Section 441.24.37. Twenty-three-hour crisis observation and holding.

Twenty-three-hour crisis observation and holding services may be a stand-alone service or embedded within a crisis stabilization residential service. Twenty-three-hour crisis observation and holding services are designed for individuals who need short-term crisis intervention in a safe environment less restrictive than hospitalization. This level of service is appropriate for individuals who require protection or when an individual’s ability to cope in the community is severely compromised and it is expected the crisis can be resolved in 23 hours. Twenty-three-hour crisis observation and holding services include, but are not limited to, treatment, medication administration, meeting with extended family or significant others, and referral to appropriate services. Twenty-three-hour crisis observation and holding chairs can be utilized.

         24.37(1) Admission criteria. The services may be provided if any of the following admission criteria are met:

            a.               There are indications the symptoms can be stabilized and an alternative treatment can be initiated within a 23-hour period.

            b.               The presenting crisis cannot be safely evaluated or managed in a less restrictive setting, or no such setting is available.

            c.               The individual does not meet inpatient criteria, and it is determined a period of observation assists in the stabilization and prevention of symptom exacerbation.

            d.               Further evaluation is necessary to determine the individual’s service needs.

            e.               There is an indication of actual or potential danger to self or others as evidenced by a current threat or ideation.

            f.                There is a loss of impulse control leading to life-threatening behavior and other psychiatric symptoms requiring stabilization in a structured, monitored setting.

            g.               The individual is experiencing a crisis demonstrated by an abrupt or substantial change in normal life functioning brought on by a specific cause, sudden event or severe stressor.

         24.37(2) Staffing requirements.

            a.               A designated medical director or administrator is responsible for the management and operation of the organization or facility.

            b.               Registered nurse practitioners and physician assistants have at least two years of mental health experience.

            c.               At least one mental health professional is available for consultation 24 hours a day, 365 days a year.

            d.               A mental health professional as defined in Iowa Code section 228.1(6) provides mental health services appropriate to the individual’s needs.

            e.               Crisis response staff are on duty 24 hours a day.

            f.                A registered nurse is available on site 24 hours a day.

         24.37(3) Twenty-three-hour observation and holding safety.

            a.                Performance benchmark. An incident report is created when staff are notified an incident has occurred.

            b.                Performance indicators.

             (1)             The incident report documents:

            1.      The name of the individual or individuals who were involved in the incident.

            2.      Date and time of occurrence of the incident.

            3.      A description of the incident.

            4.      Names and signatures of all staff present at the time of the incident.

            5.      The action taken by the staff.

            6.      The resolution or follow-up to the incident.

             (2)             A copy of the incident report is kept in a centralized file and a copy is given to the individual, the mental health and disability services region, and the individual’s parent or guardian when appropriate.

         24.37(4) Service requirements.

            a.                Performance benchmark. A treatment summary is provided to the individual and the individual’s treatment team when applicable.

            b.                Performance indicators. The minimum treatment summary requirements include:

             (1)             Action plan.

             (2)             Crisis assessment, including challenges and strengths.

             (3)             Course and progress of the individual with regard to each identified challenge.

             (4)             Evaluation of the individual’s mental status to inform ongoing placement and support decisions.

             (5)             Recommendations and arrangements for further service needs.

             (6)             Signature of the mental health professional.

             (7)             Treatment interventions.

            c.                Performance benchmark. The individual using this service is provided a safe, secure observation and holding service in a location meeting the needs of the individual and in the least restrictive setting.

            d.                Performance indicators.

             (1)             Individuals give informed consent.

             (2)             Treatment providers, family members and other natural supports as appropriate are contacted within 23 hours of the individual’s admission.

             (3)             Written policies and procedures cover medication administration, storage and documentation.

             (4)             Individual records include, but are not limited to, a treatment summary and verification of individual choice.

             (5)             The 23-hour crisis observation and holding facility is a welcoming and comfortable environment conducive to recovery.

             (6)             The 23-hour crisis observation and holding is primarily used as a diversion from hospital level of care.

             (7)             Communication attempts and contact with the individual’s team will be documented.

             (8)             A follow-up appointment with the individual’s preferred provider will be made, and crisis response staff will follow up with the individual and document contact or attempt to contact on a periodic basis until the appointment takes place.

             (9)             There are written policies and procedures of how to document and track discharge locations.

             (10)            The actual number of individuals served within the 23-hour period is documented. Individual treatment records contain reasons why individuals stay beyond the 23-hour period.

             (11)            Readmission data and length of time between admissions are tracked for data trend reports.

            e.                Performance benchmark. Policies and procedures address the additional safety standards for 23-hour crisis and observation services.

            f.                 Performance indicators.

             (1)             Service compliance is documented regarding state fire marshal rules and fire ordinances and applicable local health, fire, occupancy code, and safety regulations.

             (2)             Based on standards used for public facilities, all food and drink is clean, wholesome, free from spoilage, and stored and served in a manner safe for human consumption.

             (3)             Doors must not be locked from the inside. The use of door locks is as approved by the fire marshal and professional staff.

             (4)             Twenty-three-hour observation and holding services have an emergency preparedness plan to describe the process for an individual to continue receiving services during a disaster including, but not limited to, cases of severe weather or fire.

            g.                Performance benchmark. Policies and procedures address the cleanliness of the 23-hour observation and holding service.

            h.                Performance indicators.

             (1)             Services provide a safe, clean, well-ventilated, properly heated environment in good repair and free from vermin.

             (2)             An individual’s resting or sleeping area includes:

            1.      A sturdily constructed bed or comfortable chair.

            2.      A sanitized mattress protected with a clean mattress pad, or sanitized chair.

            3.      Curtains or blinds are on bedroom windows.

            4.      Available clean linen.

            5.      Doors or partitions for privacy.

            6.      Right to privacy is respected.

             (3)             Bathrooms include items necessary for personal hygiene and personal privacy.

            1.      A safe supply of hot and cold running water which is potable.

            2.      Clean towels, electric hand dryers or paper towel dispensers, and an available supply of toilet paper and soap.

            3.      Natural or mechanical ventilation capable of removing odors.

            4.      Tubs or showers have slip-proof surfaces.

            5.      Partitions with doors which provide privacy if a bathroom has multiple toilet stools.

            6.      Toilets, wash basins, and other plumbing or sanitary facilities are maintained in good operating condition.

            7.      Privacy in bathrooms for male and female individuals.

            i.                 Performance benchmark. Personal rights are acknowledged.

            j.                 Performance indicator. The following are allowed:

             (1)             Areas in which an individual may be alone when appropriate.

             (2)             Areas for private conversations with others.

             (3)             Secure space for personal belongings.

             (4)             Personal clothing is allowed in accordance with organization policy.

            k.                Performance benchmark. Policies and procedures address health and safety standards.

            l.                 Performance indicators.

             (1)             An emergency preparedness plan is designed to provide effective utilization of available resources during a disaster event including, but not limited to, cases of severe weather or fire.

             (2)             Services comply with rule 441—24.39(225C).

             (3)             There are written policies on safety.

             (4)             Seclusion is not used.

             (5)             Mechanical or chemical restraints are not used at any time.

             (6)             The smokefree air Act, Iowa Code chapter 142D, is followed.

[ARC 1660C, IAB 10/15/14, effective 12/1/14]