Colorado Mental Health Institute at Pueblo POLICY MANUAL ... · 11/10/2014 · Colorado Mental Health Institute at Pueblo POLICY MANUAL SECTION - ADMISSIONS POLICY NO. 10.00 Effective

Colorado Mental Health Institute at Pueblo POLICY MANUAL

SECTION - ADMISSIONS POLICY NO. 10.00

Effective Date: 8/13/14

TITLE: ADMISSIONS This replaces CMHIP policy 10.00, dated 12/11/13. I. DEFINITION/PURPOSE

It is the policy of CMHIP to accept only admissions of patients whose needs can be met within the hospital’s scope of services. The purpose of this policy is to provide specific admission criteria, and to describe how assignments to units are made. LEGAL STATUS DEFINITIONS Alcohol and Drug Abuse Division (ADAD) Commitment – A court order pursuant to 25-1-11 parts 3 and 11 of Title 25, Article 1, C.R.S., enacted due to a person’s drug/alcohol abuse that has escalated to a level that continued use would cause him/her to be a danger to health and safety of him/herself or others. ADAD commitments are referred to the Circle Program. (§27-81-100 et seq., §27-82-101 et seq., C.R.S.) Community Placement (CP) – Community Placement is a forensic NGRI patient who has been released with the committing court’s permission on a Temporary Physical Removal (TPR) order. These patients are inpatients on extended leave living in the community. These patients are followed by the CMHIP Forensic Community-Based Services (FCBS) team or by a mental health center if the patient lives outside of Pueblo. (§16-8-101 et seq., C.R.S.) Competency Evaluations – When ordered by a court, a competency evaluation is performed to determine if an individual is competent to assist in his/her defense. (§16-8.5-101 et seq., C.R.S.) Conditional Release (CR) – Conditional Release (CR) is a forensic NGRI patient released from CMHIP per court order from the committing court. These patients are “paroled” from CMHIP and must follow specific court orders. The majority of CR’s are followed by mental health centers, some by Forensic Community-Based Services (FCBS). (§16-8-101 et seq., C.R.S.)

ADMISSIONS POLICY NO. 10.00 PAGE 2

Department of Corrections (DOC) Institutional Transfers – CMHIP reserves a number of beds for the Department of Corrections (DOC) to use for stabilization of mentally ill inmates. (§17-23-101, C.R.S.) Emergency Civil Admission (M-1, M-3) – Most such admissions are admitted to the Low-Security Admission Unit. Some individuals may be admitted to the High-Security Admission Units for security reasons. These individuals may be sent from county jails or elsewhere in CMHIP, or from CMHIFL,. These admissions are generally accomplished through court orders. (§27-65-105, C.R.S.) Emergency Admission forms (Provided by CDHS pursuant to §27-65-105, C.R.S.) M-1: Emergency Mental Illness Report and Application M-3: Affidavit, Motion, and Order for Evaluation and Treatment (Affidavit) M-7: Affidavit, Motion, and Order for Evaluation and Treatment (Petition) Incompetent to Proceed (ITP) – If the court finds individuals incompetent to proceed, they are sent to CMHIP until competency is restored or the individual is determined by the court to be non-restorable. Once CMHIP determines the individual is competent to proceed, he/she typically will return to jail for the competency hearing. (§16-8.5-101 et seq., C.R.S.) Not Guilty By Reason of Insanity (NGRI) – Individuals found not guilty by reason of insanity are committed to CMHIP and are treated until the court approves their release. (§16-8-101 et seq., C.R.S.) Revocation of Conditional Release (REV CR) – C.R.S. 16-8-115.5. Individuals conditionally released from NGRI status can be re-admitted to CMHIP if the person fails to comply with one or more conditions of release, or is suffering from a mental disease or defect, which is likely to cause him/her to be dangerous to him/herself, to others, or to the community in the reasonably foreseeable future. Sanity Evaluation – A sanity evaluation is performed to determine if the individual was sane at the time of the alleged crime and is competent to proceed. (§16-8-101 et seq., C.R.S.) Voluntary [CRS 27-65-103] – Individuals may be admitted under voluntary status, in which case they will sign form 670,Voluntary Admission and Treatment Consent. This is most likely for the Circle Program (see section III.F.4).

II. ACCOUNTABILITY

Individuals responsible for implementing this policy include Admissions Department staff, medical staff, Administrators on Call, Program Directors, and any staff person determining the suitability of a patient for admission.


III. PROCEDURE

All persons being referred and/or admitted for services to be provided by CMHIP will begin the admission process through contact with the CMHIP Admissions Department. A. Emergency Admissions for Adults and Minors

1. Involuntary Detention for 72-Hour Evaluation (M-1, M-3, M-7)

a. Persons admitted under the Care and Treatment of Persons with the Mental Illness Act (Section 27-65-101, et. seq., C.R.S.), M-1 - not referred by the court, shall be prescreened by the responsible community mental health center. Prescreening by the responsible mental health center is also required for jail inmates meeting 27-65 criteria.

The admission procedure for patients who have been prescreened by the mental health center is as follows: 1) Admissions staff shall obtain all pertinent information on form 100 (Pre-

Admission/Admission Information). 2) Admissions staff shall also attempt to complete form 100C, Authorization

to Release Patient Protected Health Information. 3) The Admissions Liaison or designee shall determine the appropriateness

of the admission, to include referral/consultation with a CMHIP medical provider for medical review/clearance.

b. The court of civil jurisdiction may also order a person to CMHIP for a 72-hour evaluation (M-3 or M-7). Mental health centers shall be notified of any court-ordered admission as soon as possible following a court-ordered admission.

3. Voluntary Admission of Minors – See Section E below. 4. Patients may be transferred to CMHIP from CMHIFL per CMHIP policy 6.30,

Behavioral Transfers. (The patients’ certifications are “transferred” from CMHIFL to CMHIP, although patients are discharged from CMHIFL and admitted to CMHIP.)

B. Medical Clearance

Medically cleared means CMHIP has the ability to care for the patient’s medical needs. Referring parties may need to be reminded that CMHIP no longer has a Medical-Surgical Inpatient Service which previously allowed admission of some patients who needed acute medical care. Even though a patient might be medically


cleared, that is not a sufficient condition to judge whether the admission is otherwise appropriate. 1. All referrals shall require medical clearance by the CMHIP admitting Medical

Provider prior to admission. Medical clearance includes the review of a current toxicology screen, Blood Alcohol Level (BAL) below 0.08 ng/microliter, other lab tests or diagnostic screening as requested.

2. The admitting physician shall determine medical stability through a review of

medical information provided by the referring medical facility and through doctor-to-doctor consultations and receipt of form 616 (CMHIP Physicians Assessment and Certification to Transport Patient from Outside Hospital to CMHIP) completed by the referring/sending physician.

3. Medical conditions may be managed on the psychiatric units at CMHIP, if the

following clinical parameters are present: a. Medical condition is stable and well controlled and is unlikely to worsen or

destabilize during the course of hospitalization.

b. Medical condition does not require IV therapies.

c.

c. Patient would not require specialized diagnostic testing, specialty consultation, or acute medical workup to guide the course of medical management.

d. Independent performance of ADLs is not primarily limited by a medical problem and minimal nursing assistance is required.

e. Prior to admission, any specialized equipment and assistive devices must be: 1) available 2) cleared for safety by Biomed (contracted outside vendor), if being supplied

from the community or patient 3) practical and safe as determined by the Admitting Medical Provider for

usage in a psychiatric setting 4) CMHIP staff must know how to properly and safely operate the equipment

and device.

f. Medications must be available from CMHIP’s pharmacy unless supplied by the community or prearrangement has been made with CMHIP’s pharmacy to assure availability before arrival.

g. Post-surgical or wound care which requires minimal medical/nursing management and does not include drainage tubes.

h. Substance withdrawal that is unlikely to require medical detoxification.

i. Methadone maintenance only when CMHIP can confirm that the patient is currently enrolled and receiving services in a licensed Narcotic Addiction


Treatment program and arrangements have been made with CMHIP’s pharmacy to provide the ordered dose of Methadone. CMHIP does not provide medical treatment for acute addictive substance detoxification, therefore, any patient on Methadone, whose enrollment in a licensed program cannot be verified should not be admitted to CMHIP but rather to a medical/psychiatric facility that can manage the detoxification.

j. Chronic pain that is stable and requires no modification of current treatment regime and does not require services of a pain management specialist or team.

k. Post-overdose patients who are clearly physiologically and metabolically stable and do not require any further medical interventions.

l. Women who are known to be in their first trimester of pregnancy will not be admitted to CMHIP. Women in their second or third trimester, who have an established prenatal provider and care plan, and who have been assessed by their medical provider as having a low risk, uncomplicated pregnancy, may be admitted if medically cleared by a CMHIP physician. Pregnant individuals will not be admitted after regular business hours or on weekends unless Admissions has been notified that the patient has previously been medically cleared for admission.

m. HIV patients who are stable with a CD4 count >200 and with no signs of advanced infection or AIDS defining conditions, and for whom HIV medications are readily available.

n. Homozygous sickle cell disease patients cannot be managed at CMHIP.

o. Patients with a primary psychiatric diagnosis and also with co-morbid dementia may be accepted if the dementia is mild and a clear disposition plan is in place. These patients may require an in-person evaluation by CMHIP staff prior to acceptance. Patients with a primary dementia diagnosis or clinical presentation are beyond the scope of management at CMHIP.

q. Patients with a primary psychiatric diagnosis who also have mild co-morbid, Developmental Delay, Autism, Autism Spectrum Disorders, Pervasive Developmental Disorder, or Traumatic Brain Injury may be accepted if the condition(s) are mild and a clear disposition plan is in place. These patients may require an in-person evaluation by the CMHIP admitting physician before appropriateness can be determined.

C. Admission Criteria for Civil Patients (Adults and Minors)

1. Persons are admitted who meet 27-65 criteria for grave disability and/or danger to self or others as a result of mental illness. a) Grave disability means persons are in danger of serious physical harm due to

inability or failure to provide or obtain the essential human needs of food, clothing, shelter, and medical care. The grave disability is due to mental


illness and not a result of acute substance abuse intoxication, a brain injury, or as a result of a developmental disability.

b) Danger to self or others means a credible, imminent threat of serious physical self-injury (e.g., para suicide, self-mutilation), physical injury/assault to other people, or homicide.

2. If admitted by an M-1, the 72-hour evaluation period begins when the person is

taken into custody (the time and date on the M-1). 3. If admitted by court order, e.g., an Affidavit, Motion, and Order for Evaluation and

Treatment (form M-3) or Motion, Order for Evaluation, Treatment (form M-7), and the 72-hour evaluation period begins at the time of the patient's arrival at the hospital.

4. At any time during the course of a civil involuntary evaluation or certification, the

patient may elect to sign in voluntarily on form 670, Voluntary Admission and Treatment Consent, except for patients who are court commitments. Conversely, a patient on voluntary status may be converted to involuntary, if the clinical condition and circumstances warrant.

5. Persons are not admitted if the following diagnoses/conditions are primary:

� Eating disorders � Substance/alcohol intoxication or withdrawal � Mental disorders due to general medical conditions � Autism � Brain injury � Developmental disability � Dementia � Medical conditions and/or the intensity of treatment required interfere with or

preclude psychiatric care, or participation in a psychiatric program. D. Patients With Criminal Charges (Adults and Minors)

1. Patients charged with misdemeanor crimes may be admitted to the Low-Security Admission Unit. A law enforcement officer must present a detainer (hold order from the jail/detention facility), and a written documented request and permission to admit to the Low-Security Admission Unit from the judge of the court where the criminal action is pending [pursuant to section 27-65-123, C.R.S.].

2. All adult patients charged with the following offenses, which are either felonies or

are considered crimes of violence and require a detainer (“hold order” as above) shall be admitted to a High Security Admission Unit.. (Any offense that is charged as “attempted” or “conspiracy to commit” is considered the same as the actual offense.)


Arson, 1st, 2nd and 3rd Degree Assault, 1st or 2nd Degree Burglary, 1st Degree Domestic Violence (Felony only) Harassment, Stalking (Felony only) Inciting a Riot Kidnapping, 1st or 2nd Degree Manslaughter Menacing, with deadly weapon Murder, 1st or 2nd Degree Rioting, in Correctional Facility Robbery and Aggravated Robbery Sexual Assault, 1st or 2nd Degree Sexual Assault on a Child

3. All individuals under the age of 18 charged with any crime shall be admitted to

the Locked Adolescent Unit (LAU) unless the Superintendent approves admission to a high security unit.

4. Except for patients with the felony charges listed below, patients who have been

released from jail on bond should be admitted to the Low-Security Admission Unit. Arson, 1st Degree Assault, 1st Degree Kidnapping, 1st Degree Murder, 1st Degree Murder, 2nd Degree Sexual Assault, 1st Degree

5. Persons with the above charges shall be admitted to a High-Security Admission

Unit if CMHIP is aware that there has been a parole violation. Such patients will be assigned to the appropriate security setting based upon the crime for which he/she was originally sentenced. Should the crime be unknown, the patient will be admitted to a High-Security Admission Unit.

6. If a patient has been admitted to the Low-Security Admission Unit and later a

competency, sanity, or other forensics evaluation is ordered by the court, the patient may remain on the Low-Security Admission Unit for the evaluation, unless clinical considerations warrant moving the patient to a higher security setting or to the Restoration Program

7. In cases where a patient is admitted to the Low-Security Admission Unit and is

near discharge, then is required by the court to undergo a competency or sanity evaluation, the patient may be transferred to a higher security setting.


8. The admitting physician may make the decision to admit to a High-Security Admission Unit, regardless of the charges, if the patient’s behavior warrants.

9. Competency evaluation cases with special court orders will be designated as

treatment cases in Avatar once the competency evaluation is complete. The orders direct that treatment should begin (or continue) at the time that CMHIP recommends to the court that the patient/defendant be found ITP. For cases with this specific type of court order, CMHIP is ordered NOT to return the patient to jail at the conclusion of the evaluation. (See CMHIP Policy 1.05, Plan of Care.)

E. Revocation of Conditional Releases

The CR revocation process is started when the individual is in the community. The following procedures will be followed: 1. The FCBS Director/Designee will complete a Revocation Application, which

includes an arrest warrant, an order to transport and an order to examine. FCBS will notify the District Attorney of the committing county.

2. The person whose conditional release is being revoked is taken into custody and

returned to CMHIP. The person will be evaluated within 20 days of re-admission to ascertain his/her ability to remain on Conditional Release.

3. Within 30 days after the person is re-admitted to CMHIP, the committing court

will hold a hearing on the petition for revocation of Conditional Release. If the court finds the person ineligible to remain on CR, the court shall enter an order revoking the conditional release and recommit the person to CMHIP. If the court does not find the person ineligible to remain on CR, the court shall dismiss the petition and reinstate or modify the original CR order and the person would return to the community.

F. Voluntary Admission of Minors

1. Minors at least 15 years of age and older may request voluntary admission, with or

without the consent of a parent or legal guardian. If admitted, the attending physician may advise the parent or guardian of the mental health services needed or given, without the consent of the minor patient.

2. A voluntarily admitted minor under the age of 15 who is in the custody of the

Department of Social Services (DSS), shall not be admitted unless a guardian ad litem has been appointed for the minor, or a petition for the minor has been filed with the court by DSS. An exception to the above is that an application for hospitalization may be made under emergency circumstances requiring immediate hospitalization, in which case DSS shall file a petition for appointment of a guardian ad litem within 72 hours of the patient’s admission.


3. Prior to admitting a minor under the age of 15 for voluntary hospitalization, the minor shall be evaluated by an independent professional person not involved in the patient’s treatment. This independent review shall determine if:

a. the minor is mentally ill, and meets acute care criteria;

b. a less restrictive treatment setting is unavailable or inappropriate; and,

c. hospitalization is likely to be beneficial.

4. No independent review is required if the minor (age 15 or older), the parents, and the responsible mental health center all agree to the need for hospitalization. The minor will be advised, however, of his/her right to withdraw consent at any time.

5. The minor will sign the Advisement of Rights of Minors (form 664a) and receive

a copy upon admission indicating that he/she has been provided a copy of this document, the objection procedure has been explained, and that his/her questions have been answered.

6. At least every two months (or two months after an independent review triggered

by an objection), an independent professional person who is not a member of the minor’s treating team shall review the need for continued hospitalization. If the minor and the minor’s parent or guardian does not object to continued hospitalization, the hospital staff may conduct this review internally. The criteria for continued hospitalization is the same as for admission. The minor shall have ten days notice prior to the review. The unit or CMHIP Patient Representative shall assist the minor in articulating his/her views on continued hospitalization, if necessary.

7. Every six months, an independent professional person who is not a member of the

minor’s treatment team and who has not reviewed the child within the preceding six months shall review the need for continued hospitalization.

8. When a minor objects to hospitalization in writing, he/she will be given 48 hours

to confirm his/her objection.

a. Staff shall return the Minor’s Objection to Continued Voluntary Hospitalization (form 664) to the minor after 48 hours and ask the minor if he/she still objects to hospitalization. Staff shall sign indicating that there was an opportunity for the minor to object to hospitalization and arrange for any assistance he/she may need in completing the request.

b. Within ten days of the minor’s affirmed objection to hospitalization, CMHIP will arrange for an independent professional person not on his/her treatment team to review the minor’s psychiatric condition.

c. The minor shall be informed of the findings of this examination as soon as possible and provided a copy of the written summary and conclusions within


three days of completion. The full report shall be placed in the minor’s medical record.

d. If this review calls for continued hospitalization, and the minor objects to this result within 24 hours, staff will tell the minor that at any time in the future he/she has the right to consult with an attorney at any time and unit staff or Patient Representative shall file, within three days of the request of a minor, a statement requesting an attorney for the minor or, if the minor is under 15 years of age, a guardian ad litem. The minor, his/her attorney, parent, legal guardian or guardian ad litem shall be given written notice to that effect.

e. If the minor files her/his objection to with the court, the minor may file either with the court of legal residence of the minor, or with the court with jurisdiction where the facility is located.

f. A minor may not again object to hospitalization for another 90 days. g. If a minor’s legal status changes from involuntary to voluntary and the patient

was not given written notice of the rights of minor children upon admission, the minor shall be informed of his/her right to object to hospitalization and the procedure for the objection.

G. Division of Youth Corrections’ (DYC) referrals require neither an independent

review nor a mental health screen to be admitted to the LAU.

H. Assignment to Clinical Program/Population-Specific Unit

1. Geriatric Services usually admits patients 60 years of age or older. Persons under age 60 whose symptoms or physical condition more closely resemble the elderly population may be evaluated for admission to Geriatrics.

2. Adolescent Services admits patients ages 12 through 17. A younger child may be admitted under special circumstances with the approval of the Clinical Team Leader/Coordinator and the attending psychiatrist.

4. Circle Program admits individuals over the age of 18 (following detoxification). These patients are not admitted under 27-65 emergency procedures, but must meet the following criteria:

a. Dual diagnosis of an active substance use disorder and at least one the

following:

Affective Disorder

Anxiety Disorder

Depressive Disorder

Dissociative Disorder

Paranoid or Other Psychotic Disorder

Personality Disorder (except Antisocial Personality)


Schizophrenia Spectrum Disorder

b. Prior to admission, staff on the Circle program evaluate the prospective patient to determine if admission criteria are met and whether the person has intellectual functioning to be capable of insight; sufficient ego strength to tolerate confrontations; and, sufficient contact with reality to participate in all phases of program. At the time of this evaluation, Circle staff shall inform applicants that they will be required to consent to a Breathalyzer test at the time of admission to confirm that their BAL is zero.

c. Staff on the Circle program advise Admissions Office staff of the date and

anticipated time of admission of approved patients. Prior to admitting anyone to the Circle program, Admissions staff may obtain verbal consent from the prospective patient for a Breathalyzer test, and may conduct the test. If the prospective patient does not give consent for a Breathalyzer test, he/she will not be admitted to Circle. Prospective patients must have a BAL of zero to proceed with admission. Exceptions to this may be considered on a case–by-case basis.

d. The Circle Program accepts ADAD commitments pursuant to parts 3 and 11

of Title 25, Article 1, C.R.S. All ADAD commitments must meet admission criteria as identified in III, F, 2, d, 1 and 2 above.

e. The Circle program does not accept interstate transfers.

5. Generally, CMHIP admission units accept persons who are age 18 or older under any criminal or civil order. On a case-by-case basis, the Superintendent may approve the admission of a minor to an adult admission unit. Patients are assigned a clinical program/unit based on current psychiatric clinical presentation and security need.

6. Persons currently on conditional release or community placement who experience an exacerbation of psychiatric illness may return voluntarily or involuntarily to CMHIP. Patients are assigned a clinical program based on current psychiatric clinical presentation and security need.

7. Inmates of a correctional facility may be admitted to a High-Security Admission Unit for psychiatric evaluation and treatment.

I. Photographs of Patients on Admission

1. All patients shall be photographed upon admission to CMHIP for identification

and administrative purposes. Photographing patients at admission is part of the admission procedure and does not require consent. All photographs shall be confidential and shall not be released, except by a court order.


2. Photographs of patients are defined as Protected Health Information and are covered under HIPAA Privacy Rules and Regulations, per CMHIP policy 14.40, Identifying Protected Health Information.

J. Notice of Privacy Practices

The Notice of Privacy Practice, form 635, shall be provided upon admission to all patients with whom CMHIP has a direct treatment relationship. (CMHIP policy 14.52 – Notice of Privacy Practices, with the exception of “inmates.”)

K. Notice of Patient Representative

All persons admitted to the facility shall be advised of the assistance/representation for patient’s rights available through the patient representative. The Patient Representative’s picture, name and telephone number shall be posted on each patient care unit.

L. Institutional Disclosure

In order to comply with the provisions of C.R.S. 12-43-201, et. seq., which require that certain information must be disclosed to psychotherapy clients during the initial contact, an Admission Office staff member will review with the patient the Institutional Disclosure Form (form 672). This form will be dated and signed by the patient and staff member. 1. The original signed form will be placed in the medical record and a copy given to

the patient. 2. For minors, 14 years of age or younger, the form should also be signed by the

parent or guardian, whenever possible. A copy of the form will be provided to the parent or guardian.

M. Additional Information Obtained at Time of Patient Admission

1. Information Page, form 098 - Admissions staff will file this form on the chart at time of patient admission. This form will capture information on patient’s allergies, precautions, advance directives, duty to warn, hold orders, metabolic monitoring, and family notification for involuntary medications.

2. Medication reconciliation, form 100.1 is completed by the admitting RN or

Liaison in the CMHIP Admissions Department when the patient is admitted or readmitted through the Admissions Department to the hospital. (See CMHIP policies 3.01, Medication Practices and 12.07, Interim Admissions and Discharges, Intra-Hospital Patient Transfers, and Return after Other Inpatient Care.)


N. Protocol for Patients Returning From an Outside Medical Facility (e.g., Parkview,

St.Mary Corwin) after an Overnight Stay

When a CMHIP patient is returning from an outside Medical Facility (e.g., Parkview or St. Mary Corwin) after an overnight stay, the following protocol is to be implemented. This applies to any patient who was either (a) admitted to the outside facility as an inpatient, or (b) on “Observation Status” overnight. 1. The Medical Provider at the transferring medical facility contacts the CMHIP

Medical Provider directly:

a. The Medical Provider at the transferring medical facility talks directly with the CMHIP Medical Provider, i.e., a doctor to doctor discussion about the patient’s clinical/medical presentation (“Doc-to-Doc”):

b. The CMHIP Medical Provider will contact the CMHIP Admissions

Department (extension 4406) to inform them that the patient is cleared for admission to CMHIP

c. The Admission Psychiatric Liaison is to do the following:

1) Check the nursing folder for information on patient. If there is no information on patient in the “nursing folder,” request information from the sending medical facility.

2) Proceed with the Nurse-to-Nurse call 3) Call CTU transport.

2. If the transferring medical facility calls to report that a patient is ready to return to

CMHIP, and the Admissions Department has not received a call from the CMHIP Medical Provider, do the following:

a. Get the name and number of the transferring Medical Provider for the Doc-to-

Doc. Get information on the patient from the “nursing folder.” If there is no information in the nursing folder, request information from the transferring facility, i.e., assessments, test results, and discharge documentation including medications (i.e., the MARS)

b. Contact the CMHIP Medical Provider for the Doc-to-Doc. The CMHIP

Medical Provider will request any additional information from the Medical Provider at the Transferring Facility during the Doc-to-Doc.

c. The CMHIP Medical Provider will notify the Admissions Psych Liaison

(extension 4406) of clearance/acceptance of the patient.


d. The Admission Psych Liaison will proceed with the Nurse-to-Nurse and call

CTU for transport.

3. All returning patients are to be transported to Building 125 CMHIP Admission Department for readmission to CMHIP.

_______________________________ _________________________ Birgit M. Fisher, PhD Date Interim Superintendent


SECTION - PATIENT CARE DOCUMENTATION POLICY NO. 10.01


TITLE: REFERRAL AND SUPPORT SERVICES FOR THE OFFICE OF

BEHAVIORAL HEALTH (OBH) RESTORING INDIVIDUALS SAFELY AND EFFECTIVELY (RISE) PROGRAM

This replaces policy 10.01 dated 10/31/13. I. DEFINITION/PURPOSE

It is the policy of CMHIP to provide efficient referral and support services for the OBH RISE Program. This policy describes CMHIP processes that support the OBH RISE Program.

II. ACCOUNTABILITY Individuals responsible for implementing this policy include CMHIP Court Services staff, CMHIP Department of Public Safety (DPS) staff, CMHIP Admissions Department staff, CMHIP Medical and Legal Records Department staff, and the OBH Program Director for Jail Based Restoration.

III. PROCEDURE A. Medical Clearance

The CMHIP Admissions staff and Medical staff will contact the referring agency to obtain clearance using the same process as for all admissions including medical clearance.

B. Referral and Admission Process

1. The target population for the RISE Program is adult male defendants primarily referred from the Denver Metropolitan area counties for restoration to competency treatment, though exceptions may occur. CMHIP Court Services, Admissions staff and the OBH Program Director for Jail Based Restoration will obtain information and assemble a referral packet. This packet will include medical clearance and history, psychiatric treatment history, court order for restoration to competency treatment, collateral information such as police reports and charging documents, and any other available pertinent information. If CMHIP has treatment records, evaluation reports, assessments or treatment plans, they will be included in the referral packet.

2. The OBH Program Director for Jail Based Restoration will participate in the CMHIP weekly admissions meeting. The OBH Program Director for Jail Based Restoration will identify referrals from the courts that appear appropriate for direct admission to the RISE Program and current CMHIP inpatients referred for

REFERRAL AND SUPPORT SERVICES FOR THE OFFICE OF BEHAVIORAL HEALTH (OBH) RESTORING INDIVIDUALS SAFELY AND EFFECTIVELY (RISE) PROGRAM POLICY NO. 10.01 PAGE 2

transfer to RISE, forward a copy of the information packets to the RISE staff, and present the cases at the weekly meeting. Patients referred to the program will be discussed at this meeting and when accepted, an admission date agreed upon. All admission offer dates must comply with the settlement agreement outlined for the Center for Legal Advocacy (CLA) vs. Bicha.

3. The CMHIP Admissions Department, Medical Records Legal Department, and Court Services staff will all be represented at the weekly admissions meeting. They will initiate all contacts with the originating jails for admissions to and discharges from both CMHIP and the RISE Program. These departments will complete all patient information data entry for RISE patients the same as for all CMHIP patients.

4. The OBH Program Director for Jail Based Restoration will directly notify the CMHIP Admissions Department, Medical Records Legal Department, and DPS staff of all patient movements, and confirm all actual arrival and departure dates for the RISE patients. The appropriate CMHIP staff will complete all patient information data entry for the Avatar and Anticipate systems.

C. Transfers Between CMHIP inpatient status and the RISE Program

1. Emergency Transfer a. When a patient is in treatment in the RISE Program and the staff assess there

is need for acute emergent inpatient services for severe behavioral problems, suicidal gestures, involuntary medication initiation or acute medical issues that may require long term management or frequent transfers outside of the jail setting, etc., the OBH Program Director for Jail Based Restoration will contact CMHIP for immediate transfer to inpatient status. The Admissions staff will treat this referral the same as an emergency treatment hold referral. Admission staff will initiate a new CMHIP record when a RISE patient is transferred. If needed, placement in the jail’s behavioral control cells in the infirmary will be utilized until transfer can be accomplished.

b. The OBH Program Director for Jail Based Restoration will directly notify the CMHIP Admissions Department, Medical Records Legal Department, and DPS staff to arrange transfer. CMHIP DPS will transport the patient to CMHIP as soon as can be arranged.

2. Non-Emergency Transfer a. Patients admitted to CMHIP for acute inpatient treatment or an inpatient

competency evaluation and an Incompetent To Proceed (ITP) commitment order is received, the CMHIP treatment team staff may initiate a referral for transfer to the RISE Program to complete restoration treatment if appropriate. The team will notify the CMHIP Court Services Department and OBH Program Director for Jail Based Restoration to refer the patient. If transfer is to occur, the OBH Program Director for Jail Based Restoration will contact DPS staff to coordinate date and times for the transfer to the RISE Program.

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b. The RISE Program staff will assess the patients at regular intervals for treatment response and progress to restoration. If it becomes clear that the person requires more intensive inpatient services for restoration, the OBH Program Director for Jail Based Restoration will refer the patient to CMHIP for discussion at the weekly admissions meeting as a non-emergent transfer. The OBH Program Director will contact DPS staff to coordinate date and times for transfer from the RISE program to CMHIP.

D. Transport

1. Jail transport officers perform transport for admission to the RISE Program from a county jail. The county transport staff will be asked for a detainer so that they may easily perform return transport without a new court order. a. When non-emergent transport is needed between CMHIP and the RISE

Program, the request will be made at the weekly admissions meeting and the OBH Program Director for Jail Based Restoration will coordinate with the CMHIP Department of Public Safety to arrange transport.

b. The CMHIP Admissions Department staff will initiate all transport requests for admissions to RISE or CMHIP from a county jail.

c. To initiate a discharge from RISE, the OBH Program Director for Jail Based Restoration will notify the CMHIP Medical Records Legal Department staff and they will initiate all transports from RISE for return to other jails.

d. Transport delays are possible, so in all cases the OBH Program Director for Jail Based Restoration will notify CMHIP staff of actual admission and discharge dates for accurate entry into the CMHIP patient information systems by assigned CMHIP staff.

2. CMHIP transport officers will transport the completed treatment records of the RISE Program patients to CMHIP Medical Records Department for final storage. All patient records will be placed in sealed and secured transport containers during transport between facilities.

E. Patient Evaluation for Restoration to Competency Progress

1. CMHIP Court Services Department staff will assign evaluation of the patient’s progress of restoration to competency every 90 days at a minimum. The CDHS forensic evaluation staff will complete all court reports and be available for court testimony.

2. The OBH Program Director for Jail Based Restoration will continually assess the response to treatment. The patient may be referred to CMHIP Court Services at any time for an immediate evaluation of progress to competency. Court Services staff will assign and complete a new evaluation within seven (7) days of a referral.

______________________________________ ___________________________ Birgit M. Fisher, PhD Date Interim Superintendent


SECTION – ADMISSIONS POLICY NO. 10.10


TITLE: DIET ORDERS This replaces Policy 10.10 dated 3/30/11. I. DEFINITION/PURPOSE

It is the policy of CMHIP Nutrition Services Department to use the CMHIP Living Healthy Diet Manual and provide for the nutritional and therapeutic needs of the patient according to physicians’ orders. The purpose of this policy is to provide a communication tool between the physician and the Nutrition Services Department when prescribing a patient’s diet.

II. ACCOUNTABILITY Individuals responsible for implementing this policy include all Nutrition Services’ staff, physicians, and all nursing staff.

III. PROCEDURE A. Living Healthy General Diet Orders

Diets known as regular, cardiac, low cholesterol, low fat, high fiber, low sodium (3gm), consistent carbohydrates or any combination of these are no longer used at CMHIP. The Living Healthy (LH) General diet has replaced all the foregoing diets. LH General is the basic “house” diet, adapted for age and other patient specific population parameters. The LH General provides approximately 2600 calories daily with three meals and an evening snack. The physician will select an appropriate diet for the patient from the Nutrition Services Department Living Healthy Diet Manual.

1. Prescribed diets are predicated on medical necessity. The LH General Diet is to be ordered unless there are medical issues or religious practice dietary needs.

2. The protocol for ordering religious diets, as described in CMHIP Policy 18.05: Spiritual Care Department, Section III.E. Religious Diets will be followed.

3. A patient may request a vegetarian diet per the Living Healthy Diet Manual. A physician’s order is required for a vegetarian diet.

4. Each time a patient is transferred to another unit, a new complete diet order must be entered into the OMS.mdb database. Until the prescribed diet order is received, verbal direction from the nursing staff may be accepted for one meal only.

DIET ORDERS POLICY NO. 10.10 PAGE 2

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5. An order for a diet not identified in the Living Healthy Diet Manual will initially be served using the standard diet closest to available diet, pending review by a dietitian. The unit dietitian will be notified by the Diet Office staff immediately upon the receipt of the order to review the diet. The dietitian will direct the Diet Office staff on the diet for the patient and make recommendations to the physician.

6. Diet modifications are available to accommodate a food allergy or intolerance.

7. Diets are not customized for individual preferences. An alternate choice for the main entrée is always available in the dining room upon request for any meal. The alternate choice is ½ cup cottage cheese, #30 (2 Tbs.) peanut butter and #30 (2 Tbs.) jelly or 2 oz. of American cheese.

8. All diets include a programmed evening snack.

9. When medically necessary, a standard morning and/or afternoon snack may be prescribed. Snacks are not a replacement for patients “wanting to sleep in.” Reference Nutrition Services Policy: Nutritional Supplements Enteral Feeding.

B. Texture Modified Diets

CMHIP uses the National Dysphagia Diet and standardized terminology for Texture Modified Diets. Reference the Living Healthy Diet Manual.

1. LH Dysphagia Level 1, 2, or 3

2. LH Dental Soft

3. LH Finger Foods

4. Liquid Thickness: Honey or Nectar

5. Straws: If recommended by the Speech Language Therapist, a physician’s order is required before a straw will be given with the patient’s meal.

C. Food With Respect to Management of Patient Milieu

1. Food provided by Nutrition Services shall not be used to modify a patient’s behavior nor will food be withheld for punitive reasons.

2. A “diet of exception” may be given to a patient when the patient’s psychiatric disorder dictates. All “diets of exception” require a physician’s order and corresponding physician and dietitian progress note justifying the exception. The dietitian may attend the patient’s Plan of Care review meeting as needed and will coordinate the “diet of exception” advancement for a return to a standard diet when appropriate, with the patient’s treatment team and physician.

D. Patient’s Right to Refuse a Special Diet

The patient has the right to refuse a special diet. See CMHIP Policy 16.50: Patients’ Rights, Section III.A.4, Refusal of Treatment. Dining room staff is authorized to serve meals in accordance with the patient’s diet order only. In the event the patient expresses dietary concerns, nursing staff and dining room staff will collaborate to resolve concerns. Staff on the patient’s care unit will inform the patient’s attending physician of the patient’s request to a change in the ordered diet. The physician may

DIET ORDERS POLICY NO. 10.10 PAGE 3

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request a consult from the unit dietitian using the electronic 405, Outside Medical Services OMS.mdb system. The dietitian will make recommendations to the physician.

E. Diet Orders

1. The unit staff enters the physician’s order for a patient’s diet electronically using the OMS.mdb database. a. Unit staff prints two copies of form 312, Current Diet.

i. One copy is placed in the patient’s medical record. ii. One copy is given to the unit’s dining room staff. Dining room staff

updates the modified menu sets then files the Current Diet alphabetically (by patient’s last name) in the respective unit notebook.

b. Staff on each unit prints a daily roster of Current Diets, inclusive with each patient’s picture, to be given to the respective unit dining room staff. This roster of Current Diets is kept on the serving line as one form of patient identification and for reference when serving modified diets.

2. An electronic list of all diet order activity (Unit Diets list) is generated daily. a. Dietitians and the Diet Office staff receive an e-mail daily indicating the Unit

Diets list has been generated. b. The Unit Diets list is accessed via Y:\CAPP\Services\OMS.mdb. c. The Diet Office Administrative Assistant prints each patient’s Current Diet,

form 312. d. The Administrative Assistant enters the diet information into the Visions

software program from form 312. e. Snacks are handwritten in red in the Nourishment Log for processing. f. Each Current Diet is given to the Menu Technician to review and initial. g. The Administrative Assistant files each initialed Current Diet in the respective

Patient Care Unit notebook, located in the Diet Office.

3. Each Current Diet (diet order) supersedes the previous Current Diet in its entirety. Any item omitted will not be carried over.

4. The Diet Office may contact the patient care unit to verify diet orders.

5. Upon receipt in the Diet Office, a properly completed Current Diet order will be implemented within 24 hours.

6. Should the electronic diet order system be unavailable for an extended period of time, a hand written Current Diet, form 312 (blank forms are kept on the unit) will be completed by the nursing staff. a. Two copies are given to the dining room staff for processing. b. Dining room staff will immediately call the Diet Office informing Diet Office

staff of a handwritten Current Diet. ______________________________________ ___________________________ William J. May Date Superintendent


SECTION - ADMISSIONS POLICY NO. 10.11


TITLE: MEAL SERVICES PROVIDED IN UNIT DINING ROOMS This replaces Policy 10.11 dated 4/20/11l. I. DEFINITION/PURPOSE

It is the policy of the CMHIP Nutrition Services Department to provide quality meals for patients in a decentralized dining room setting, assuring compliance with regulatory standards.

The purpose of this policy is to describe the scope of meal services provided in an environment allowing our patients to focus on a healthy lifestyle that supports their recovery. (Nutrition Services documents referred to in this policy are located in Food Preparation and Service Guidelines, a desk manual.)

II. ACCOUNTABILITY Individuals responsible for implementing this policy include all Nutrition Services employees and unit staff.

III. PROCEDURE

A. Tray-line Dining Service Tray-line dining service is provided for each unit with the exception of E1, E2, and E3. These units receive meals via a modified tray-line in the Hawkins Building “E” satellite dining room provided from hot and cold cart service.

B. Meal Pattern

The meal pattern is Breakfast, Lunch, Supper, and evening (hs) nourishment.

C. Dining Room Meal Schedules

1. Each unit is scheduled for a 30-minute meal period.

2. All meals are served per the times listed on the Dining Room Meal Schedules form (Appendix A) and the Hawkins Building Central Dining Meal Configuration form (Appendix B). Allowing for delays, the dining room staff will call each unit notifying them of the readiness to serve. The unit staff escort patients to the unit dining room.

3. Meals are scheduled with less than a 15-hour interval overnight between supper and breakfast.

MEAL SERVICES PROVIDED IN UNIT DINING ROOMS POLICY NO. 10.11 PAGE 2

D. Meal Cancellation Procedure

1. The unit notifies the dining room no less than one hour before the meal to cancel a meal for any given patient.

2. The unit notifies the North Kitchen Production Manager and Purchasing Manager via e-mail at least two weeks prior to a special function to cancel meals for a partial or an entire unit (e.g., picnics, holidays, and other special events). The North Kitchen Production Manager or Purchasing Manager in turn notifies other pertinent Nutrition Services Department staff as needed.

E. Patients on “transition” or at an alternate meal site on a routine basis as reflected on a

Current Diet order generated to address the patient’s specific need

1. Transition (to another unit on campus) a. The patient eats at the unit dining room he/she is on at that mealtime. b. If the patient is on a modified diet, the special food is sent to the transitional

dining room from North Kitchen. c. The patient eats all other meals on his/her home unit.

2. Alternate meal site (not on campus) a. The Nutrition Services Diet Office receives a Current Diet order identifying the

patient, the day(s) of the week, the meal(s), and the frequency a “sack” meal is needed.

b. The standard “sack” meal requires refrigeration. If the meal is not to be consumed within two hours of pickup and refrigeration is not available, the requestor needs to advise Nutrition Services, at which time an alternate menu sack meal (allowing storage at room temperature) will be provided.

c. North Kitchen sends the sack meal to the patient’s dining room one day in advance.

d. The dining room staff informs the unit the sack meal is ready for pick-up at the respective dining room.

e. The patient takes a sack meal off campus for consumption. f. The patient eats all other meals on his/her unit.

F. Tray Order Procedure

1. Room/day hall trays are for patients who are unable to attend regular meal service in the dining room. a. The unit staff provides the dining room with a Tray Order request, form 6510 for

each patient requiring tray service. b. Hawkins Building “E” satellite dining room staff provides the “Tray Orders and

Alternates for Satellite Dining Room” (Appendix C) for the unit staff to complete by recording patients’ names needing room trays and/or alternates.

c. A tray order for any given patient must be resubmitted daily for those patients requiring extended tray service.


d. Food, in accordance with the patient’s diet, is portioned into disposable food-grade dishware that is microwaveable (e.g., a Styrofoam clam-shell container, Styrofoam bowl, etc.). Plastic utensils are given.

e. The patient’s name is written on each container. f. The unit staff picks up the room tray(s) following dining room meal service when

returning to the unit. g. The unit staff is responsible for all dishware and its disposal.

2. Food Safety

The unit staff is responsible for storing and serving the meal to the patient. Hot food is reheated in the microwave oven and cold food is refrigerated, per CMHIP Infection Control Policies DSIC-13, Nutrition Services and IC-04, Food Safety.

G. Sack meals are made per Nutrition Services Policy No. 3.3, Meal Planning

1. Hawkins Building patient admissions: Sack meals are prepared by Position # 86.

2. Clinic Admissions (Building 125): Sack meals are prepared in GW1dining room by Position #29.

3. ECT sack breakfast: are prepared per Nutrition Services Procedure - ECT Sack Breakfast (Food Preparation and Service Guidelines manual).

4. Other Sack Meal Needs a. The Nutrition Services Diet Office informs North Kitchen Position #11 via the

Tally Sheet of the need to make a sack meal for a patient on a LH General diet. b. The Nutrition Services Diet Office informs the North Kitchen Diet Kitchen to

prepare a special modified diet sack meal for a patient on a modified diet. c. North Kitchen staff prepare the sack meal. The components are placed in a brown

paper bag identified with the patient’s name, date, and meal.

5. Sack meal for a patient being discharged: The request comes to the Nutrition Services Diet Office by a telephone call from the unit staff. The sack meal is made at North Kitchen.

H. Availability of unit staff in the dining room during meal times

1. Unit staff shall be present in the dining room continuously throughout the respective unit’s meal service period.

2. A unit staff member shall be positioned at the start of the serving line before the dining room staff commences serving meals.

3. The unit staff are readily accessible to the dining room staff and the patients to: a. jointly count flatware with dining room staff prior to and following each meal, b. assist with identifying patients, and c. troubleshoot issues that arise.


I. Flatware/Sharps (Reference CMHIP Policy 32.14, Knife, Utensil, and Flatware Accountability)

1. Designated eating utensils for each unit are given, per the Meal Service Flatware Grid.

2. Flatware is counted before and after each unit’s meal and documented on the Flatware and Adaptive Equipment Count form.

3. Sharps (e.g., knives, scissors, thermometer) are counted and documented separate from flatware.

4. Missing flatware/sharps a. Dining room staff are to report missing flatware and/or sharps. b. Dining room staff are to complete and fax the Incident Report, form 1300, in

accordance with CMHIP Policy 32.02, Critical Incident Reporting.

J. Diet Orders

1. Dining room staff serve meals in accordance with the Current Diet order received for any given patient, per CMHIP Policy 10.10, Diet Orders.

2. The dining room staff writes the patient’s first name and last initial on the appropriate diet menu for the entire set of menus on hand. New/changed prescribed nourishments are written on the Nourishment Log.

3. The dining room staff shall notify the Nutrition Services Diet Office immediately about a Current Diet with an urgent medical need (e.g., allergen, test diet, clear liquid) or for which food is not available from the LH General menu.

4. The Current Diet, form 312 is filed alphabetically, by the patient’s last name, in the respective dining room patient care unit notebook.

5. Dining room staff compares all Current Diets on file in the dining room notebook with the Roster of Current Diets daily to ensure accuracy.

6. Discrepancies are brought to the attention of the unit and Nutrition Services Diet Office staff by the dining room staff.

K. Menus

1. The Nutrition Services Diet Office staff sends the weekly LH General Menu electronically to each unit for posting. Given the large number of special diets, modified diet menus are not posted or made available to patients.

2. The Nutrition Services Diet Office staff delivers a hard copy of the LH General and modified diet menu set to each dining room weekly a. The dining room cook cuts and tapes all modified diet menus needed daily for the

patients in their respective dining room. b. The dining room cook writes the patient’s name on the respective diet menu.


L. Serving Meals

1. Dining room staff shall serve the meal taking time to place food items on the plate in an attractive manner.

2. Dining room staff will use appropriate food handling techniques, per Section III, U, below.

3. Dining room staff shall encourage patients to take and sample all menu items offered.

4. Nutrition Services staff is authorized to serve meals in accordance with a patient’s diet order only. a. Provide only those items on the respective diet menu; alternates allowed, per

Section III.O, below. b. No other substitutes may be offered without authorization by a physician or

registered dietitian. c. Serve only the designated portion for any given menu item (i.e., no extra

condiments).

5. Special condiments are requested by patients. However, certain condiments are regulated for safety/security due to the possibility of harm to patients or staff. a. All dining rooms may serve chili pequin. b. All dining rooms except Hawkins Building dining rooms may serve “hot sauce.”

M. Serving Special Diets

1. Patient Identification a. Use at least two patient identifiers when serving meals to patients

i. Look at current patients’ photos provided to the dining room by unit staff.

ii. Ask the patient his/her name.

iii. Ask another staff person familiar with the patient to identify the patient. b. Reference CMHIP Policy 1.01, Patient Identification.

2. Kosher Diets/Food Preparation Guidelines a. Kosher is the American term for the set of Jewish dietary laws identifying what

can or cannot be eaten, when it can be eaten, and how it must be prepared and served. It is essential dining room staff be knowledgeable of the guidelines and put them into practice when preparing and serving kosher meals (Food Preparation and Service Guidelines manual).

b. Reference CDOC Administrative Regulation #1550-06, Religious Diets. c. Reference CDOC Jewish/Messianic Jewish Meal Service Guidelines.

N. Patient’s Refusal of Diet and/or Items Served

1. Patients have the right to decline any particular menu item or refuse a special diet a. Reference CMHIP Policy 16.50, Patients’ Rights. b. A determination needs to be made as to the reason for refusal


i. Dining room staff shall be responsive to issues of poor food quality (burned, etc.) and attempt to rectify.

ii. In the event a patient expresses dietary concerns, nursing staff and the dining room staff will collaborate to resolve these concerns, per CMHIP Policy 10.10, Diet Orders.

iii. Unit staff will inform the patient’s attending physician of a patient’s request to change the prescribed diet.

2. A verbal order by an R.N. for diet concessions can be accepted for one meal only, to dispel disruptive behavior on the serving line.

O. Providing Alternate Diet Upon Patient Request

1. Alternates are available for patients on a LH General diet and modified diets (except clear/full liquid diets; test diets; and a 60 gm protein, 2 gm sodium diet).

2. Alternate or substitute availability ½ cup cottage cheese, #30 (2 Tbs.) peanut butter and #30 (2 Tbs.) jelly or 2 oz. of American cheese.

3. Process for serving the alternate diet a. The patient being served in the tray line must request the alternate before his/her

plate is served. b. Patients on room tray service (except Hawkins Building “E” satellite dining room)

must request an alternate and identify what meal it is replacing. The unit staff designates the patient’s request on the Tray Order, form 6510.

c. For patients eating in the Hawkins Building “E” satellite dining room: i. The patient must designate his/her preferred alternate to the unit staff one meal

prior. ii. Unit staff completes a Tray Orders and Alternates for Satellite Dining Room

form (Appendix C) by recording the patient’s name and the alternate requested.

iii. At the end of the meal, the form is given to the satellite dining room staff to prepare for the next meal.

iv. Trays are served accordingly

P. Availability of “Seconds”/Large portions

1. Food to be prepared is forecasted/tallied according to census, minimizing surplus while assuring sufficient quantity to feed the entire patient population.

2. Menu portions are designed to provide nutritionally balanced meals while avoiding excessive nutrients, which may be contra-indicated for some patients (e.g., calories, sodium, fat, etc.).

3. “Seconds” or extra portions a. Seconds or extra portions are not allowed even when surplus food is available,

given limited product is not universally available to all patients and the need to maintain nutritional standards without excess.


b. A High Calorie diet may be prescribed when a medical necessity has been established for all patient populations other than LAU. Reference the Living Healthy Diet Manual pertaining to High Calorie diets.

Q. Carry Out Food or Beverage

No carryout of food or beverage is permitted from the dining rooms following meals, related to concerns with contraband (bartering, fermentation of sugars, etc.), rodent/insect control, and food safety/storage issues.

R. Recovery Model Principles as applied to Dining Room Meal Services

1. The Recovery Model, as applied to dining room meal service, is for the purpose of assuring patient safety while providing a dining environment as close to a community-like setting for comfort and practice towards reintegration to the community.

2. Patient responsibilities while in the dining room a. “Patients are responsible for providing information, asking questions, following

instruction, and accepting consequences, following rules and regulations, showing respect and consideration…” per CMHIP Policy 16.50, Patients Rights.

b. Patients are expected to comply with hospital/division/dining room procedures set forth to create a safe patient dining milieu, quality meal services, efficiency in serving meals and mutual dignity/respect.

c. “No Shirt/No Shoes/No Service” - Patients are to be dressed in street clothes, inclusive of footwear for their safety while dining.

3. Dining room staff shall apply Verbal Defense Influence interacting skills and immediately elicit intervention from the unit staff on-site to de-escalate potentially volatile situations involving patients. Unit staff, as a temporary solution to disruptive conduct, may consider tray service for meals to maintain a peaceful milieu for all while dining.

S. Bussing Dishes Procedure

1. Bus carts are placed in every dining room (except GW1 and Circle) to collect soiled dishware. There are tubs, a container and a rubber scraper for the food scraps, dishware, and trays. a. The unit staff collects flatware separately from other dishes following the meal to

count and sign the Flatware and Adaptive Equipment Count form before the patients leave the dining room.

b. The unit staff watches as patients scrape and stack their dishes into the tubs, assisting as necessary.

c. After the patients leave the dining room, dining room staff takes the bus cart to the dish room for cleaning.

d. Clean bus carts are again placed in each dining room prior to the next meal service.

2. Dining rooms GW1 and Circle bussing procedure


a. Patients return their trays to the wash window of the tray line after discarding paper goods in the dining room trash container.

b. The dining room staff responsible for washing dishes separates the patients’ flatware from other dishes by placing the flatware into the caddy to count and sign the Flatware and Adaptive Equipment Count form before the patients leave the dining room.

3. The dining room staff provides a cloth and diluted all-purpose detergent solution for Industrial Therapy (IT) patients to clean tables. Patients in Dining Room 106 and Circle are also provided a cloth and the cleaning solution to clean their tables.

T. Feedback from Patients Regarding Meal Services

1. Dining room staff record comments made by patients during meal service on the Load Sheet.

2. The “Living Healthy Feedback” form is available for patients to comment about meal services during mealtimes in all dining rooms.

3. Patient Council Meetings - A Nutrition Services representative is designated to attend each meeting to address issues presented by patients.

4. The annual Nutrition Services “Food Acceptance” survey is disseminated to patients by unit staff.

5. Patient grievances are processed per CMHIP Policy 16.35, Patient Grievances.

U. Dining Room Food Preparation/Sanitation Guidelines

1. CDPHE/Consumer Protection Division/Retail Food Establishments Rules and Regulations 6-CCR 1010-2

2. CMHIP Infection Control Policy IC-04, Food Safety

3. CMHIP Infection Control Policy DSIC-13, Nutrition Services

4. The Load Sheet for each meal designates: a. Living Healthy General menu b. Food preparation instructions

i. Equipment to use (e.g., oven, griddle) ii. Cook temperature/cook time for hot food items.

c. Portioning i. Portion size for each menu item ii. Bulk portioning guidelines - Reference Food Preparation and Service

Guidelines d. Dishware upon which to serve food. e. Food temperatures are recorded by:

i. North Kitchen staff at time of loading the delivery carts; ii. Dining room staff upon receipt of food at the dining room; iii. Dining room staff at the start of meal service;


iv. Dining room staff during midline of meal service.

f. Space for the cook to write comments on the appearance and taste of the prepared food.

5. The completed Load Sheet is returned to North Kitchen for review by the Charge Cooks.

6. Restricted use of plastic bags, plastic wrap, and trash can liners a. Dining room trash containers with plastic trashcan liners are locked at all times

and serviced by Housekeeping staff. b. Kitchen trash containers have plastic liners. Should the container get too full,

contact Housekeeping to request service. c. No bread bags or pieces of plastic wrap are allowed out of the kitchen except for

approved snacks and bulk snacks (e.g., birthday cakes, cookies, and cheese) that must be covered with plastic wrap for sanitation. Plastic wrap from these items, as well as plastic bags, must be accounted for and disposed of properly by unit staff.

V. Employee/Visitor Meals in Unit Dining Rooms

1. Meal Tickets a. Nutrition Services staff cannot accept cash for a meal. b. A meal ticket must be purchased prior to the meal, per CMHIP Policy 30.48,

Meals For Employees. c. The State of Colorado Fiscal Rule 2-8.03, Meals regulates the cost of a meal

ticket. 2. Reservations through the respective dining room are to be made at least two hours

before the meal in order to assure adequate amounts of food can be prepared. 3. A meal consists of one serving of each menu item as provided for patients on a LH

General Diet in the unit dining room. 4. Employee trays taken to outlying units shall be set up with disposable service.

W. Potential Conflict of Interest

Relative or acquaintance of the dining room staff admitted to the unit serviced by the employee 1. Immediately upon learning of a patient’s admission to the unit, the dining room staff

shall submit written notification to the Supervisor/Nutrition Services Director, disclosing his/her relationship with the patient.

2. The Nutrition Services Director shall review the disclosure of the relationship and make a determination whether or not to temporarily reassign the employee out of the unit for the duration of the patient’s stay in the unit. In most cases, the employee will be reassigned.


MEAL SERVICES PROVIDED IN UNIT DINING ROOMS POLICY NO. 10.11 PAGE 10 Appendix A

DR No. SubUnit Breakfast Lunch Supper Breakfast Lunch Supper

#1 C1 7:15 a.m. 11:45 a.m. 4:45 p.m.

#2 C2 7:15 a.m. 12:15 p.m. 5:15 p.m.

#3 L1 7:45 a.m. 12:45 p.m. 5:45 p.m.

#4 J1 7:00 a.m. 12:00 Noon 5:00 p.m.

#5 J2 7:30 a.m. 12:30 p.m. 5:30 p.m.

#6 F1 8:00 a.m. 1:00 p.m. 6:00 p.m.

N/A F2

E1 7:00 a.m. 12:00 Noon 5:00 p.m.

E2/E3 7:45 a.m. 12:45 p.m. 5:45 p.m.

F5 7:15 a.m. 11:45 a.m. 4:30 p.m.

SLP 8:15 a.m. 12:45 p.m. 5:00 p.m.

CRU 7:45 a.m. 12:15 p.m. 5:45 p.m.

115 69 7:00 a.m. 12:00 Noon 5:00 p.m.

67 67 7:30 a.m. 12:00 Noon 5:00 p.m.

ACBU 6:30 a.m. 11:30 a.m. 4:30 p.m.

AdvCot. 6:30 a.m. 11:30 a.m. 4:30 p.m.

GW-1 7:30 a.m. 12:30 a.m. 5:30 p.m.

GW-7 7:00 a.m. 12:00 Noon 5:00 p.m.

GW2 Circle 7:00 a.m. 12:00 Noon 5:00 p.m.

137 LAU 7:30 a.m. 12:00 Noon 5:00 p.m.

115

GW-1

HAWKINS

Satellite E

Satellite F

Dining Room Meal Schedules Daily (except as noted otherwise

on weekends) Weekends/HolidaysPatient Unit

106

CMHIP NUTRITION SERVICES Dining Room Meal Schedules

April 8, 2014

I:\Admin\Forms\Dining Room Meal Schedules.xls


Appendix B

DR #1(28 Seats)

C1(24-Bed)

B: 7:15 a.m.L: 11:45 a.m.S: 4:45 p.m.

1

Dining Sequence:

DR #2(28 Seats)

C2(24-Bed)

B: 7:15 a.m.L: 12:15 p.m.S: 5:15 p.m.

3

DR #3(28 Seats)

L1(24-Bed)

B: 7:45 a.m.L: 12:45 p.m.S: 5:45 p.m.

5 6

East Tray Line

Dining Sequence:

2DR #4(28 Seats)

J1(24-Bed)

B: 7:00 a.m.L: 12:00 NoonS: 5:00 p.m.

DR #5(28 Seats)

J2(24-Bed)

B: 7:30 a.m.L: 12:30 pm.S: 5:30 p.m.

4

DR #6(24Seats)

F1/BTU(16-Bed)

B: 8:00 a.m.L: 1:00 p.m.S: 6:00 p.m.

Patient entry

Patient entry

CMHIP Nutrition Services

HSFI Central Dining Configuration

1/7/11

West Tray Line


Appendix C (This page is shrunk to fit portrait layout; it is to be printed landscape.)

DATE________________ CENSUS_____________ MEAL: B L D

TRAY ORDERS AND ALTERNATES FOR SATELLITE DINING ROOM

UNIT

STAFF UNIT NAME STYRO

TRAY

YES / NO

DIET

ALTERNATE PB&J Cottage

Cheese Cheese

NOTES:_______________________________ ______________________________________ ______________________________________ I:\Admin\FORMS\TRAY ORDER For Hawkins Building Satellite Dining Room.doc Rev. 4-8-14

TOTAL E-1 TOTAL E-2/E-3


SECTION – ADMISSIONS POLICY NO. 10.12


TITLE: NUTRITIONAL SUPPLEMENTS AND ENTERAL FEEDINGS This replaces CMHIP policy 10.12, dated 4/20/11. I. DEFINITION/PURPOSE

It is the policy of the CMHIP Nutrition Services Department to provide nutritional supplements and enteral feedings when necessitated by patients’ medical needs. A nutritional supplement (also referred to as nourishment, snack, or a packaged commercial enteral product) is any food or beverage added to the diet for the purpose of improving nutritional status. Meals, as provided, are designed to meet and may exceed the nutritional requirements for all patient populations at CMHIP. However, some patients have individual needs for which a special supplement may be indicated. Nutritional supplements are intended to increase overall calories and/or nutrients in the diet. The purpose of this policy is to address indications for which a special supplement may be appropriate and identify procedures for providing nourishments.

II. ACCOUNTABILITY Individuals responsible for implementing this policy include all Nutrition Services’ staff, physicians, and patient care unit staff.

III. PROCEDURE A. Bedtime (hs) Nourishments (Reference CMHIP Policy10.10, Diet Orders and CMHIP

Nutrition Services Living Healthy Diet Manual)

1. A standard hs nourishment is provided to all CMHIP patients and offenders at the Youthful Offender System/Intake Diagnostic and Orientation (YOS/IDO). No physician order is required.

2. Standard hs nourishments are incorporated into daily meal plans and identified on the 5-week cycle menu.

3. CMHIP patients and YOS/IDO offenders on a modified diet receive an hs snack appropriate to the respective modified diet menu.

4. Hs snacks for the Locked Adolescent Unit (LAU) and YOS/IDO must meet the nutritional criteria for the Colorado Department of Education After School Snack Program.

5. Unit staff distribute hs nourishments to the patients.

6. Patient birthdays are recognized on the 15th of each month. Special cakes are baked, decorated and sent with one carton of milk per patient to each dining room for distribution, in place of the standard hs snack that night.

NUTRITIONAL SUPPLEMENTS AND ENTERAL FEEDINGS POLICY NO. 10.12 Page 2

7. Trays of bulk hs snacks, such as cheese, birthday cakes, and cookies, are covered with plastic wrap for sanitation and freshness.

8. Dining room employees will send disposable spoons, plates, bowls, etc., as needed with nourishments to the patient care units.

9. All plastic wrap, plastic bags, and disposable flatware sent must be accounted for and disposed of properly by the unit staff.

10. The unit staff will discard food not consumed by patients; food is not returned to the dining room (reference CDPHE regulation 3-315).

B. Religious Diet Observances

CMHIP patients and Pueblo-campus Colorado Department of Corrections (CDOC) offenders whose religious beliefs require the adherence to religious dietary laws receive snacks that satisfy recognized religious dietary requirements per CDOC Administrative Regulation 1550-06: Religious Diets and the CDOC Kosher Meal Program Guidelines current version.

C. Mid-morning (a.m.) and mid-afternoon (p.m.) standard nourishments are available for

patients with a medical need (reference CMHIP Living Healthy Diet Manual)

1. A physician order is required. (See CMHIP Policy 10.10, Diet Orders.)

2. The Registered Dietitian Nutritionist (RDN) assesses the patient and makes recommendations concerning snacks.

3. Rotation for snack variety is identified on the Standard Weekly Nourishment Schedule. (Reference Food Preparation and Service Guidelines.)

4. Snacks are not a substitute for patients choosing to sleep in or skipping meals.

D. Customized nourishments for a.m., p.m., or hs

1. Customization is used when the standard nourishment is inadequate and/or does not meet the needs of the patient.

2. The RDN ensures the patient’s medical needs are met when recommending a customized snack.

3. A physician’s order is required and the medical necessity must be documented in the patient’s chart. (See CMHIP Policy10.10, Diet Orders.)

E. Alternative to Adding Special Nourishments

1. Patients on LAU may be prescribed a “Large Portion” adolescent modified diet, when medically indicated.

2. The LH3000 or High Calorie diet may be prescribed for all other patient populations (excluding LAU) when medical necessity has been established.


F. Commercial Oral Supplements, for which a physician’s order is required

1. Medical Nutrition Therapy products, i.e., Boost or other commercial oral supplements, used for customized nourishments

a. Available oral supplements are listed in the Pharmacy formulary; others may be prescribed.

b. The Nutrition Services Purchasing Manager procures the oral supplements per Nutrition Services policy, Procurement and Inventory Management: Food, Supplies, and Equipment. Those not listed in the formulary may be procured with assistance from the Pharmacy.

c. Oral supplements are provided at the expense of the Nutrition Services Department.

2. Enteral Tube Feedings

The patient who is unable to consume adequate calories and nutrients by mouth may be prescribed a tube feeding, i.e., Nasogastric (NG) and Percutaneous Endoscopic Gastrostomy (PEG).

a. The specific product prescribed shall be selected from the Pharmacy formulary when a listed product meets the patient’s need. When the specific product is not listed in the formulary, Nutrition Services may request the Pharmacy assist in procuring non-formulary commercial enteral products (reference Pharmacy Department Policy No. 1.00, Rx Policies and Procedures).

b. Formulary and non-formulary commercial enteral products are provided at the expense of the Nutrition Services Department.

G. Alternative and Herbal products

Use of herbal/dietary supplement products is discouraged due to lack of standardization. (See CMHIP Policy 3.01: Medication Practices & Pharmacy Department Policy 1.00, Rx Policies and Procedures.)

H. Tracking of Nourishments and Supplemental Feedings

1. Admission Discharge Transfer (ADT) Report

The ADT report is a listing of all patients on any given unit and their respective diets.

2. Nourishment Log

a. The list of patients receiving nourishments between meals.

b. Identifies foods ordered and time given (e.g., a.m., p.m., and/or hs).

c. Sorted by patient care unit.

d. Maintained and distributed by the Diet Office staff.


3. Diet Office procedures when receiving a Current Diet (form 312) that includes a snack

a. The patient’s name and food item(s) are added or removed from the hard copy of the Nourishment Log, using red ink.

b. The Diet Office administrative assistant updates the Nourishment Log weekly. The red ink draws attention to the items to be updated.

i. One copy of the log is placed in each Dining Room ADT/Nourishment Log book.

ii. An electronic copy of the log is sent to each clinical dietitian. I. Preparation of Nourishments

1. Each dining room prepares nourishments daily, for their units, as identified in the Nourishment Log.

2. Nourishment will be labeled with patient’s name, current date, and time to be consumed (a.m., p.m., hs).

3. Unit staff pick up the snacks following each meal when returning to the unit.

4. Nourishments are prepared, stored, and served in accordance with CMHIP Infection Control Policy IC-4, Food Safety; CMHIP Infection Control Policy DSIC-13, Nutrition; and CDPHE/Consumer Protection Division/Retail Food Establishment Rules & Regulations 6CCR 1010-2.

J. Floor Stock

1. Bulk floor stocks, such as individually wrapped packages of saltine crackers and graham crackers, punch crystals, applesauce (#303 cans), pudding, Fiber Basic, straws, thickening agents, etc., may be requisitioned by the patient care unit directly from the CDHS Southern District Warehouse at the patient care unit’s expense. These are not supplied by Nutrition Services Department.

2. DOC/SCCF requisitions are per Exhibit 1 (to the DOC/CMHIP Interagency Agreement)/Cooperative Agreement “Standing Bulk Food Order.”

______________________________________ ___________________________ William J. May Date Superintendent


SECTION - ADMISSIONS POLICY NO. 10.15 Effective Date: 3/13/13

TITLE: TEMPORARY OFF-UNIT THERAPEUTIC STAYS This replaces Policy 10.15 dated 9/12/12. I. DEFINITION/PURPOSE

It is the policy of CMHIP to treat patients in the most appropriate, least restrictive environment, considering the patient’s clinical needs and progress, and the safety of the patient and others.

The purpose of this policy is to describe circumstances under which a patient may

temporarily move from one unit to another or be re-admitted briefly to certain units, and the requirements for documentation.

The following are associated definitions in future policies, procedures, clinical manuals

or guidelines. Temporary Off Unit Therapeutic Stays (TOUTS): Refers to the temporary movement of a patient from his/her designated unit to a unit of similar or higher security level. This move is done in the event that a patient is demonstrating behaviors that are jeopardizing his/her safety or the safety of others, as part of a behavioral treatment program, or progress the patient has made in treatment on his/her assigned unit. For example: a patient assigned to a unit with an Intermediate Security Stage may be moved to a unit with a Medium Security Stage in the same program due to clinical risk assessment findings of the probability, imminence or severity of a negative outcome if not moved. In such a case, if the patient is on voluntary status and does not consent to the move, it is necessary to implement an M1 prior to the transfer. TOUTS is designed to alter a cycle of escalation that places a patient at risk of becoming dangerous to him/herself or others or jeopardizing the progress he/she has made in treatment. With appropriate use of TOUTS, it is hoped that the patient’s behavior can be stabilized without the use of locked-door seclusion or restraint or permanent transfer to a more restrictive treatment unit or a unit with a higher security stage. TOUTS does not preclude consideration of these interventions, however. TOUTS is intended for a short-term stay, i.e., less than seven calendar days (which includes Saturdays, Sundays, and holidays). On rare occasions, the stay on the higher security unit may last up to ten calendar days with the authorization of the Chief of the Department of Psychiatry or the Chief of Medical Staff, or his/her designee. (In most circumstances, if it is anticipated that the stay will exceed seven calendar days in duration, the patient shall be transferred to the higher stage security level following the procedure outlined in Policy 12.07, Interim Admissions and Discharges.) TOUTS may not be used when a patient is transferred when discharge and readmission are required, e.g., from a certified bed to an uncertified bed, or from an uncertified bed to a certified bed, due to Medicaid regulations.

TEMPORARY OFF UNIT THERAPUETIC STAYS POLICY NO. 10.15 PAGE 2

II. ACCOUNTABILITY

Individuals responsible for implementing this policy include the attending psychiatrist/mid-level provider (i.e., PA or NP), the receiving psychiatrist/mid-level provider, nursing staff, Lead Nurses, Clinical Team Leaders/Coordinators, the Chief of the Department of Psychiatry or designee and the Program Director or Administrator-On-Call.

III. PROCEDURE A. Among other factors, the clinical assessment of the patient shall take into account:

1. The patient’s history

2. The presence of cues or triggers in the current setting that led the patient to act out

3. Likelihood the patient will be able to gain control in the absence of those cues or triggers

4. Likelihood the transfer/admission will interrupt an escalating cycle of acting out behavior

5. Likelihood the patient will stop escalating negative or dangerous behavior

6. Likelihood the patient will not need seclusion and/or restraint

7. Likelihood the patient will be able to return to a lower security unit or back to community placement.

The above factors will also be considered in the discussion between receiving and sending psychiatrists/mid-level provider to be sure the patient’s needs and the receiving unit’s capability are both taken into account.

B. Assessment of Risk and Implementation of Temporary Off Unit Therapeutic Stays

1. The findings of the violence risk assessment upon which the decision to move a patient is based must be recent (within the last week) and documented in the medical record.

2. The decision to move the patient for a TOUTS must be made by the psychiatrist

or mid-level provider with input from the treatment team, the patient, and significant others as appropriate. The psychiatrist/mid-level provider on the sending unit shall talk directly with the psychiatrist/mid-level provider on the proposed receiving unit of the need to briefly move the patient to a more secure setting. Included in the discussion will be the patient’s needs and the receiving unit’s capability of meeting those needs. In the event that the two psychiatrists involved fail to agree regarding the use of a TOUTS for a patient, the Chief of Psychiatry or Chief of Medical Staff will review the case and make the final determination. When such transfers need to occur after normal working hours, the on-call physician will make the decision and give the orders. The Clinical Team Leaders/Coordinators or their designees shall assist the psychiatrist, particularly in identifying bed availability.


3. The patient will be assigned to a higher security level treatment unit in the same program based on clinical needs of the patient and bed availability. Patients requiring TOUTS cannot be moved to non-certified beds. Based on violence risk assessment and recent history, the patient should be assigned to a unit with the next highest level of security within the same program that is still the least restrictive.

4 TOUTS will be designated by a physician’s order, which is to include the

rationale. The rationale for movement to another unit must be documented by the sending physician in the patient’s medical record prior to movement of the patient.

5 The sending Clinical Team Leader/Coordinator or designee is responsible for

notifying the patient’s family (if form 100C authorizes family contact) and the appropriate Mental Health Center of the temporary move.

6 The Clinical Team Leader/Coordinator shall notify the Program Director or

designee (if not previously involved in the decision to move the patient as noted in B above) of this patient movement. Additionally, the sending unit shall notify Nutrition Services of the move electronically. Nursing staff on the sending unit shall secure the patient’s personal property on that unit until the patient’s return.

7 When a patient is sent to another unit for a TOUTS, the sending and receiving

RNs shall complete their sections on Form 140-TOUTS, the Nursing Patient Handoff Communication for Temporary Off-Unit Therapeutic Stays. The patient’s medications shall be sent to the receiving unit with appropriate medication reconciliation documented on this form. Additionally, an Interim Plan of Care (107.5) addressing the concerning behavior will be initiated by the sending RN to guide the treatment the patient receives on the receiving unit. Follow the Lead Nurse to Lead Nurse report guidelines per INS-140.

8 While it is the expectation that the sending treatment team will remain involved in

the ongoing care and treatment of the patient, staff on the receiving unit (the unit where the patient is physically located) are responsible for the patient’s safety, security and treatment during the brief stay. There must be a nursing progress note written by the receiving team on each shift on the receiving unit documenting the patient’s response to TOUTS beginning on the shift during which the transfer occurred and for the duration of the transfer, as driven by the new Interim Plan of Care (107.5). The psychiatrist/mid-level provider on the receiving unit shall write orders deemed necessary to keep the patient safe while he/she is on that unit (e.g., placing the patient on suicide precautions or increasing the level of precautions). However, proposed changes to the clinical treatment, such as medication adjustments, should be discussed with the sending psychiatrist prior to making any such changes.

9 TOUTS should be of the shortest duration possible. These are usually intended to

be done on an overnight basis, but might be done for a longer period based on the patient’s response or in the event of a weekend and/or holiday. TOUTS cannot be longer than seven calendar days (including Saturdays, Sundays, and holidays).


10 For the patient’s safety and to comply with federal regulations, the daily census must accurately reflect the patient’s whereabouts when TOUTS is utilized. The patient will be designated as “sleeping” on the receiving unit in Avatar, and will continue to be designated as “programmed” on the sending unit in Avatar. Both the sending and receiving/admission units must indicate where the patient is physically located on his/her Patient Wellness Census Sheet (form 5604a). The unit designation is changed once on the day the patient is moved, not each day.

11 In cases in which TOUTS are used more than once with a specific patient, the

treatment team should consider adding the criteria for the use of TOUTS to the patient’s Plan of Care.

C. Reduction of Privileges and TOUTS

1. When a patient’s privileges have been pulled because of an infraction involving substantiated illegal activity, TOUTS shall automatically be implemented until specifics of the infraction are clarified and addressed on the patient’s Plan of Care.

2. When a patient’s privileges have been pulled because of an infraction involving

alleged illegal activity, TOUTS may be implemented at the discretion of the treating psychiatrist/mid-level provider.

3. In either case, the duration of the TOUTS shall be the shortest amount of time

possible, lasting only until the sending treatment team can clarify the specific details of the infraction and appropriately address them on the patient’s Plan of Care.

______________________________________ ___________________________ William J. May Date Superintendent


SECTION - CARE OF PATIENTS POLICY NO. 10.23


TITLE: ADMISSION, DISCHARGE, AND TRANSFER PROCESS OF INDIVIDUALS WITH

INTELLECTUAL DISABILITIES This policy replaces policy 10.23, Admission, Discharge, and Transfer Process of

Individuals with Developmental Disabilities, dated 9/15/11. I. DEFINITION/PURPOSE

It is the policy of CMHIP to assure that case management and discharge planning for patients with intellectual disabilities provide eligible inclusion of appropriate level of services from community or state intellectual disability (ID) agencies. It is also the policy of CMHIP to assure that patients admitted with potential needs for post-discharge ID-related services be centrally tracked during their inpatient stays. The purpose of this policy is to provide a method for the assessment, case management and continuity of care for ID patients admitted for psychiatric care, and to establish a method for centrally tracking these cases for both hospital and CDHS/IDS uses.

DEFINITIONS

ID: Intellectual Disability CCB: Community Centered Board: County-based private agencies in contract with the state to

provide services to the intellectually disabled. IDS: Intellectual Disabilities Services, which is an agency under the authority of the Colorado

Department of Human Services RC: A regional center maintained by the Colorado Department of Human Services.

II. ACCOUNTABILITY Individuals responsible for implementation of this policy include unit social workers and physicians.

III. PROCEDURES

1. Assessment of new admissions will note whether any of the following apply:

a. A diagnosis of intellectual disability b. History of intellectual disability c. Any presenting evidence that may indicate the individual has intellectual disability d. History of receiving services for intellectual disability and agencies involved

ADMISSION, CARE, AND TRANSFER PROCESS OF INDIVIDUALS WITH INTELLECTUAL DISABILITIES POLICY 10.23 PAGE 2

2. In all cases where the above information was not obtained on admission, the same factors

will be addressed in the continuity of care/discharge planning process. 3. Where factors a., b., or c. above are identified, but without history of services, the

appropriate Community Centered Board (CCB) will be contacted to establish current eligibility status or to initiate application for services.

If no previous eligibility was established, the patient will be assisted in completing an application, which may require eligibility testing; the patient will be assisted in the process if any appeal or re-application should ensue. Testing results will be forwarded to the CCB. A referral to CCB will be coordinated with the MHC and patient’s guardian if the patient is discharged before application or testing can be accomplished.

4. When the patient has either a closed or open case with a CCB, the social worker will

request CCB participation in the discharge planning process. In the case of patients with guardians, discharge planning is arranged through the guardians.

5. The patient or patient’s guardians may refuse consent to a CCB referral. 6. If the patient is admitted from a Regional Center (RC), the discharge planning process

directly involves the RC staff. 7. If the patient has an open case for CCB services, the CCB case manager is directly

involved (this may be instead of a County Department of Human Services caseworker) in the discharge planning process.

a. In the case of long-term patients with active CCB status, appropriate effort will be

made to coordinate a review of the Individualized Plan (IP) created by the CCB with the case manager for an updated continuity of care plan (i.e., whether to community-based or RC services). This review is done with the annual psychosocial assessment update.

b. In the case of long-term patients previously found to be ineligible, there is review at

the time of the annual psychosocial assessment, of any basis for re-application. This basis for review would rest on factors such as evidence of ID prior to age 22, supportive testing results consonant with an intellectual disability, or history of receiving ID services.

8. When the patient has an open case with a CCB or is directly admitted from an RC, staff

from those agencies will be contacted as needed in order to provide appropriate special programming for the patient during the inpatient stay.



SECTION – LEGAL/CONSENT POLICY NO: 10.45


TITLE: LEGAL STATUS CATERGORIES AND COMPUTER CODES This replaces CMHIP policy 10.45, dated 10/12/11. I. DEFINITION/PURPOSE

It is the policy of CMHIP to admit patients according to the to requirement of Colorado laws. The purpose of this policy is to describe the legal status categories for enrollment and to identify the statutory authority under which CMHIP provides services to patients.

The statutory authority may also impose certain conditions, restrictions, or procedures upon CMHIP in relation to the patient and the courts. Thus, knowledge of each patient's specific legal status is essential to carry out CMHIP’s legal responsibilities.

The major sources of legal status categories in the Colorado Revised Statutes (CRS) are:

Title 27, Article 65 - Care and Treatment of Person with the Mental Illness Titles 16-18 - Criminal Justice Code Title 19 - Children's Code Title 27, Part -81 - Alcoholism and Intoxication Treatment

II. ACCOUNTABILITY

Individuals responsible for implementing this policy include all CMHIP staff. The attending physician is deemed the responsible person for ensuring that the patient has a legal status category for enrollment as prescribed by law.

III. PROCEDURE

Each legal status is described below; “with charges” indicates that the patient has a detainer or hold from a Law Enforcement Agency, and must be returned to that Agency upon discharge. (The computer code numbers are noted before the legal status. The statute citations are in brackets.) A. Care and Treatment of Person with Mental Illness (Mental Health Act)

1. Voluntary [CRS 27-65-103]

Voluntary enrollments are encouraged by the legislative intent expressed in this Act. If an already hospitalized patient is charged with a crime, he/she cannot be changed from Voluntary to an Involuntary status under the terms of CRS 27-65 without written authorization from the District Court having jurisdiction over the crime. Present subclasses of Voluntary are: 301WC - Voluntary with Charges 322 - Voluntary - Probation

LEGAL STATUS CATEGORIES AND COMPUTER CODES POLICY NO. 10.45 PAGE 2

2. Involuntary Detention for 72-Hour Evaluation [CRS 27-65-105, 106]

72-hour custody in a designated facility for the purpose of evaluation and treatment of alleged dangerousness or grave disability due to mental illness may be initiated in the following ways: a. Emergency Mental Illness Report and Application (form M-1), further

classified and coded as: 471 - No Charges, initiated by peace officer. 472 - No Charges, initiated by professional person. 473 - Criminal Charges Pending, initiated by peace officer. 474 - Criminal Charges Pending, initiated by professional person.

b. 475NC - Court Order pursuant to Affidavit, no charges (form M-3) [CRS 27-65-105]

475WC - Court Order pursuant to Affidavit, with charges (form M-3) [CRS 27-65-105]

c. 477NC - Court Order pursuant to Petition and Screening, no charges (form M-7) [CRS 27-65-106] 477WC - Court Order pursuant to Petition and Screening, with charges

(form M-7) [CRS 27-65-106]

3. 414WC - Notice of Certification & Certification for Short-Term Treatment, with charges (form M-8)

414NC - Notice of Certification & Certification for Short-Term Treatment, no charges [CRS 27-65-107] A person who has had a 72-hour evaluation may be certified for not more than 90 days of treatment. The respondent shall be given written notice that a hearing upon his/her certification for short-term treatment may be held before the court or a jury, upon written request directed to the court, within 10 days of the request for a hearing. A professional person who participated in the evaluation shall sign the Notice of Certification. Certifications must be filed with the court within 48 hours from the date of certification.

4. 415WC - Extended Certification for Short-Term Treatment, with charges

(form M-11)

415NC - Extended Certification for Short-Term Treatment, no charges [CRS 27-65-108] The attending physician may file with the court an extended certification for an additional 90 days. The original order for short-term care and treatment shall expire upon the date specified therein, unless further extension has been requested.


The patient shall be given written notice that a hearing upon his/her certification for short-term treatment, or extension of, may be held before the court or a jury upon written request directed to the court at any time. Short-term treatment or extension of short-term treatment shall be terminated when in the opinion of the attending physician the respondent has received maximum benefit of hospitalization. The court shall be notified within five days of such termination.

5. 421NC - Order for Long-Term Care and Treatment, no charges (form M-13)

421WC - Order for Long-Term Care and Treatment, with charges [CRS 27-65-109] See number 6 below.

6. 422WC - Order for Extension of Long-Term Care and Treatment, with

charges (form M-16)

422NC - Order for Extension of Long-Term Care and Treatment, no charges Whenever a patient has received short-term treatment for five consecutive months, the attending physician may file a Petition for Long-Term Care and Treatment (form M-12) with the court for long-term care and treatment, and a mandatory hearing shall be held. An original order of long-term care and treatment, or any extension of such order, shall expire upon the date specified therein, unless further extension has been requested at least 30 days prior to the expiration date of the order in force. The attending physician shall certify to the court that the patient needs continued hospitalization with a Petition for Extension of Long-Term Care and Treatment (form M-14). If the court or jury finds this to be a fact, the court shall issue an extension of the order. Any extension shall be for a period of not more than six (6) months. The patient shall be given a written notice that a hearing after his/her certification for long-term treatment may be held before the court or a jury upon written request directed to the court at any time. Long-term treatment or extension of long-term treatment shall be terminated when in the opinion of the attending physician the respondent has received maximum benefit of hospitalization. The court shall be notified within five days of such termination.

7. Imposition of Legal Disability [CRS 27-65-125 127] 499 - Civil Unclassified – Imposition of Legal Disability Any interested person may obtain a determination as to the imposition of a legal

disability or the deprivation of a legal right for any person who is mentally ill and a danger to self or others, or is gravely disabled. The court may be petitioned for a specific finding as to disability or deprivation of a legal right. Teams may petition the court for a deprivation of a legal right for patients participating in behavior


management programs that include the use of wrist-to-waist restraint or seclusion as part of the program, if circumstances warrant such a determination.

8. Transfer of Certification (M-9) Although not separately classified as a legal status category for enrollment, a patient with Certification for Short or Long-Term may be transferred into or out of CMHIP and to or from another designated treatment facility, with notification to the court. The court may also issue an Order to Transport (form M-18) directing the sheriff to transport the patient being transferred. Patients must be given 24-hour notice of transfer to other designated facilities, except in an emergency.

9. Mental Health Hearings and Jury Trials

Any patient being treated shall be represented by counsel if he/she so requests. Any patient certified for short-term or long-term treatment (or extension thereof) may request at any time in writing that the court conduct a hearing or a jury trial to determine whether the patient is a danger to others or himself/herself, gravely disabled, or whether he/she can be released to a less restrictive setting. A hearing or jury trial shall be scheduled within 10 days of the request. Burden of proof from beginning of hospitalization to the present must be supported by clear and convincing evidence indicating that the patient is a danger to self or others or gravely disabled. It is, therefore, of continuing importance that all treatment be accurately documented in the patient's record. The attorney representing CMHIP will need the professional person who certified the respondent, and/or the attending physician (if different from the professional person who certified), for each hearing or trial to act as witnesses.

B. Criminal Justice Codes

1. Criminal Observations XXX codes designate inpatient status, XXXop codes designate outpatient status a. 271 or 271op - Competency Examination [CRS 16-8-111] [CRS 16-8.5-103]

During a criminal proceeding, the court commits the defendant for psychiatric examination to advise whether the accused is competent to proceed with trial, in terms of understanding the nature of the proceeding with which he/she is confronted and has a level of understanding necessary for meaningful cooperation with his attorney.

b. 272 or 272op - Sanity (and Competency) Examination [CRS 16-8-105] When a plea of Not Guilty by Reason of Insanity is accepted, the court commits the defendant for psychiatric observation and examination to develop information relevant to whether the defendant was sane at the time of the commission of the act with which he/she is charged and also has the competence to proceed. The definition of legal insanity is found in 16-8-101. Instructions for the report to the court are listed in 16-8-106.


c. 276 or 276op - Impaired Mental Condition Examination [CRS 16-8-103.5

(4)] When the affirmative defense of impaired mental condition has been asserted, the court shall order an examination to develop information as to whether the defendant had the capacity to form a culpable mental state at the time of the commission of the act with which he/she is charged.

d. 273 or 273op - Convicted Sex Offender Examination [CRS 18-1.3--908] Two examining psychiatrists write independent reports of their opinions as to whether the defendant is likely to be dangerous to the public, is mentally deficient, could benefit from treatment, and could be adequately supervised on probation. The reports must be filed with the court and probation department within the time ordered, which may not exceed 60 days.

e. 274 or 274op - Pre-sentence Examination [CRS 16-11-102] The court orders a mental examination as part of the pre-sentence or probation investigation of a convicted felon. No specifications for the examination are given in the statute.

f. 212 - Re-examination of Continued Eligibility for Conditional Release [CRS 16-8-115.5(7)] Prior to any final hearing on a petition for Revocation of a conditional release, the court may order a current examination of eligibility for release and, if the defendant refuses to submit and cooperate, shall recommit the defendant to the Institute.

g. 277 or 277op – Mental Cond Exam h. 279 or 279op – Criminal Observation – Other

This is a category for a legal status not listed above, including an Order for a Mental Condition Evaluation [CRS 16-8-106 3 (a)]; [CRS 18-1.3-1104 (mentally retarded – death penalty case)]; [CRS 18-1.3-1404 (c)].

2. Criminal Commitments

a. 201 - Incompetent to Proceed [CRS 16-8-112 (2)] 16-8.5-111 A person who has already been examined during a criminal proceeding and determined by the court to be incompetent to proceed is committed to the Institute for treatment to restore him/her to competency. This hospitalization, however, may not be longer than the maximum confinement in prison that could have been imposed for the offense charged, including "minimum good time." Furthermore, the court must review the case at least every six three months as to the probability of eventual restoration and the justification of continued commitment [CRS 16-8-114.5]. [CRS 16-8.5-116]


b. 210 - Not Guilty by Reason of Insanity (NGRI) [CRS 16-8-105 (A)]

A person who has been found NGRI by the court is committed to the Institute until the court finds him/her eligible for release according to the test specified in [CRS 16-8-120].

c. 216 - Not Guilty by Reason of Impaired Mental Condition (NGRIMC) [CRS 16-8-103.5 (5)] If the court finds the defendant not guilty by reason of impaired mental condition, the court shall commit the defendant to the custody of the Department of Human Services until such time as found eligible for release pursuant to [CRS 16-8-115] and [CRS 16-8-120]. The Executive Director of the Department of Human Services shall designate the state facility at which the defendant shall be held for psychiatric treatment, and may transfer the defendant from one institution to another.

d. Conditional Releases and Returns of NGRI and NGRIMC Commitments (1) 211 - Conditional Release [CRS 16-8-115 (3c)]. When granted a

conditional release, the person's progress continues to be monitored by the Institute on behalf of the Department of Human Services, even though aftercare is provided by CMHIP or another agency. Therefore, such patients carry this legal status for continued enrollment for indirect service.

(2) 213 - Conditional Release Returned for Stabilization. Under its general powers to enforce its conditions of release, the courts sometimes order the patient returned for treatment without revoking the release, leaving to the Institute the decision to release again when the patient's condition is stabilized.

(3) 214 - Revoked Conditional Release [CRS 16-8-115.5 (8)]. If the court finds that the defendant has become ineligible to remain on conditional release, as defined in [CRS 16-8-102(4.5)], it shall enter a final order revoking the conditional release and recommitting the patient to the Institute.

(4) 228 – Revoke CR Eval

Evaluation is done if there is indication that the defendant has become ineligible to remain on conditional release.

(5) 229 – Unconditional Discharge Eval

Evaluation is done to determine if the defendant could be discharged with no conditions.

3. Transfer of Mentally Ill Inmates

122 - Transfer for Evaluation and Treatment [CRS 17-23-101 (1)] The Executive Director, in coordination with the Executive Director of the Department of Human Services, is empowered to transfer an inmate who is


mentally ill and cannot be safely confined in a correctional facility operated by the Department of Human Services for observation and stabilization.

C. Children's Codes

1. 572 - 72-hour Evaluation During Proceedings [CRS 19-2-702] If it appears from the evidence presented at an adjudicatory trial or otherwise that a juvenile may be mentally ill, as defined in CRS 27-65-105 and CRS 27-65-106, and the juvenile has not had a mental health hospital placement prescreening, the court shall order a prescreening to determine whether the juvenile requires further evaluation. Based upon a mental health hospital placement prescreening, that the juvenile may be mentally ill, the court shall order the juvenile placed for an evaluation at a facility designated by the Executive Director of the Department of Human Services for a 72-hour treatment and evaluation pursuant to CRS 27-65-105 or CRS 27-65-106.

2. 572WC – JUV 72-HR, with charges Juvenile Hold under same conditions as "572" when juvenile has legal charges pending.

3. 153 - Youth Services Transfer [CRS 19-2-923(3a)] A juvenile committed to the Department of Human Services may be transferred from a facility to the Institute for the purpose of diagnosis, evaluation, and emergency treatment, except that no juvenile may be transferred to a mental health facility until the juvenile has received a mental health prescreening resulting in a recommendation that the juvenile be placed in a facility for evaluation pursuant to CRS 27-65-105 or CRS 27-65-106. The period of such temporary transfer shall not exceed 60 days. When a juvenile has remained in the treatment facility for 60 days, the treatment facility shall determine whether the juvenile requires further treatment or services, and, if so, the treatment facility shall confer with the sending facility concerning continued placement. If both facilities agree that the juvenile should remain in the treatment facility, the Executive Director of the Department of Human Services shall be notified of the recommendation, and he/she may authorize an additional 60-day placement. When an additional placement is authorized, the court shall be notified of the transferred placement. The juvenile shall remain in transferred placement until the facilities agree that such placement is no longer appropriate. The period of placement shall not exceed the length of the original commitment to the Department of Human Services unless authorized by the court after notice and a hearing. When a juvenile is in continued transferred placement and the treatment facility and the sending facility agree that the need for placement of the juvenile is likely to continue beyond the original period of commitment to the Department of Human Services, the treatment facility shall initiate proceedings with the court having jurisdiction over the juvenile under CRS, Title 27, Article 65.


4. 150 – DYC Commit [CRS 19-2-923(3a)]

A juvenile committed to the Department of Human Services, Division of Youth Corrections may be transferred from a facility to the Institute for the purpose of diagnosis, evaluation, and emergency treatment.

D. Involuntary Commitment of Alcoholics [CRS 25-1-311 (5)(6)] [CRS 27-81-112

(7)(8)] A person may be committed to the custody of the Alcohol and Drug Abuse Division of the Department of Health and placed by them in the Circle Program of this Institute for either a 30-day or 90-day period of treatment for alcoholism. 1. 630 - Alcoholism 30-day Commitment. 2. 690 - Alcoholism 90-day Commitment. 3. 691 - Alcoholism 90-day Recommitment.

E. Termination or Change of Legal Status

1. The attending physician will order a legal status terminated when:

a. The time in the status exceeds the time specified by statute or court order

b. A court with jurisdiction orders the legal status terminated or changed

c. A civil commitment, under CRS 27-65, does not meet criteria of being dangerous to self or have grave disability due to mental illness

d. A voluntary patient requests that the status be terminated.

2. The actual date that the attending physician will order the termination of the legal status will be when one of the following instances occur:

a. The Institute receives the legal documents requiring the change

b. The Institute verifies a court order to terminate the legal status as found in the Colorado Judicial Branch’s official information system

c. The maximum time for the legal status, as specified by statute or court order, expires

d. A voluntary patient requests the attending physician to terminate the status. ______________________________________ ___________________________ William J. May Date Superintendent

Documents

Colorado Mental Health Institute at Pueblo POLICY MANUAL ... · 11/10/2014 · Colorado Mental Health Institute at Pueblo POLICY MANUAL SECTION - ADMISSIONS POLICY NO. 10.00 Effective