1. (a) General. Any facility used for the primary purpose of providing inpatient diagnostic care and treatment of persons having mental disorders shall be considered a psychiatric hospital and shall conform with 20 CAR §§ 41-101 – 41-181.

2. (b) Personnel.

   1. (1)

      1. (A) The hospital shall furnish, through the use of qualified personnel:

3. (i) Psychological services;

   1. (ii) Social work services;

      1. (iii) Occupational therapy;

         1. (iv) Recreational therapy; and
         2. (v) Psychiatric nursing.
      2. (B) Provisions shall be made for specialty medical requirements, i.e., neurologist, internist, etc.
      3. (C) Each hospital or unit shall have the capability of providing or arranging emergency services twenty-four (24) hours per day, seven (7) days per week.

   2. (2)

      1. (A) A board-certified psychiatrist shall be the medical director.
      2. (B) The medical director shall coordinate the psychiatric services in conjunction with other medical, nursing, therapy, and hospital administration.
   3. (3) The diagnosis, care, and treatment for patients shall be under the direction of a psychiatrist.

   4. (4)

      1. (A) The unit shall have a qualified director of nursing:

         1. (i) With a master’s degree; or
         2. (ii) Qualified by education and experience in the care of individuals with mental illness.
      2. (B) If the director does not meet the qualifications, there shall be regular documented consultation by a qualified registered nurse.
   5. (5) All personnel working within an area of psychiatric patients shall be trained in psychiatric patient care.

   6. (6) Policies and procedures shall be developed specifically for psychiatric services.

      1. (c) Seclusion and restraints.

   7. (1) Seclusion.

      1. (A) Patients shall be placed in seclusion only on the written order of the physician.

      2. (B) Documentation shall reflect:

         1. (i) Time in seclusion;
         2. (ii) Frequency of observation; and
         3. (iii) Frequency of re-evaluation for continued seclusion.

   8. (2) Restraints — Mechanical.

      1. (A) The medical staff shall establish criteria for use.

      2. (B) If locked restraints are used, a designated staff member shall:

         1. (i) Have possession of the key; and
         2. (ii) Keep the patient under constant observation.
      3. (C) A schedule shall be developed for releasing the restraints.

      4. (D) Restraints shall be used only as a last resort for prevention of:

         1. (i) Harm self-inflicted; or
         2. (ii) Harm to others.

   9. (3)

      1. (A) Patients shall be grouped according to:

         1. (i) Age (children, adolescents, and adults);
         2. (ii) Sex; and
         3. (iii) Treatment needs.

      2. (B) Patients with communicable diseases shall be isolated.

         1. (d) Health Information Services. See 20 CAR § 41-113, Health Information Services.

4. (e) Special precautions.

   1. (1) Special precautions shall be taken so medications and controlled substances are not accessible to patients.
   2. (2) Sharp instruments, knives, ice picks, or other objects that could be used for homicidal or suicidal purposes shall not be available to patients.

5. (f) Patient identification.

   1. (1) If the facility does not choose to follow 20 CAR § 41-109, patient identification, they shall take three (3) pictures of the patient at the time of admission.

   2. (2) Pictures shall be attached:

      1. (A) To the medication sheet;
      2. (B) To the face sheet of the patient’s medical record; and
      3. (C) In the dietary department.
6. (g) Physical environment. A psychiatric hospital shall comply with 20 CAR § 41-145, physical environment.

7. (h)

   1. (1) Clinically relevant educational programs shall be conducted on a regularly scheduled basis of not less than twelve (12) per year.

   2. (2) There shall be evidence of:

      1. (A) Program dates;
      2. (B) Attendance; and

      3. (C) Subject matter.

         1. (i) There shall be an ongoing QA/PI program that is specific to patient care.
8. (j) Physical facilities. A psychiatric hospital shall comply with 20 CAR § 41-181, physical facilities — psychiatric hospitals and alcohol/drug abuse inpatient treatment centers.

Codification Notes: “QA/PI” means quality assurance/performance improvement.