902 KAR 20:091. Facilities specifications, operation and services; community mental health center.
RELATES TO: KRS 202A.011(4), 202B.010(6), 210.370, 210.410, 210.450, 216B.010, 216B.015, 216B.030, 216B.105, 216B.990, 311.560(4), 314.011(8), 314.042(8), 320.210(2), 645.020(5)
STATUTORY AUTHORITY: KRS 210.450(1), 216B.010, 216B.042
NECESSITY, FUNCTION, AND CONFORMITY: KRS 216B.042 and 216B.105 require the Kentucky Cabinet for Health and Family Services to regulate health facilities and services. KRS 210.450(1) requires the secretary to promulgate administrative regulations prescribing standards for qualification of personnel, quality of professional service, and personnel management operations. This administrative regulation establishes licensure requirements for the operation and services, and facility specifications of a community mental health center.
Section 1. Definitions. (1) "Center" means a community mental health center.
(2) "Clinical psychologist" means a clinical psychologist certified or licensed pursuant to KRS 319.050(7), 319.056(2), (4), or 319.064(5).
(3) "Crisis stabilization unit" means a community-based facility operated by or under contract with a center to provide emergency services to no more than twelve (12) clients who require overnight stays.
(4) "Designated regional service area" means the geographical area to be served by the community mental health center.
(5) "Licensed marriage and family therapist" means an individual licensed in accordance with KRS 335.300(2).
(6) "Licensed professional clinical counselor" means and individual licensed in accordance with KRS 335.500(3).
(7) "Licensee" means the governing body legally responsible for the community mental health center.
(8) "Plan of care" means a written plan that delineates the services to be provided to a client, and includes the short- and long-term goals of the plan.
(9) "Psychiatric nurse" means a registered nurse who:
(a) Has a master's of science degree in nursing with a specialty in psychiatric or mental health nursing;
(b) Is a graduate of a four (4) year educational program with a bachelor of science degree in nursing and a minimum of one (1) year of experience in a mental health setting;
(c) Is a graduate of a three (3) year educational program with two (2) years of experience in a mental health setting; or
(d) Is a graduate of a two (2) year educational program with an associate degree in nursing and three (3) years of experience in a mental health setting.
(10) "Qualified social worker" means a social worker with a master's degree from an accredited school of social work who is licensed or exempt from licensure pursuant to KRS Chapter 335.
(11) "Time out" means a treatment intervention that separates a client from others in a nonsecure area for a time-limited period to permit the client time to regain control over his behavior.
Section 2. Scope of Operation and Services. A community mental health center shall provide a comprehensive range of accessible and coordinated mental health and mental retardation services, including direct or indirect mental health or mental retardation services, to the population of a designated regional service area, as required by KRS 210.370 to 210.480.
Section 3. Administration and Operation. (1) Licensee.
(a) The licensee shall be legally responsible for:
1. The center;
2. The establishment of administrative policy; and
3. Compliance with federal, state, and local law pertaining to the operation of the center.
(b) To obtain or renew a license to operate a center, the licensee shall comply with the requirements of this administrative regulation and the requirements of relevant statutes and administrative regulations.
(2) Executive director. The licensee shall designate an executive director, qualified by training and experience, who shall be responsible for:
(a) The total program of the center and its affiliates in accordance with the center's written policies; and
(b) Evaluation of the program as it relates to the client's needs.
(3) Policies. The licensee shall establish written policies for the administration and operation of the center which shall be available to staff and which shall include:
(a) A description of the organizational structure specifying the responsibility, function and interrelations of each organizational unit, and the lines of administrative and clinical authority;
(b) The appropriate method and procedure for storage, dispensing and administering of a drug or biological agent;
(c) Client grievance procedure;
(d) Confidentiality and use of client records in accordance with federal, state, and local statutes and regulations; and
(e) Personnel policy, including:
1. A job description and qualifications for each personnel category;
2. Wage scale, hours of work, vacation and sick leave;
3. A plan for orientation of personnel to the policies and objectives of the center and for on-the-job training, if necessary; and
4. Periodic evaluation of employee performance.
(4) Client records. A client record shall be maintained for each individual receiving services.
(a) Each entry shall be current, dated, signed, and indexed according to the service received;
(b) A client record shall be retained for at least five (5) years or, in the case of a minor, three (3) years after the client reaches the age of majority, whichever is longer;
(c) Each client record shall be kept in a locked file and treated as confidential. Information contained in a client record shall:
1. Be disclosed to an authorized person; and
2. Not be disclosed to an unauthorized person;
(d) Each client record shall contain:
1. An identification sheet;
2. Information on the purpose for seeking a service;
3. A history of findings and treatments rendered;
4. Screening information pertaining to the problem;
5. Staff notes on services provided;
6. Pertinent medical, psychiatric and social information;
8. Assigned status;
9. Assigned therapists; and
10. A termination study recapitulating findings and events during treatment, clinical impressions, and condition on termination.
(5) Personnel. A community mental health center shall employ the following full-time personnel:
(a)1. A program director who shall be a:
b. Certified or licensed psychologist;
c. Psychiatric nurse;
d. Licensed professional clinical counselor;
e. Licensed marriage and family therapist; or
f. Qualified social worker.
2. The program director may be the executive director;
(b)1. A board-certified or board-eligible psychiatrist who shall:
a. Be responsible for treatment planning;
b. Provide psychiatric service as indicated by client needs; and
c. Supervise and coordinate the provision of psychiatric services by the center.
2. This position may be filled by more than one (1) psychiatrist if the total hours worked are equivalent to one (1) full-time position;
(c) A clinical psychologist who shall provide evaluation and screening services for the client and individual or group therapy;
(d) A licensed professional clinical counselor who shall provide evaluation and screening services for the client and individual or group therapy;
(e) A licensed marriage and family therapist who shall provide evaluation and screening services for the client and individual or group therapy;
(f) A psychiatric nurse who shall provide or supervise nursing service for psychiatric care;
(g) A qualified social worker who shall provide social services as required; and
(h) A person who shall assure that client records are maintained and that information is immediately retrievable.
Section 4. Services. (1) The center shall provide services in the designated regional service area directly or through contract.
(2) Direct services. The center shall provide a sufficiently wide range of treatment to meet client needs, including:
(a) Individual therapy;
(b) Family therapy;
(c) Group therapy;
(d) Play therapy;
(e) Behavior modification; and
(3) Plan of care.
(a) Each client receiving direct treatment under the auspices of a community mental health center shall have an individual plan of care signed by a clinically licensed or certified professional provider of the treatment.
(b) A medical service, including a change of medication, a diet restriction, or a restriction on physical activity shall be ordered by a physician or other ordering practitioner acting within the limits of his statutory scope of practice.
(4) The center shall provide:
(a) A therapeutic program for a person who requires less than twenty-four (24) hour a day care, and more than outpatient care (i.e., partial hospitalization or day care). A psychiatrist shall be present on a regularly scheduled basis to provide consultant services to staff;
(b) Inpatient services through affiliation with a licensed community hospital for a person requiring full-time inpatient care. A center that does not have an affiliation contract in effect shall be considered to be in compliance with this requirement if the center documents a good faith effort to enter into an affiliation contract;
(c) Outpatient service on a regularly scheduled basis with arrangements made for a nonscheduled visit during a time of increased stress or crisis. The outpatient service shall provide diagnosis and evaluation of a psychiatric problem and a referral to other services or agencies as indicated by the client's needs;
(d) Emergency service for the immediate evaluation and care of a person in a crisis situation on a twenty-four (24) hour a day, seven (7) day a week basis. All components of the emergency service shall be coordinated into a unified program that enables a client receiving an emergency service to be readily transferred to another service of the center as client needs dictate; and
(e) Consultation and education services for an individual and various community agencies and groups to increase the visibility, identifiability, and accessibility of the center and to promote mental health through the distribution of relevant mental health knowledge.
(5) The center shall have a utilization and review plan for the evaluation of the service needs of each client. The need for continuing a service element for each individual shall be evaluated with sufficient frequency to ensure that proper arrangements have been made for discharge, for transfer to other elements of service, or referral to another service provider if appropriate.
(6) Medications. A treatment involving medication or chemotherapy shall be administered under the direction of a licensed physician or other qualified practitioner, acting within the scope of his practice, and:
(a) Medication or chemotherapy used in treatment shall be recorded in the staff notes on a special medications chart in the client record;
(b) A copy of the prescription shall be kept in the client record;
(c) Blood or another laboratory test or examination shall be performed in accordance with accepted medical practice on each individual receiving medication prescribed or administered by the center;
(d) Drug supplies shall be stored under proper sanitary, temperature, light and moisture conditions;
(e) Medication kept by the center shall be properly labeled;
(f) A medication shall be stored in the originally received container unless transferred to another container by a pharmacist or another person licensed to transfer the medication; and
(g) Medication kept in the center shall be kept in a locked cabinet.
1. A controlled substance shall be kept under double lock (e.g., in a locked box in a locked cabinet).
2. There shall be a controlled substances record, in which is recorded:
a. The name of the patient;
b. The date, time, dosage, balance remaining and method of administration of each controlled substance;
c. The name of the prescribing physician or other ordering practitioner acting within the limits of his statutory scope of practice; and
d. The name of the nurse who administered it, or staff who supervised the self-administration.
3. Except for medication to be self-administered in a crisis stabilization unit, access to the locked cabinet shall be restricted to a designated medication nurse. Medication to be self-administered in a crisis stabilization unit shall be made available to the patient at the time of administration.
Section 5. Crisis Stabilization. (1) Emergency services provided in a crisis stabilization unit shall include the following:
(a) A mental status evaluation and physical health questionnaire of the client upon admission;
(b) A treatment planning process;
(c) Procedure for crisis intervention; and
(d) Discharge and aftercare planning processes.
(2) A program shall have a written policy concerning the operation of a crisis stabilization unit including:
1. At least one (1) direct-care staff member shall be assigned direct-care responsibility for:
a. Every four (4) clients during normal waking hours; and
b. Every six (6) clients during normal sleeping hours;
2. Administrative oversight of the program shall be provided by a staff member who shall be:
a. A person licensed or certified to provide mental health services independent of clinical supervision;
b. A qualified mental health professional as defined in KRS 202A.011(12); or
c. A person qualified to be program director under Section 3(5)(a) of this administrative regulation.
3. The center shall provide a training program for direct care staff pertaining to the care of a client in a crisis stabilization unit.
(b) Criteria to assure that each client in a crisis stabilization program shall be:
1. In either one (1) of two (2) separate programs, child or adult, separated by physical location. A children's program may serve a resident up to age twenty-one (21) if it is more developmentally appropriate for that resident;
2. In need of short-term behavior management and at risk of placement in a higher level of care;
3. Able to take care of his own personal needs, if an adult;
4. Medically able to participate in services; and
5. Served in the least restrictive environment available in the community.
(c) Referrals for physical health services to include diagnosis, treatment, and consultation for acute or chronic illnesses occurring during the client's stay in the crisis stabilization unit or for problems identified during the admission assessment.
(d) Rights of a crisis stabilization client, to include:
1. A description of the client's rights and the means by which these rights are protected and exercised.
2. At the point of admission, the program shall provide the client and his parents, if he is a child, his guardian, or other legal representative with a clearly written and readable statement of rights and responsibilities. The statement shall be read to the client and his parents, if he is a child, his guardian, or other legal representative if either cannot read and shall cover:
a. The right to treatment, regardless of race, religion, or ethnicity;
b. The right to recognition and respect of personal dignity in the provision of all treatment and care;
c. The right to be provided treatment and care in the least restrictive environment possible;
d. The right to an individualized plan of care;
e. The right of the client and his parents, if he is a child, or his legal representative, to participate in treatment planning;
f. The nature of care, procedures, and treatment that he shall receive;
g. The risks, side effects, and benefits of all medications and treatment procedures used; and
h. The right, to the extent permitted by law, to refuse the specific medications or treatment procedures and the responsibility of the facility if the client refuses treatment, to seek appropriate legal alternatives or orders of involuntary treatment, or, in accordance with professional standards, to terminate the relationship with the client upon reasonable notice.
3. The rights of clients shall be written in language which is understandable to the client, and his parents, if he is a child, his guardian or other legal representative, and shall be posted in appropriate areas of the facility.
4. The policy and procedure concerning the clients' rights shall assure and protect client personal privacy within the constraints of his plan of care. These rights to privacy shall include:
a. Visitation by family or significant others in a suitable area of the facility; and
b. Telephone communications with family or significant others at a reasonable frequency.
5. If a privacy right is limited, the client and his parents, if he is a child, or his guardian or other legal representative, shall receive a full explanation. A limitation to a privacy right shall be documented in the client's record.
6. The client and his parents, if he is a child, his guardian, or other legal representative, shall be informed of the use and disposition of a product of special observation and audio visual techniques such as:
a. One (1) way vision mirror;
b. Audio recording;
c. Video tape recording;
e. Movie; or
7. Written policy and procedure developed in consultation with professional and direct-care staff shall provide for behavior management of a child client, including the use of a time-out room. The policy and procedure for use of a time-out room shall be approved by the Department for Mental Health and Mental Retardation. Behavior management techniques shall be explained fully to each client and his parents, or his guardian or other legal representative.
8. The facility shall prohibit cruel and unusual behavioral management measures, including corporal punishment, the use of a seclusion room, and mechanical restraint as defined in 902 KAR 20:320.
9. Written policy shall prohibit a client from administering a disciplinary measure upon another client and shall prohibit a person other than professional or direct-care staff from administering a disciplinary measure to a child client.
(e) The use of therapeutic holds as a safe behavioral management technique. The policy shall describe:
1. Criteria for appropriate use of therapeutic holds;
2. Documentation requirements; and
3. The requirement for completion of a training course approved by the Department of Mental Health and Mental Retardation, prior to using therapeutic holds.
(f) The requirement that a licensed psychiatrist shall be available to evaluate, provide treatment and participate in treatment planning on a regular basis.
(g) The procedure for proper management of pharmaceuticals, consistent with the requirements of Section 4(6) of this administrative regulation.
(h) Except for a program accredited by the Joint Commission for Accreditation of Health Organizations or the Commission on Accreditation of Rehabilitation Facilities, general procedures that address the following:
1. Procedures to be followed by staff in the event of a medical emergency of a client;
2. Proper nutrition;
3. Emergency preparedness;
4. Security; and
5. School attendance for children.
(3) Facility requirements for a crisis stabilization unit.
(a) A living unit shall be located within a single building and shall include:
a. More than four (4) clients shall not sleep in a bedroom.
b. A bedroom shall be equipped with a bed for each client.
c. A bed shall be at least thirty-six (36) inches wide and at least five (5) feet in length and shall be long and wide enough to accommodate the client's size.
d. A bed shall have a mattress cover, two (2) sheets, a pillow, and bed covering as is required to keep the client comfortable.
e. A bed shall be equipped with a support mechanism and a clean mattress.
f. A bed shall be placed so that a client shall not experience discomfort because of proximity to a radiator or heat outlet, or exposure to a draft.
g. There shall be separate sleeping quarters for males and females.
h. A client shall not be housed in a room, a detached building, or other enclosure that has not previously been inspected and approved for residential use by the licensure agency and the Department of Housing, Buildings and Construction.
2. Bathrooms. Each living unit shall have at least one (1) wash basin with hot and cold water, one (1) flush toilet, and one (1) bath or shower with hot and cold water for every eight (8) resident clients. If separate toilet and bathing facilities are not provided, males and females shall not be permitted to use those facilities at the same time.
3. Living area.
a. The living area shall provide comfortable seating for all clients housed within the living unit.
b. Each living unit shall be equipped with a working sink, stove and refrigerator, unless a kitchen is directly available within the same building as the living unit.
c. A living unit shall house a maximum of twelve (12) clients.
Section 6. Facility Specifications. (1) A facility housing a community mental health center or a crisis stabilization unit shall be a general purpose building of safe and substantial construction and shall be in compliance with applicable state and local laws relating to zoning, construction, plumbing, safety, and sanitation. The following shall apply if relevant and as adopted by the respective agency authority:
(a) Requirements for fire safety pursuant to 815 KAR 10:060; and
(b) Requirements for making a building or facility accessible to and usable by an individual with disabilities, pursuant to KRS 198B.260 and administrative regulations promulgated thereunder.
(2) Prior to occupancy, the facility shall have final approval from appropriate agencies.
(3) A facility shall be currently approved by the Department of Housing, Buildings and Construction in accordance with 815 KAR 10:060, before relicensure is granted by the licensure agency. (8 Ky.R. 418; eff. 1-6-82; Am. 16 Ky.R. 1001; eff. 1-12-90; 24 Ky.R. 1788; 2378; eff. 5-18-98; 25 Ky.R. 2469; 2916; 26 Ky.R. 394; eff. 8-16-99; 32 Ky.R. 2157; 33 Ky.R. 117; eff., 7-24-06.)