipt of
services and/or admission to the CSU, each individual shall receive a written
statement of his or her rights and responsibilities. Receipt of this
information shall be documented in the clinical record and validated by the
signature of the individual. If the individual is unable or unwilling to sign,
this shall be recorded.
4.
The CSU
and its associated CSC and/or Temp Obs functions shall inform the individual or
guardian in writing of any changes in rights and responsibilities.
5.
Individual rights related to required
notices, lengths of stay on involuntary status, or other processes related to
rights specified in Georgia law, DBHDD rule or policy, shall be
maintained.
Rule 82-3-1-.18 Confidentiality
The CSC and any associated CSC and/or Temp Obs functions
shall:
1.
Have records management
policies, procedures and practices to manage and to protect the confidentiality
and protected health information of individuals' records, to include electronic
records;
2.
Have records management
policies which support secure, organized records and shall be consistent with
all applicable policies and procedures and federal and state laws and
regulations;
3.
Ensure that the
individual's rights regarding his or her own confidential and protected health
information are protected, including but not limited to, access to protected
health information, requesting amendment(s) to the clinical record, requesting
restriction of disclosure, and requesting an accounting of disclosures that
have been made;
4.
Have a Notice of
Privacy Practices regarding confidentiality of the individual's protected
health information, which Notice shall comply with the requirements of Health
Insurance Portability and Accountability Act (HIPAA);
5.
Post the Notice of Privacy Practices at
all times in the admissions area and in prominent locations where it is
reasonable to expect individuals to be able to read the notice. Additional
copies must be available for distribution upon request;
6.
Provide a copy of the Notice of Privacy
Practices to the individual and his or her representatives, as defined by state
law, upon the individual's admission;
7.
Have policies, procedures and practices
that are compliant with the requirements of HIPAA regarding:
a.
Complaints regarding violation of
confidentiality and privacy rights;
b.
Reports of breaches of HIPAA to the
Department, and as required by law when applicable to the individual, to the
United States Secretary of Health and Human Services, and to the
media;
c.
Sanctions of employees
for violations of HIPAA; and
d.
Identifying business associates, as defined by HIPAA, of the CSU and obtaining
satisfactory assurances of the business associates' compliance with the
requirements of HIPAA.
8.
Ensure the clinical record, information about an individual contained in
incident reports and any documents that are not part of the clinical record,
and all information about an individual whether oral or written, and regardless
of how stored, is confidential;
9.
Not, unless authorized in writing by a valid authorization signed by the
individual, or by applicable law:
a.
Confirm
or deny whether an individual is receiving or has received services from the
CSU; or
b.
Disclose any
confidential or protected health information regarding the
individual.
Rule 82-3-1-.19 Documentation of Legal Status
The legal status of each individual shall be clearly recorded
within the clinical record to include:
1.
Documenting the legal and clinical basis
for the individual's admission to the CSU, whether voluntary or involuntary,
consistent with all applicable state laws, rules and regulations;
2.
Documentation of the legal and clinical
basis for continued admission to the CSU for purposes of evaluation when
consistent with all applicable state laws, rules and regulations;
3.
A record of voluntary or involuntary
status change, including the date and time of such change;
4.
Documentation of the assessment of the
individual's capacity to understand and exercise the rights and powers of
voluntary admission; and
5.
Where
specific Departmental legal forms exist to document any of the above mentioned
actions, those forms shall be utilized.
Rule 82-3-1-.20 Performance Improvement Plan and Activities
The CSU and any associated CSC and/or Temp Obs functions
shall develop a quality assurance plan and update it annually:
1.
The quality assurance plan shall address
and ensure a comprehensive integrated review of all services and practices
which shall include, but shall not be limited to the following:
a.
High-risk situations and special cases
(such as suicide, death, serious injury, violence and abuse of any individual)
are reviewed within twenty-four (24) hours;
b.
Medical emergencies;
c.
Medication variance;
d.
Infection control;
e.
Emergency safety interventions including
any instances of seclusion or restraint; and
f.
Environmental safety and maintenance,
including an environmental scan which self-assesses risk for individuals served
by or working in the facility and identified strategies and subsequent plans
for mitigating those risks.
2.
The quality assurance plan shall use
performance measures and data collection that continually assess and improve
the quality of the services being delivered;
3.
The quality assurance committee shall
submit a quarterly report to the nursing administrator, medical director,
agency CEO, and governing body for their review and appropriate
action;
4.
The CEO and governing
body shall evaluate the facility's effectiveness in improving
performance.
Rule 82-3-1-.21 Environment of Care
Areas accessible by individuals shall meet the following
requirements:
1.
The CSU and any
associated CSC and/or Temp Obs shall maintain an environment that is clean and
is in good repair;
2.
The
environment of the CSU shall have natural light and exterior views;
3.
The general architecture of the CSU and
any associated CSC and/or Temp Obs, along with tools and technology, shall
provide for optimal line-of-sight observations from the nurses' station
throughout the unit, mitigating hidden spots and blind corners;
4.
The CSU shall be a locked
facility;
5.
Interior finishes,
lighting, and furnishings of the CSU and any associated CSC and/or Temp Obs
shall conform to applicable fire and safety codes as classified for
Health Care Occupancy/Limited Care Facilities
in the current
edition of National Fire Protection Association's NFPA 101 Life Safety Code
Handbook, Chapter 18/19: New and Existing Health Care Occupancies;
6.
Furnishings, hardware, fixtures, or
protrusions of the CSU and any associated CSC and/or Temp Obs must be:
a.
Made of materials which mitigate the risk
of use as weapons or for self-harm (hanging, cutting, etc.);
b.
Intact and functional;
c.
Maintained in good condition;
and
d.
Tamper
resistant.
7.
The ceiling
and the air distribution devices, lighting fixtures, sprinkler heads, and other
appurtenances of the CSU and any associated CSC and/or Temp Obs shall be of the
tamper-resistant type;
8.
Doors of
the CSU must meet the following requirements:
a.
Doors in seclusion and/or restraint rooms
shall not be locked from within;
b.
The CSU shall have a policy in effect to address locking doors in bedrooms and
bathrooms which will address an individual's privacy and safety and which
addresses staff access at all times to supervise and monitor that individual's
clinical status and safety;
c.
The
CSU must have written risk management protocols in place to address situations
in which an attempt might be made to prevent access to any area of the
CSU;
d.
If the CSU is equipped with
electronic locks on internal doors or egress doors, the CSU shall ensure that
such locks have manual common key mechanical override that will operate in the
event of a power failure or fire;
9.
Light switches and electrical outlets of
the CSU and any associated CSC and/or Temp Obs shall be secured with
tamper-resistant type screws;
10.
For CSUs and any associated CSC and/or Temp Obs which are new facilities and
who apply for licensure on or after (PUBLISH DATE OF NEW RULES), sprinkler
heads shall be flush mounted on ceilings lower than nine (9) feet. Sprinklers
shall have institutional heads that are recessed and drop down when
activated;
11.
Security and safety
devices of the CSU and any associated CSC and/or Temp Obs shall be mounted,
installed, secured in a manner which:
a.
Mitigates the risk of use as weapons or for self-harm (hanging, cutting,
etc.);
b.
Prevents interference;
and
c.
Prevents any attempt to
render inoperable with its purpose as a security device.
12.
Upon request, the CSU and any associated
CSC and/or Temp Obs shall provide a means of locked storage for any
individual's valuables or personal belongings;
13.
The CSU and any associated CSC and/or
Temp Obs must have policies/procedures to address identification, detection,
handling, and storage of individuals' belonging that are determined to be
potentially harmful;
14.
The CSU
and any associated CSC and/or Temp Obs shall maintain the environmental
temperature between 65°F and 82°F (18°C to 27°C);
15.
The interior of the CSU, and any
associated CSC and/or Temp Obs shall be non- smoking. If the CSU offers
smoking, the facility must designate a sheltered, outside space as a smoking
area;
16.
Lighting fixtures of the
CSU and any associated CSC and/or Temp Obs shall be recessed and
tamper-resistant with Lexan or other strong translucent materials;
17.
Windows shall be protected with Lexan or
other shatter-resistant material that will minimize breakage;
18.
The CSU and any associated CSC and/or
Temp Obs shall be equipped and maintained so as to provide a sufficient amount
of hot water for individuals' use;
19.
Heated water provided for individuals'
use must be maintained between 110°F and 120°F (43°C and
48°C);
20.
The CSU and any
associated CSC and/or Temp Obs must have policies/procedures to routinely check
and document the hot water temperature at various outlets throughout the CSU
and to correct any variance from the standard temperature if needed;
21.
The CSU and any associated CSC and/or
Temp Obs shall have consistently available drinking water for individuals'
access using mechanisms which meet general expectation of infection control
procedures;
22.
The pre-admission
waiting area of the CSU, including restroom(s), must meet all safety
requirements applicable to designated individual areas;
23.
The CSU and any associated CSC and/or
Temp Obs shall have written policies and procedures for the provision of, or
arrangement for, services for individuals with physical disabilities (including
those with sensory impairments) in compliance with all federal rules and
regulations;
24.
The CSU and any
associated CSC and/or Temp Obs shall have facilities accessible to and usable
by physically disabled individuals which meet the minimum requirements of
Section 504 of the Rehabilitation Act of 1973. CSUs shall install required
alterations or modifications in accordance with the 1984 Law of Georgia
regarding Access to and Use of Public Facilities by Physically Handicapped
Persons O.C.G.A. Sec.
30-3-1
et
seq
;
25.
The CSU and any
associated CSC and/or Temp Obs shall maintain safety equipment to include an
Automated External Defibrillator (AED) and all other necessary medical safety
supplies;
26.
The CSU shall provide
laundry facilities on the premises for the individual's personal
laundry;
27.
Entrances and exits,
sidewalks, and escape routes of the CSU and any associated CSC and/or Temp Obs
shall be constantly maintained free of all impediments and hazards;
28.
The CSU shall have at least one (1)
operable, non-pay telephone which is private and accessible at reasonable times
for use by the individual; and
29.
The CSU shall, at a minimum, have designated areas within its facility which
meet the following requirements:
a.
A
screening area
with capacity to be locked where searches can be
done in a private and safe manner, respecting individual rights and
privacy;
b.
Exam
room;
c.
Bedrooms
:
i.
Beds and other heavy
furniture capable of use to barricade a door shall be secured to the floor or
wall;
ii.
The use of beds with
springs, cranks, rails or wheels, including hospital beds, rollaway beds, cots,
bunk beds, stacked, hide-a beds and studio couches is prohibited;
iii.
Rooms utilized for more than one
individual shall have a minimum of 60 (sixty) square feet per individual; a
private room shall not be less than 80 (eighty) square feet.
iv.
Windows may be textured to provide
privacy without the use of curtains or blinds.
d.
Bathrooms
:
i.
The CSU shall have gender specific
bathrooms with proper ventilation;
ii.
Exposed plumbing pipes shall be covered
to prevent individual access;
iii.
The CSU shall have a minimum ratio of one (1) shower for each six (6)
individuals receiving services and one (1) toilet and lavatory for each six (6)
individuals receiving services;
iv.
Individual shower stalls and dressing areas shall be provided;
v.
The CSU shall have a bathroom facility
that is in compliance with the Americans with Disabilities Act (ADA) for use by
individuals with physical disabilities. It shall include toilet, lavatory,
shower and flush-mounted safety grab bars;
vi.
Access to a bathroom shall not be through
another individual's bedroom;
vii.
The shower head shall be recessed or have a smooth curve from which items
cannot be hung;
viii.
Overhead
rods, fixtures, privacy stalls, supports or protrusions must be selected and
installed in a manner which mitigates the risk of use of weapons or for
self-harm (hanging, cutting, etc.). If the physical plant space of the CSU is
prohibitive of this, there must be written policies and protocols to monitor
and reduce this risk with supporting evidence of compliance to these policies
and protocols;
ix.
The toilet shall
be secured and tamper resistant;
x.
Mirrors shall not be common glass and must be fully secured and flat mounted to
the wall is required.
e.
Seclusion and/or Restraint Room.
For CSUs which apply for
licensure on or after (PUBLISH DATE OF NEW RULES), the privacy of the person is
protected by the seclusion and/or restraint room location either being not
visible from the common consumer areas, or if visible, the seclusion and/or
restraint room is constructed to be offset from main thoroughfares and have
restricted visibility to the interior of the room:
i.
At least one (1) identified room used for
seclusion and/or restraint shall have a bed commercially designed for use with
restraints that is bolted to the floor and without sharp edges. The surface of
the bed must be impermeable to resist penetration by body fluids;
ii.
The floors and walls, up to a height of
three (3) feet, shall be finished to resist penetration of body fluids; and be
constructed of a high impact sheetrock;
iii.
For CSUs which apply for licensure on or
after (PUBLISH DATE OF NEW RULES), the seclusion and/or restraint room shall
have a minimum of seventy (70) square feet with one wall of the room no less
than nine (9) feet in length;
iv.
For CSUs which apply for licensure on or after (PUBLISH DATE OF NEW RULES), the
ceiling height shall be at least nine (9) feet;
v.
The door to the room shall open
outward;
vi.
The bed placement in
the seclusion and/or restraint room shall provide adequate space for staff to
apply restraints and shall not allow individuals to access the lights, smoke
detectors or other items that may be in the ceiling of the room;
vii.
Rooms used for seclusion and/or
restraint must provide staff full visual access to the individual and shall
include a vision panel installed in the door;
viii.
Where the interior of the seclusion
and/or restraint room is padded; it is in good repair and must be fully
intact.
f.
Fenced
Recreational Area:
i.
The CSU shall have an
outdoor area enclosed by a privacy fence no less than six (6) feet high, where
individuals may have access to fresh air and exercise. It must provide privacy
from public view and shall not provide access to contact with the public;
ii.
This area shall be constructed
to retain individuals inside the area and minimize elopements from the
area;
iii.
The fenced area shall be
designed for safety without blind corners to be readily visible by one staff
individual standing in a central location, and designed to minimize
elopement.
30.
CSUs and any associated CSC and/or Temp Obs shall meet rules specified in Rule
82-3-1-.21, Environment of Care or
shall submit a Risk Mitigation Plan to the Department for approval addressing a
particular citation and related protocols for safety management. This shall be
submitted at the time of licensing review and annually thereafter.
Rule 82-3-1-.22 Fire Prevention and Safety Requirements
1.
The CSU and any associated CSC and/or Temp
Obs functions shall have an emergency fire and disaster plan that includes the
following:
a.
Protocols for and documentation
of practice of monthly fire drills rotated so that all shifts have had at least
one (1) drill quarterly including time taken to complete the drills and
follow-up recommendations for drills that are unsatisfactorily
completed;
b.
Disaster drills
protocols such as flood, tornado, and hurricane are practiced at least
quarterly;
c.
Directions for
evacuation of the CSU and any associated CSC and/or Temp Obs utilizing posted
evacuation routes;
d.
Preparation
of the individuals for evacuation;
e.
Documentation of monthly fire extinguisher
inspection;
f.
Documentation of
annual inspections of other safety mechanisms such as sprinklers, smoke alarms,
emergency lights, kitchen range/hood, etc.
g.
Provision for annual review and revision
of the fire and emergency safety plan;
h.
Procedures for training staff on all
emergency and disaster drills;
2.
The CSU and any associated CSC and/or Temp
Obs shall comply with all federal, state local, and accreditation fire safety
standards. Local fire codes with more stringent standards or additional
requirements shall supersede the minimum requirements set forth in this
rule.
Rule 82-3-1-.23 Human Resources
The CSU and any associated CSC and/or Temp Obs shall comply
with the following:
1.
Develop and
implement policies and procedures that address the hiring, training, promotion
and termination of staff;
2.
Define
the responsibilities, qualifications, competencies of staff for all
positions;
3.
Ensure that the type
and number of professional staff attached to the unit are:
a.
Properly licensed or credentialed in the
professional field as required;
b.
Present in numbers to provide adequate supervision to staff;
c.
Present in numbers to provide services,
supports, care and treatment to individuals as required;
d.
Experienced and competent in the
profession they represent; and
e.
At
least one (1) staff trained in Basic Cardiac Life Support (BCLS) and first aid
shall be on duty at all times. In addition, one (1) staff trained in the use of
the Automated External Defibrillator (AED) equipment shall also be on
duty.
4.
Paraprofessionals working in mental health, addictive diseases and co-occurring
disability services must complete the standard training requirements for
paraprofessionals;
5.
Have
procedures for verifying licenses, credentials, experience and competence of
staff:
a.
Document implementation of these
procedures for all staff attached to the CSU; and
b.
Licenses and credentials shall be current
as required by the field.
6.
Ensure that all persons providing services
comply with all applicable laws, rules and regulations regarding professional
licenses, qualifications and requirements related to the scope of
practice;
7.
Comply with all
applicable laws, rules and regulations governing criminal history records
checks;
8.
Have processes for
managing personnel information and records;
9.
Have provisions for sanctioning or
removing staff when:
a.
Staff are determined
to have deficits in required competencies; or
b.
Staff are accused of abuse, neglect or
exploitation.
10.
Ensure
that, prior to providing direct care to individuals, all staff, volunteers, and
contactors shall be trained and show evidence of competence in all areas as
defined in the DBHDD Provider Manual for Community Behavioral Health
Providers;
11.
Ensure that, within
the first sixty (60) days of providing direct care to individuals, all staff,
volunteers and contractors having direct contact with individuals shall receive
training in all areas as defined in the DBHDD Provider Manual for Community
Behavioral Health Providers;
12.
Have documentation of an annual training plan that addresses 100% of staff who
deliver therapeutic content is trained in at least one (1)
clinical/programmatic content topic related to the delivery of care;
13.
Ensure that all employees are tested for
tuberculosis prior to direct contact with individuals and are retested at least
annually thereafter.
Rule 82-3-1-.24 Transportation
1.
The CSU and any
associated Temp Obs functions shall assist in the coordination of necessary
transportation through transfer and/or discharge to community-based
services.
2.
The CSU shall provide
transportation in compliance with the DBHDD Provider Manual for Community
Behavioral Health Providers for individuals in transitional beds who are
otherwise unable to access services in the community while in transitional
status.
Rule 82-3-1-.25 Incident and Complaint Reporting and Investigation Procedures
The CSU, CSC and/or Temp Obs shall:
1.
Report critical incidents to the
Department as defined by the Departmental policy on reporting of
incidents;
2.
Have internal
mechanisms to document, investigate and take appropriate action for complaints
and incidents which are not required to be reported to the
Department;
3.
Post in a visible
area the procedure to be taken to make a complaint directly to the
Department.
Rule 82-3-1-.26 Department Complaint and Incident Investigation Procedures
1.
The Department
shall be authorized to conduct investigations:
a.
Investigations shall be conducted to
ensure compliance with all applicable laws, rules and regulations;
b.
Department representatives shall be
authorized to enter the premise at any time to survey or investigate to ensure
compliance with or prevent a violation to ensure the quality and integrity of
care of individuals;
c.
The
Department shall have complete access to, including but not limited to
authorization to examine and reproduce, any records required to be maintained
in accordance with contracts, standards, laws, rules and regulations of the
Department;
d.
The Department shall
maintain the confidentiality of records as specified by federal and state
law.
2.
The Department
shall have the authority to conduct announced or unannounced on-site reviews at
its discretion at any time or as part of the investigation of complaints or
incidents. The Department shall issue written findings within a reasonable
period of time. Based on its findings of the review, the Department may:
a.
Require corrective action that is approved
by the Department:
i.
When the Department
finds that any licensee has violated any provision of this Chapter, the
Department will prepare a written report identifying each violation and
anticipated corrective action;
ii.
The facility shall submit to the Department a written plan of correction in
response to the report of violations, which includes details related to the
types of anticipated corrections along with stated timeframes for completions
of corrections. The facility may, in addition, offer an explanation for the
violation or dispute the findings of the Department as long as an acceptable
plan of correction is submitted within thirty (30) days of the facility's
receipt of the written report of inspection;
iii.
If the initial plan of correction is
unacceptable to the Department, the facility will be provided with at least one
(1) opportunity to revise the unacceptable plan of correction. Failure to
submit an acceptable plan of correction may result in the Department initiating
enforcement procedures;
iv.
The
facility shall comply with its plan of correction.
b.
Prohibit admissions to the CSU for a
defined period of time;
c.
Temporarily suspend the CSU license upon findings determined to be of
significant risk to health or safety of individuals; or
d.
Revoke the license.
Rule 82-3-1-.27 Enforcement
The Department shall have the authority to impose any one or
more of the sanctions enumerated in Rules
82-3-1.28 and
82-3-1.29 upon a finding that an
applicant or licensee has:
1.
Knowingly made any verbal or written false statement of material fact either in
connection with the application for a license, on documents submitted to the
Department as part of any inspection or investigation, or in the falsification
or alteration of facility records made or maintained by the facility;
2.
Failed or refused, without legal cause, to
provide the Department with access to the premises subject to regulation or
information pertinent to the initial and continued licensing of the
facility;
3.
Failed to comply with
any licensing requirements of this state; or
4.
Failed to comply with the provisions of
state law or with any provisions of these rules.
Rule 82-3-1-.28 Sanctions and Penalties
1.
Sanctions against Licensees. When the
Department finds that any licensee has violated any provision of these rules
and regulations, the Department, subject to notice and opportunity for a
hearing, may impose any one or more of the sanctions in subparagraphs (a)
through (e) below:
a.
Administer a Public
Reprimand. If the sanction of public reprimand is finally imposed, as defined
by a final adverse finding, the public reprimand shall consist of a notice
prepared by the Department that the CSU has been reprimanded; such notice shall
include a written report of the Department's findings along with the CSU's
response and corrective action plan;
b.
Suspend any License. The Department may
suspend any license for a definite period or for an indefinite period in
connection with any condition which may be attached to the restoration of said
license;
c.
Prohibit Persons in
Management or Control. The Department may prohibit a licensee from allowing a
person who previously was involved in the management or control of any CSU
which has had its license revoked or application denied within the past twelve
(12) months to be involved in the management or control of such CSU. Any such
person found by the Department to have acted diligently and in good faith to
ensure correction of violations in a CSU which has had its license revoked or
denied; however, shall not be subject to this prohibition if that person became
involved in the management or control of the CSU after the CSU was notified by
the Department of violations of licensing requirements giving rise to a
revocation or denial action. This subparagraph shall not be construed to
require the Department to obtain any information that is not readily available
to it regarding any person's involvement with a CSU. For the purpose of this
Rule, the twelve- month period will begin to run from the date of any final
adverse finding or the date that any stay of enforcement ceased, whichever
occurs first;
d.
Revoke any
License. The Department may revoke any license. If the sanction of license
revocation is finally imposed, as defined by a final adverse finding, the
Department shall effectuate it by requiring the CSU to return its license to
the Department;
e.
Limit or
Restrict any License. The Department may limit or restrict any license as the
Department deems necessary for the protection of the public (a provisional or
temporary time-limited license granted by the Department shall not be
considered to be a limited or restricted license).
2.
Sanctions against Applicants. When the
Department finds that any applicant for a license has violated any provision of
these rules, the Department, subject to notice and opportunity for a hearing,
may impose any one or more of the following sanctions in subparagraphs (a)
through (c) below:
a.
Refuse to Grant License.
The Department may refuse to grant (deny) a license and the
i.
Department may do so without first holding
a hearing prior to taking such action:
The Department may deny an application for a license where
the CSU has failed to demonstrate compliance with licensing requirements.
Additionally, the Department may deny an application for a license where the
applicant or alter ego of the applicant has had a license denied, revoked, or
suspended within one (1) year of the date of an application, or where the
applicant has transferred ownership or governing authority of a CSU within one
(1) year of the date of a new application when such transfer was made in order
to avert denial, revocation, or suspension of a license;
ii.
For the purpose of determining the one
(1) year denial period, the period shall begin to run from the date of the
final adverse finding, or the date any stay of enforcement ceased, whichever
occurs first. In further determining whether to grant or deny a license, the
Department may consider the applicant's overall record of compliance with
licensing requirements;
b.
Prohibit Persons in Management or Control.
The Department may prohibit an applicant from allowing a person who previously
was involved in the management or control of any CSU which has had its license
revoked or application denied within the past twelve (12) months to be involved
in the management or control of such CSU. Any such person found by the
Department to have acted diligently and in good faith to ensure correction of
violations in a CSU which has had its license revoked or denied, however, shall
not be subject to this prohibition if that person became involved in the
management or control of the CSU after the CSU was notified by the Department
of violations of licensing requirements giving rise to denial action. This
subparagraph shall not be construed to require the Department to obtain any
information that is not readily available to it regarding any person's
involvement with a CSU. For the purpose of this rule, the twelve-month period
will begin to run from the date of any final adverse finding or the date that
any stay of enforcement ceased, whichever occurs first;
c.
Limit or Restrict any License. The
Department may limit or restrict any license as it deems necessary for the
protection of the public (a provisional or temporary time- limited license
granted by the Department shall not be considered to be a limited or restricted
license).
3.
Standards
for Taking Sanctions. In taking any of the actions pursuant to this rule, the
Department shall consider the seriousness of the violation or violations,
including the circumstances, extent, and gravity of the prohibited act or acts
or failure to act, and the hazard or potential hazard created to the physical
or emotional health and safety of the public and/or the individuals
served.
4.
Non-Compliance with
Sanctions. Failure on the part of any CSU to abide by any sanction which is
finally imposed against it shall constitute grounds for the imposition of
additional sanctions, including revocation.
5.
Settlements. With regard to any contested
case instituted by the Department pursuant to this Chapter or other provisions
of law or regulation which may now or hereafter authorize remedial or
disciplinary grounds and action, the Department may, in its discretion, dispose
of the action so instituted by settlement. In such cases, the Department, the
CSU, and those persons deemed by the Department to be successors in interest to
any settlement agreement, shall be bound by the terms specified therein.
Violation thereof by any applicant or licensee, their agents, employees, or
others acting on their behalf, shall constitute grounds for the imposition of
any sanctions enumerated in this Chapter, including revocation.
Rule 82-3-1-.29 Extraordinary Sanctions Where Imminent and Substantial Danger
Where the commissioner of the Department determines that
individuals in the care of CSU and any associated CSC and/or Temp Obs subject
to licensure are subject to an imminent and substantial danger, the
commissioner may order any of the extraordinary sanctions listed in any part of
this rule to take effect immediately unless otherwise specified in the order,
without notice and opportunity for hearing prior to the order taking
effect:
1.
Content of the Order. The
order shall contain the following:
a.
The
scope of the order;
b.
Reasons for
the issuance of the order;
c.
Effective date of the order if other than the date the order is
issued;
d.
Person to whom questions
concerning the order are to be addressed; and
e.
Notice of the right to obtain a
preliminary hearing and an administrative hearing after the issuance of the
order regarding the emergency order as a contested case.
2.
Emergency Relocation. The commissioner may
order emergency relocation of the individual of any CSU and any associated CSC
and/or Temp Obs subject to licensure to the nearest appropriate facility. Prior
to issuing an emergency order, the commissioner may consult with persons
knowledgeable in the field of psychiatric care and a representative of the CSU
to determine if there is a potential for greater adverse effects on the
individual or the individual's care as a result of the proposed issuance of an
emergency order. The commissioner shall provide notice to the individual, his
or her next of kin or guardian and his or her physician of the emergency
relocation and the reasons therefore; relocation to the nearest appropriate CSU
designed to ensure the welfare and, when possible, the desires of the
individual;
3.
Emergency Placement
of Monitor. The commissioner may order the emergency placement of a monitor in
a CSU and any associated CSC and/or Temp Obs subject to licensure when
conditions at the facility require immediate oversight for the safety of the
individuals;
4.
Emergency
Prohibition of Admissions. The commissioner may order the emergency prohibition
of admissions to a CSU when such CSU has failed to correct a violation of
Departmental permit rules within a reasonable period of time, as specified in
the Department's corrective order, and the violation could either jeopardize
the health and safety of any individuals if allowed to remain uncorrected or is
a repeat violation over a twelve (12) month period, which is intentional or due
to gross negligence;
5.
Emergency
Suspension of Admissions. The commissioner may order admissions to a CSU be
suspended until the Department has determined that the violation has been
corrected or until the Department has determined that the CSU has undertaken
the action necessary to effect correction of the violation;
6.
Preliminary Hearing. The CSU affected by
the commissioner's emergency order may request that the Department hold a
preliminary hearing within the Department on the validity of the order and the
need for its continuation. Such hearing shall occur within ten (10) days
following the request;
7.
Cumulative Remedy. The Department shall not be limited to a single emergency
action under these rules, nor is the Department precluded from other actions
permitted by other law or regulations during the time an emergency order is in
force.
Rule 82-3-1-.30 Waivers and Variances
The Department may, in its discretion, grant waivers and
variances of specific rules upon application or petition being filed on forms
provided by the department. The Department may establish conditions which must
be met by the program in order to operate under the waiver or variance granted.
Waivers and variances may be granted in accordance with the following
considerations:
1.
Variance. A variance
may be granted by the Department upon a showing by the applicant or petitioner
that the particular rule or regulation that is the subject of the variance
request should not be applied as written because strict application of the rule
would cause undue hardship. The applicant or petitioner must also show that
adequate standards affording protection for the health, safety and care of
individuals exist and will be met in lieu of the exact requirements of the rule
or regulations in question;
2.
Waiver. The Department may dispense entirely with the enforcement of a rule or
regulation by granting a waiver upon a showing by the applicant or petitioner
that the purpose of the rule or regulation is met through equivalent standards
affording equivalent protection for the health, safety and care of
individuals;
3.
Experimental
Variance or Waiver. The Department may grant waivers and variances to allow
experimentation and demonstration of new and innovative approaches to delivery
of services upon a showing by the applicant or petitioner that the intended
protections afforded by the rule or regulation which is the subject of the
request are met and that the innovative approach has the potential to improve
service delivery.
Rule 82-3-1-.31 Severability
In the event that a rule, sentence, clause or phrase of any
of these rules and regulations may be construed by any court of competent
jurisdiction to be invalid, illegal, unconstitutional or otherwise
unenforceable, such determination or adjudication shall in no manner affect the
remaining rules or portions thereof. The remaining rules or portions thereof
shall remain in full force and effect, as if such rule or portions thereof so
determined, declared or adjudged invalid or unconstitutional were not
originally a part of these rules.
Rule 82-3-1-.32 Additional Crisis Service Center (CSC) and Temporary Observation (Temp Obs) Requirements
A CSU under contract to operate a CSC and/or Temp Obs is
expected to comply with the following in the administration of those
functions:
1.
Program Description. A
CSU under contract to operate a CSC and/or Temp Obs shall have a description of
services which shall clearly states that the distinct, yet interrelated roles
of the CSU, CSC and/or Temp/Obs as a program is designed as an alternative
and/or diversion to hospitalization.
2.
Evaluation and Admission. The CSU under
contract to operate a CSC and/or Temp Obs must follow admissions and exclusion
criteria as defined in the DBHDD Provider Manual for Community Behavioral
Health Provider.
3.
Provision of
Individualized Care. A licensed staff shall, at a minimum:
a.
Conduct an assessment of the
individual;
b.
Document the
rationale for proposed interventions, as applicable;
c.
Assess the individual's response to care
and services provided; and
d.
Assess status of the individual to determine continuity of care or referral to
community services.
4.
Environment of Care
a.
If the facility
operates an area where individuals are evaluated and/or observed prior to
admission determination being made, the facility has a secure area where
individuals who are being evaluated on an involuntary basis can be
held;
b.
The CSC/Temp Obs shall
have at least one (1) operable, non-pay telephone which is private and
accessible at reasonable times for use by the individual; and is not located
within the CSU residence space.
Rule 82-3-1-.33 Repealed
Rule 82-3-1-.01 Legal Authority
Rule 82-3-1-.02 Title and Purpose
Rule 82-3-1-.03 Definitions
Rule 82-3-1-.04 General Licensing Requirements
Rule 82-3-1-.05 Application Requirements
Rule 82-3-1-.06 Issuance of Initial and Renewal of License
Rule 82-3-1-.07 Operational Scope of Services
Rule 82-3-1-.08 Program Description
Rule 82-3-1-.09 Evaluation and Admissions
Rule 82-3-1-.10 Provision of Individualized Care
Rule 82-3-1-.11 Documentation of Care
Rule 82-3-1-.12 Protection and Safety of the Individual and of Others
Rule 82-3-1-.13 Pharmacy Services and Management of Medication
Rule 82-3-1-.14 Laboratory Services
Rule 82-3-1-.15 Food Services
Rule 82-3-1-.16 Infection Control and Prevention
Rule 82-3-1-.17 Rights and Responsibilities of Individuals
Rule 82-3-1-.18 Confidentiality
Rule 82-3-1-.19 Documentation of Legal Status
Rule 82-3-1-.20 Performance Improvement Plan and Activities
Rule 82-3-1-.21 Environment of Care
Rule 82-3-1-.22 Fire Prevention and Safety Requirements
Rule 82-3-1-.23 Human Resources
Rule 82-3-1-.24 Transportation
Rule 82-3-1-.25 Incident and Complaint Reporting and Investigation Procedures
Rule 82-3-1-.26 Department Complaint and Incident Investigation Procedures
Rule 82-3-1-.27 Enforcement
Rule 82-3-1-.28 Sanctions and Penalties
Rule 82-3-1-.29 Extraordinary Sanctions Where Imminent and Substantial Danger
Rule 82-3-1-.30 Waivers and Variances
Rule 82-3-1-.31 Severability
Rule 82-3-1-.32 Additional Crisis Service Center (CSC) and Temporary Observation (Temp Obs) Requirements
Rule 82-3-1-.33 Repealed