This Tennessee rule establishes minimum program requirements for licensed Mental Health Crisis Stabilization Unit (CSU) facilities, covering adults 18 and older who need short-term psychiatric stabilization of up to 96 hours. Operators must maintain written policies and procedures, meet specific staffing ratios (including 24/7 nursing coverage and on-call qualified prescriber), develop an Individual Plan of Care within six hours of admission, and maintain detailed individual records. The rule also sets requirements for medication administration, storage, and disposition of unused medications.
View official sourceDecember, 2022 (Revised) 1 RULES OF THE TENNESSEE DEPARTMENT OF MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES OFFICE OF LICENSURE CHAPTER 0940-05-18 MINIMUM PROGRAM REQUIREMENTS FOR MENTAL HEALTH CRISIS STABILIZATION UNIT FACILITIES TABLE OF CONTENTS 0940-05-18-.01 Definition 0940-05-18-.06 Individual Record Requirements For Crisis 0940-05-18-.02 Application Of Rules For Mental Health Crisis Stabilization Unit Facilities Unit Facilities 0940-05-18-.07 Medication Administration In Crisis 0940-05-18-.03 Policies And Procedures For Crisis Stabilization Unit Facilities Stabilization Unit Facilities 0940-05-18-.08 Storage Of Medications And Poisons 0940-05-18-.04 Personnel And Staffing Requirements In Crisis 0940-05-18-.09 Disposition Of Unused Medications Stabilization Unit Facilities 0940-05-18-.10 Reserved 0940-05-18-.05 Individual Plan Of Care (IPC) Requirements For Crisis Stabilization Unit Facilities 0940-05-18-.01 DEFINITION. (1) “Crisis Stabilization Unit” (CSU) means services specifically designed for service recipients eighteen (18) years and older in need of short -term stabilization, up to ninety -six (96) hours, who do not meet the criteria for other treatment resources, other less restrictive treatment resources are not available, or the service recipient is agreeable to receive services voluntarily at the CSU and meet admission criteria. If necessary, in order to assure that adequate arrangements are in place to allow for the safe discharge of the service recipient, the length of stay may be extended by up to twenty-four (24) hours. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-302, 33-1-305, 33-1-309, 33-2-301, 33-2-302, and 33-2-404. Administrative History: Original rule filed May 26, 1988; effective July 11, 1988. Amendment filed September 4, 2003; effec tive November 18, 2003. Repeal and new rule filed July 31, 2008; effective October 14, 2008. 0940-05-18-.02 APPLICATION OF RULES FOR MENTAL HEAL TH C RISIS STABILIZATION UNIT FACILITIES. (1) Applicable occupancy rules found in 0940- 05-04: Life Safety Healt h Care Occupancies for facilities providing services for four (4) or more service recipients who are not capable of self - preservation; Life Safety B oard and Care Occupancies for facilities providing services to four (4) or more service recipients; or Life Safety One- and Two-Family Dwellings Occupancies for facilities providing services to two (2) or three (3) service recipients; (2) If services are to be provided in a facility meeting the requirements for Board and Care or One- and Two- Family Dwelling Occ upancy and services are provided to one (1) or more mobile non- ambulatory service recipients, then Rule 0940- 05-04-.09(2) Mobile Non- Ambulatory rule; (3) Applicable rules for Adequacy of Facility Environment and Ancillary Services found in 0940- 05-05; (4) Applicable Minimum Program Requirements for all Facilities found in 0940-05-06; MINIMUM PROGRAM REQUIREMENTS FOR MENTAL HEALTH CHAPTER 0940-05-18 CRISIS STABILIZATION UNIT FACILITIES (Rule 0940-05-18-.02, continued) December, 2022 (Revised) 2 (5) Minimum Program Requirements for Mental Health Crisis Stabili zation Unit Facilities found in 0940-05-18; and (6) Requirements for the Use of Isolation, Mechanical Restraint, and Physical Holding Restraint in Mental Health Residential Treatment Facilities found in 0940-03-09. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-302, 33-1-305, 33-1-309, 33-2-301, 33-2-302, and 33-2-404. Administrative History: Original rule filed May 26, 1988; effective July 11, 1988. Amendment filed September 4, 2003; effective November 18, 2003. Repeal and new rule filed July 31, 2008; effective October 14, 2008. 0940-05-18-.03 POLICIES AND PROCEDURES FOR CRISIS STABILIZATION UNIT FACILITIES . (1) The program must maintain written policies and procedures in accordance with Chapter 0940-05-06. In addition, policies and procedures must include: (a) Policies which address the procedure for the prescription and administration of psychotropic medi cations, including policies and procedures for determining lack of capacity to consent to treatment. (b) Policies and procedures for referral to services outside the program. (c) Policies and procedures for the provision of non- emergency transportation of service recipients. (d) Policies and procedures for procuring medical treatment or monitoring primary physician medications of service recipients while in the crisis stabilization program. (e) Policies and procedures related to Treatment Review Committ ee responsibilities under TCA 33-6-107. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33- 2-302. Administrative History: Original rule filed May 26, 1988; effective July 11, 1988. Amendment filed September 4, 2003; effective November 18, 2003. 0940-05-18-.04 PERSONNEL AND STAFFING REQUIREMENTS IN CRISIS STABILIZATION UNIT FACILITIES. (1) The program must have a designated director or administrator who is responsible for the management and operation of the facility. (2) A qualified prescriber, who is author ized to prescribe medications by the Tennessee Board of Medical Examiners or the Tennessee Board of Nursing, must provide general medical services, prescription of medications and treatment. If the qualif ied prescriber is not a psychiatrist, the qualified prescriber must have psychiatric expertise, as defined by training, education or experience with consultation available from a psychiatrist. The qualified prescriber must be on call twenty-four (24) hours per day and must make daily rounds. (3) At least one registered nurse, nurse practitioner or physician assistant must be on duty and in program twenty-four (24) hours per day, 7 days per week. (4) The on-site and in program ratio of mental health personnel must not be less than one (1) full time equivalent (FTE) staff for every five (5) service recipients present. At no point shall there be fewer than two (2) staff present, one (1) of whom must be staff as identified in (3) above. MINIMUM PROGRAM REQUIREMENTS FOR MENTAL HEALTH CHAPTER 0940-05-18 CRISIS STABILIZATION UNIT FACILITIES (Rule 0940-05-18-.04, continued) December, 2022 (Revised) 3 (5) Mental health services must be provided by mental health personnel wit h expertise appropriate to the service recipient’s needs. (6) At least one (1) on- duty and on- site staff member must be certified in cardiopulmonary resuscitation (CPR) and trained in first aid, the abdominal thrust maneuver and standard precautions for infection control. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-302, 33-1-305, 33-1-309, 33-2-301, 33-2-302, and 33-2-404. Administrative History: Original rule filed May 26, 1988; effective J uly 11, 1988. Amendment filed September 4, 2003; effecti ve November 18, 2003. Amendments filed July 31, 2008; effective October 14, 2008. 0940-05-18-.05 INDIVIDUAL PLAN OF CARE (IPC) REQUIREMENTS FOR CRISIS STABILIZATION UNIT FACILITIES. (1) A plan mus t be developed for each service recipient. The plan must be based on initial and on-going assessment of need, designed to resolve the immediate psychiatric crisis, and be completed within six (6) hours of admission. The IPC must be documented in the serv ice recipient’s record and must include the following: (a) The service recipient’s name. (b) The date of plan development. (c) Standardized diagnostic formulation(s) including, but not limited to the current Diagnostic and Statistical Manual (DSM) and/or current International Statistical Classification of Diseases and Related Health Problems (ICD); (d) Problems and strengths of the service recipient that are to be addressed. (e) Observable and measurable individual objectives that relate to the specifi c problems identified. (f) Interventions that address spec ific objectives, identify staff responsible for interventions, and planned frequency. (g) Signatures of treatment staff responsible for developing plan, including qualified prescriber; (h) Signature of service recipient (and/or parent/guardian, conservator, legal custodian or attorney-in-fact). Reasons for refusal to sign and/or inability to participate in IPC development must be documented. (i) A projected discharge date and anticipated post discharge needs including documentation of resources needed in the community. (j) A review of the IPC must occur at least daily or upon completion of the stated goal(s) and objective(s) and must include the following documentation: 1. Dated signature(s) of appropriate treatment staff, including qualified prescriber. 2. Progress toward each treatment objective, with revisions as indicated; 3. Status of discharge plans, including availability of resources needed in the community, with revisions as indicated; and MINIMUM PROGRAM REQUIREMENTS FOR MENTAL HEALTH CHAPTER 0940-05-18 CRISIS STABILIZATION UNIT FACILITIES (Rule 0940-05-18-.05, continued) December, 2022 (Revised) 4 4. A statement by the staff psychiatrist or physician of justification for the level of service(s) needed including an assessment of suitability for treatment in a less restrictive environment. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-302, 33-1-305, 33-1-309, 33-2-301, 33-2-302 and 33-2-404. Administrative History: Original rule filed May 26, 1988; effective July 11, 1988. Amendment filed September 4, 2003; effective November 18, 2003. Amendments filed July 31, 2008; effective October 14, 2008. 0940-05-18-.06 INDIVIDUAL RECORD REQUIREMENTS FOR CRISIS STABILIZATION UNIT FACILITIES. (1) The individual record for each service recipient must contain the following information: (a) Intake interview and initial physical assessment. (b) A signed and dated original consent for treatment including doc umentation of informed consent for the administration of medication, if applicable. (c) The report of the mental status examination and other mental health assessments, as appropriate. (d) Daily progress notes by the qualified prescriber, nurses and other mental health professionals, as applicable; (e) Laboratory and radiology results, if applicable. (f) Documentation of all contacts with external medical and other services. (g) Original documentation of all crisis stabilization service physician medication orders. (h) A discharge summary with prognosis justified by explanation. (i) List of personal property, including its disposition if no longer with the service recipient. (j) Documentation of significant behavioral events and actions taken by staff. (k) Documentation of discharge disposition, including aftercare arrangements, if applicable. Authority: T.C.A. §§4 -4-103, 4- 5-202, 4- 5-204, 33- 1-302, 33-1-305, 33- 1-309, 33- 2-301, 33-2-302 and 33-2-404. Administrative History: Original rule filed May 26, 1988; effective July 11, 1988. Amendment filed September 4, 2003; effective November 18, 2003. Amendment filed July 31, 2008; effective October 14, 2008. 0940-05-18-.07 MEDICATION ADMINISTRATION IN CRISIS STABILIZATION UNIT FACILITIES. (1) Medications must be ordered by qualified prescribers. (2) All medication must be administered by Tennessee licensed medical or nursing personnel or by other qualified personnel as a llowed by Tenne ssee law and in accordance with the medical protocol of the facility/program. MINIMUM PROGRAM REQUIREMENTS FOR MENTAL HEALTH CHAPTER 0940-05-18 CRISIS STABILIZATION UNIT FACILITIES (Rule 0940-05-18-.07, continued) December, 2022 (Revised) 5 (3) “Oral” or “Telephone” orders may be issued by the qualified prescriber. These orders must be taken by a licensed nurse or physician assistant, qualified by tr aining and experience, and categorically approved by the medical staff of the facility/program. Upon hearing the order, the receiver shall record the order in the service recipient’s record, and then shall read back the written order to the issuing profess ional to assure that the order is understood clearly. “Oral” and “Telephone” orders must be documented as such and staff recording must sign their name and title. “Oral” and “Telephone” orders must be countersigned by the qualified prescriber no later than seventy-two (72) hours. (4) Legend drugs must be dispensed only by a licensed pharmacist. (5) All medication errors, drug reactions and suspected drug overmedication must be documented and reported to the practitioner who prescribed the drugs. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-302, 33-1-305, 33-1-309, 33-2-301, 33-2-302 and 33-2-404. Administrative History: Original rule filed May 26, 1988; effective July 11, 1988. Amendment filed September 4, 2003; effective November 18, 2003. Amendments filed July 31, 2008; effective October 14, 2008. 0940-05-18-.08 STORAGE OF MEDICATIONS AND POISONS. (1) Prescription medication must be legally dispensed and labeled according to State law. (2) All medications, poisons and other preparations intended for int ernal or external human use must be stored in medicine cabi nets or drug rooms. When preservation of the medication, poison, or other preparations depends upon refrigeration, the facility must provide a means of securely refrigerating these items. Such cabinets or drug rooms must be kept securely locked when not in use, and the key must be in the possession of the supervising nurse or other authorized person. (3) Schedule II drugs must be stored within two (2) separately locked compartments at all times and accessible only to persons in charge of administering medication. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33- 2-302. Administrative History: Original rule filed May 26, 1988; effective July 11, 1988. Amendment filed September 4, 2003; effective November 18, 2003. 0940-05-18-.09 DISPOSITION OF UNUSED MEDICATIONS. (1) Any unused portions of program- prescribed medication(s) must be either turned over to the service recipient with written authorization and directions by the qualified prescriber or returned to a pharmacy for proper disposition by the pharmacist. (2) Whenever a service recipient brings his/her own prescribed medications into the facility, such medications must not be administered unless identified and ordered by a qualified prescriber. If such medications cannot be administered, they must be packaged, sealed, and returned to an adult member of the service recipient’s immediate family or legal guardian/conservator, or securely stored and returned to the service recipient upon discharge. However, if previously prescribed medication(s) would prove harmful to the service recipient, they may be withheld from the service recipient and disposed of as in paragraph one (1) above. There must be documentation by the qualified prescriber in the service recipient’s clinical record citing the dangers or contraindications of the medication(s) being withheld. Authority: T.C.A. §§4 -4-103, 4- 5-202, 4- 5-204, 33- 1-302, 33-1-305, 33- 1-309, 33- 2-301, 33-2-302 and 33-4-404. Administrative History: Original rule filed May 26, 1988; effectiv e July 11, 1988. Amendment MINIMUM PROGRAM REQUIREMENTS FOR MENTAL HEALTH CHAPTER 0940-05-18 CRISIS STABILIZATION UNIT FACILITIES (Rule 0940-05-18-.09, continued) December, 2022 (Revised) 6 filed September 4, 2003; effective November 18, 2003. Amendments filed July 31, 2008; effective October 14, 2008. 0940-05-18-.10 RESERVED. Authority: T.C.A. §§ 4-4-103, 4-5-202, 4-5-204, 33-1-302, 33-1-305, 33-1-309, 33-2-301, and 33-2-302. Administrative History: Original rule filed May 26, 1988; effective July 11, 1988. Amendment filed September 4, 2003; effective November 18, 2003.