This Oregon rule establishes standards for Psychiatric Emergency Services (PES) delivered within hospital or hospital satellite emergency departments. It sets requirements for facility certification, physical environment, staffing (including 24/7 licensed mental health professionals and psychiatrist availability), staff training, service delivery (up to 23-hour crisis stabilization and assessment), seclusion and restraint, involuntary detainment procedures, and quality improvement reporting. Operators must develop crisis stabilization plans, provide transition of care coordination, and comply with applicable OAR chapter 309 division 33 standards.
View official sourceOregon Health Authority Health Systems Division: Behavioral Health Services - Chapter 309 Division 23 PSYCHIATRIC EMERGENCY SERVICES (PES) 309-023-0100 Purpose and Scope These rules prescribe standards of care and other requirements relating to psychiatric emergency services delivered in an emergency department at a licensed hospital or licensed hospital satellite. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 History: MHS 29-2016, f. & cert. ef. 12-29-16 MHS 15-2016(Temp), f. & cert. ef. 10-6-16 thru 4-3-17 309-023-0110 Definitions In addition to the definitions in OAR chapter 309 division 033 the following definitions apply to these rules: (1) “Behavioral Health” means mental health, mental illness, substance use disorders, and gambling disorders. (2) “Behavioral Health Assessment” means a process which determines a patient’s need for immediate crisis stabilization through evaluation of the patient’s strengths, goals, needs, and current level of functioning. (3) “Best Practice Risk Assessment” means a research-informed methodology that provides guidelines or tools to determine an individual’s level of risk for attempting or completing self-inflicted injury or death and may include tools such as the Columbia Suicide Severity Rating Scale or other tools accepted for the Substance Abuse and Mental Health Services Administration National Registry of Evidence-based Programs and Practices or the Suicide Prevention Resource Center Best Practices Registry. (4) “Care Coordination” means a process-oriented activity to facilitate ongoing communication and collaboration to meet multiple needs Including facilitating communication between family, natural supports, community resources, and involved providers and agencies; organizing, facilitating and participating in team meetings; and providing for continuity of care by creating linkages to and managing transitions between levels of care. (5) "Case Management" means the services provided to assist individuals, who reside in a community setting, or are transitioning to a community setting, in gaining access to needed medical, behavioral health, social, educational, government entitlement programs, and other applicable community services. (6) "Crisis" means either an actual, or perceived, urgent or emergent situation that occurs when an individual’s stability or functioning is disrupted and there is an immediate need to resolve the situation to prevent a serious deterioration in the individual’s mental or physical health or to prevent referral to a significantly higher level of care. (7) "Crisis Intervention" means short-term services to address an immediate crisis need. (8) “Crisis Stabilization Plan” means an individualized written plan defining specific short-term rehabilitation objectives and proposed crisis interventions derived from the patient’s mental and physical health assessment. (9) “Family” has the meaning given that term in 309-018-0150. (10) "Hospital" has the meaning given that term in ORS 442.015. (11) “Lethal Means Counseling” means providers implement counseling strategies to help patients at risk for suicide, and their families, reduce access to lethal means, including but not limited to firearms. It includes but is not limited to several components; background on suicide data and lethal means, introduction to firearms, video presentation that models the counseling strategy, presentation and discussion on conducting a counseling session, optional role plays, and a course evaluation. (http://www.sprc.org/resources-programs/calm-counseling-access-lethal-means-0). (12) “Living Room Setting” means a care setting that reflects the relaxed, warm, welcoming and non-clinical qualities of a typical living room. (13) “Medically Appropriate Treatment” has the meaning given that term in OAR 410-172-0630. (14) “Mental Status Examination” means an overall assessment of an individual’s mental functioning. (15) “Peer” has the meaning given that term in OAR 410-180-0305. (16) “Peer Delivered Services” has the meaning given that term in OAR 309-019-0100. (17) “Peer Support Specialist” has the meaning given that term in OAR 410-180-0300 and also means an individual who has completed a Division approved training program (see OAR 410-180-0312) and is providing peer delivered services to an individual or family member with similar life experience, under the supervision of a qualified clinical supervisor. (18) “Psychiatric Emergency Services (PES)” means medical and behavioral health services provided to individuals experiencing an acute disturbance of thought, mood, behavior, or social relationship that requires an immediate intervention as defined by the patient, family or the community, to prevent harm to the patient or others. (19) “Safety Plan” means a patient directed document developed through a collaborative process in which the provider assists the patient in listing strategies for the patient to use when suicide ideation is elevated or after a suicide attempt. A safety plan template is available from the Suicide Prevention Resource Center at http://www.sprc.org/resources-programs/calm-counseling-access-lethal-means-0. (20) “Transition of Care Coordination” also known as a Warm Handoff, means the process of transferring a patient from one provider to another, prior to discharge. (21) “Trauma Informed Services” has the meaning given that term in OAR 309-018-0105(77). The Authority’s trauma informed service policy may be found at https://www.oregon.gov/oha/amh/pages/trauma.aspx. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 History: MHS 29-2016, f. & cert. ef. 12-29-16 MHS 15-2016(Temp), f. & cert. ef. 10-6-16 thru 4-3-17 309-023-0120 PES Facility Requirements (1) For purposes of these rules, psychiatric emergency services shall be delivered in an emergency department through a hospital or hospital satellite licensed in accordance with OAR chapter 333 division 500. (2) The PES facility shall comply with the following: (a) Standards for Regional Acute Care Psychiatric Services for Adults pursuant to OAR 309-032-0850 to 0870. (b) Be approved as a hospital hold facility pursuant to OAR 309-033-0500 to 0550. (c) Meet the structural and physical requirements set forth in OAR chapter 333 division 535 and 309-033-0727. (3) The facility shall offer food and drink at regularly scheduled intervals and as needed, to patients receiving services. (4) The facility shall develop policies and procedures annually that demonstrate collaboration with all local licensed ambulance service agencies and police departments that specify the role of each responder in managing medical, psychiatric and other emergencies. The policies and procedures shall also include a requirement for first responder training to determine if the appropriate setting for the patient should be a PES. (5) The facility shall develop policies and procedures that demonstrate collaboration with the local community and local Coordinated Care Organizations. (6) The facility shall have phone access available for the patient, when appropriate. (7) The facility shall offer a care setting that is appropriate to the patient’s wishes and safety needs. Care settings should include a living room setting, which may accommodate the option for lying down comfortably and allowing for more privacy. Living room settings include comfortable seating, soft lighting, and are designed to encourage a sense of safety and belonging. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 History: MHS 29-2016, f. & cert. ef. 12-29-16 MHS 15-2016(Temp), f. & cert. ef. 10-6-16 thru 4-3-17 309-023-0130 Services (1) Psychiatric emergency services may include up to 23 hours of triage and assessment, observation and supervision, crisis stabilization, crisis intervention, crisis counseling, case management, medication management, safety planning, lethal means counseling, and mobilization of peer and family support and community resources. (2) The facility shall deliver services that are individualized, recovery-oriented, trauma informed, developmentally and medically appropriate and consistent with best practices for suicide risk assessment, intervention and treatment. (3) Staff must promptly conduct an assessment to determine the precipitating factors that lead to the crisis and a screening assessment which shall include a best practice evaluation of risk of harm to self or others, a mental status exam, need for immediate behavioral health assessment, including depression screening, need for emergency intervention, a medical screening exam, and collection of collateral information. (4) Staff shall develop a crisis stabilization plan that provides the most effective treatment based on the patient’s provisional psychiatric condition and, to the maximum extent possible, incorporates patient or family preferences. For purposes of these rules, the term families includes families of choice. The facility shall offer peer delivered services to the patient and family and, if accepted, shall be incorporated in care coordination and crisis stabilization plan. (5) The facility shall provide access to existing community based rehabilitation, reasonable access to peer and family support and social services that may be used to help the patient transition to the community and provide documentation of other needed interventions including crisis counseling and family counseling. (6) Transition of care coordination shall include to the extent possible and when the patient agrees: (a) A face-to-face meeting with a community provider and the patient, and if possible, family, and hospital staff prior to discharge. (b) A face-to-face meeting may be accomplished via technology that provides secure, unrecorded, audio video in a private setting with a community provider and the patient, and if possible, family and hospital staff. (7) Transition of care coordination shall include: (a) A transitional team at the PES facility to support the patient, serve as a bridge between the hospital and a community provider and to the extent possible ensure that the patient connects with a community provider, and peer and family support services if desired by the patient and their family. (b) For patients discharged to their home or other living environment, a member of the transition team shall determine through interviews with the patient, family, peer or family support specialists or lay caregiver the safety of that environment, potential mitigating factors to reduce risk, provide discharge instructions, including a safety plan, and lethal means counseling to the patient, peer and family support specialist and family. (8) Facilities shall ensure that the rights of individuals are provided pursuant to OAR 309-032-0341. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 History: MHS 29-2016, f. & cert. ef. 12-29-16 MHS 15-2016(Temp), f. & cert. ef. 10-6-16 thru 4-3-17 309-023-0140 Seclusion and Restraint (1) The facility shall be certified as a Class 1 facility pursuant to OAR 309-033-0520. A Class 1 facility is a facility that is approved under applicable administrative rules to be locked to prevent a patient from leaving the facility, to use seclusion and restraint, and to involuntarily administer psychiatric medication. (2) The facility shall comply with seclusion and restraint requirements set forth in OAR chapter 309 division 33. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 History: MHS 29-2016, f. & cert. ef. 12-29-16 MHS 15-2016(Temp), f. & cert. ef. 10-6-16 thru 4-3-17 309-023-0150 Involuntary Detainment & Informed Consent (1) For individuals who are in custody, under a civil commitment, hospital hold or on diversion, the PES facility must comply with the administrative rules in OAR chapter 309, division 33 which govern the administration, standards of care, standards for obtaining informed consent, administration of emergency procedures without informed consent, and transportation of individuals being held in custody, whether the individual is under a civil commitment order, a hospital hold, or on diversion from a civil commitment. (2) The facility shall have written policies concerning the care, custody, and treatment of individuals in custody or on diversion. These policies shall be reviewed as part of the Division’s approval process, and be in accordance with OAR chapter 309 division 33. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 History: MHS 29-2016, f. & cert. ef. 12-29-16 MHS 15-2016(Temp), f. & cert. ef. 10-6-16 thru 4-3-17 309-023-0160 Staffing Requirements (1) An adequate number of clinical staff and on-site peer support specialists shall be available and specifically trained in psychiatric emergency services. (2) A licensed psychiatrist shall be available to meet with patients as needed at any time and on site no less than 12 hours each day to assess individuals and initiate the development of a crisis stabilization plan and oversee patient care. (3) At a minimum, one registered nurse, and one licensed mental health professional shall be on-site 24/7, and shall be dedicated to providing psychiatric emergency services to individuals in crisis. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 History: MHS 29-2016, f. & cert. ef. 12-29-16 MHS 15-2016(Temp), f. & cert. ef. 10-6-16 thru 4-3-17 309-023-0170 Staff Training (1) The facility shall have policies and procedures for ongoing educational programs to instruct staff regarding best practices in psychiatric emergency services. (2) A staff training curriculum shall include, but is not limited to: (a) Criteria for the admission of an individual who can safely be served by the facility; (b) Recognition of indicators of violence to self or others, or assault and criteria for the transfer of the individual to or from the facility; (c) Indicators of medical problems, identification of medication side effects, and indicators of medical problems and medical crisis; (d) Management of aggressive behavior and de-escalation techniques; (e) Trauma Informed care in accord with the Authority’s Trauma Informed Policy at https://www.oregon.gov/oha/amh/pages/trauma.aspx; (f) Practices to provide psychoeducation and post-discharge safety to patients and families; (g) Best practice treatment for substance use disorders (h) Staff training in best practices for: (A) Lethal means counseling which may include the CALM (http://www.sprc.org/resources-programs/calm-counseling-access-lethal-means) or similar curriculum; (B) Collaboration with patients on development of safety plans which may include guidelines established by the Suicide Prevention Resource Center, http://www.sprc.org/sites/default/files/SafetyPlanningGuide%20Quick%20Guide%20for%20Clinicians.pdf; and (C) Risk assessment. (3) At a minimum, staff training shall be provided at time of hire and required annually, or more often if necessary. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 History: MHS 29-2016, f. & cert. ef. 12-29-16 MHS 15-2016(Temp), f. & cert. ef. 10-6-16 thru 4-3-17 309-023-0180 Quality Assessment and Improvement and Patient Outcomes (1) Facilities must comply with the quality assessment and improvement requirements set forth in OAR 309-032-0870 (10). (2) In addition to the quality assessment requirements in section (1) facilities shall maintain records of outcomes, for each patient, outlined in the PES provider manual. (3) Facilities shall report annually to the Authority regarding quality assessment information set forth in OAR 309-032-0870 and outcomes described in the PES provider manual. The report shall use data to demonstrate the quality, cost-effectiveness, and patient satisfaction with PES. The Authority shall review the PES facility reports annually and may make changes to PES policy or payment based on outcome performance. Statutory/Other Authority: ORS 413.042 Statutes/Other Implemented: ORS 413.042 History: MHS 29-2016, f. & cert. ef. 12-29-16 MHS 15-2016(Temp), f. & cert. ef. 10-6-16 thru 4-3-17