Fla. Admin. Code R. 65E-12.106
(1) Advisory or Governing Board. The CSU or SRT shall have either a formally constituted advisory or governing board for the CSU or SRT or operate under a provider board which has ultimate authority for establishing policy and overseeing the operation of the CSU or SRT. The board shall operate under a mission statement and a set of bylaws governing its operation.
(2) Personnel Policies. Personnel policies shall be made available in writing to all personnel. Policies shall include rules governing the ethical conduct of staff and volunteers, rights and confidentiality of information regarding individuals receiving services.
(b) Personnel Records. Records on all employees and volunteers shall be maintained by the CSU or SRT. Each employee record, available for employee review shall contain:
1. The employee’s current job description with minimum qualifications for the position;
2. The employment application or resume with evidence that references were checked prior to employment;
3. The employee’s annual evaluations;
4. A copy of the employee’s professional license, if applicable;
5. A receipt indicating that the employee has been trained and understands program policies and procedures, patient rights as stated in Section 394.459, F.S., ethical conduct, and confidentiality of information regarding individuals receiving services;
6. Documentation that the employee has been trained and understands the legal mandate under Section 415.103, F.S., to report suspected abuse and neglect as well as the use of the Florida Abuse Hotline; and,
7. Documentation that the employee or volunteer has been fingerprinted and screened, if appropriate, in accordance with Section 394.4572, F.S.
8. Documentation of training as required by Section 381.0035, F.S., for all non-licensed staff.
(c) Fingerprint Screening. All personnel, as defined in Section 394.4572, F.S. shall be screened in accordance with Sections 394.4572 and 408.809, F.S. Each CSU and SRT shall maintain fingerprint screening records as follows:
1. A current list which identifies, by position title, all positions which require fingerprint screening.
2. A continuously updated record of all active personnel which identifies for each person his position title, date of hire, and the date of the most recent fingerprint screening.
(5) Confidentiality and Clinical Records. Every CSU and SRT shall maintain a record on each individual receiving services, assuring that records and identifying information are maintained in a confidential manner, and securing valid lawful consent prior to the release of information in accordance with Section 394.4615, F.S. Clinical records may be stored on paper, magnetic material, film, or other media, including electronic storage. All staff shall receive training as part of staff orientation, with at least a triennial update on file, regarding the effective maintenance of confidentiality of clinical records, including electronic records. It shall be emphasized that confidentiality includes oral discussions regarding individuals receiving services inside and outside the CSU or SRT and shall be discussed as part of employee training.
(c) Content of Clinical Records. The required signature of treatment personnel shall be original as opposed to the facsimile. The required signature of treatment personnel shall be original as opposed to the facsimile. Policies and procedures shall require the clinical record to clearly document the extent of progress toward short-term objectives and long-term view. Clinical record documentation for each order or treatment decision shall include its respective basis or justification, actions taken, description of behaviors or response, and staff evaluation of the impact of the treatment on the individual’s progress. Clinical records shall contain:
1. The name and address of the individual receiving services;
2. Name, address, and telephone number of guardian, representatives, or others as specified by the individual receiving services;
3. The source of referral and relevant referral information;
4. Intake interview and initial physical assessment;
5. The signed and dated informed consent for treatment as mandated under Sections 394.459(3) and 394.4615, F.S.;
6. Documentation of orientation to program and program rules;
7. The medical history and physical examination report with diagnosis;
8. The report of the mental status examination and psychosocial, psychological, nursing, rehabilitation, nutritional, and mental health assessments as appropriate;
9. The original service plan developed, dated and signed by the individual receiving services and treatment staff. The plan shall contain short-term treatment objectives that relate to crisis stabilization and the description and frequency of services to be provided;
10. The signed and dated service plan reassessments and reviews;
11. Examination, diagnosis and progress notes by physician, psychiatric nurses, treatment staff and other mental health professionals that relate to the service plan objectives;
12. Laboratory and radiology results, if applicable;
13. Documentation of seclusion or restraint observations, if utilized;
14. A record of all contacts with medical and other services;
15. A record of medical treatment and administration of medication, if administered;
16. An original or original copy of all physician or psychiatric nurse medication and treatment orders;
17. Signed consent for the release of information, if information is released;
18. An individualized discharge plan;
19. Forms CF-MH 3042a, CF-MH 3042b, and CF-MH 3084, as appropriate;
20. A current, originally authorized CF-MH 3084, Feb 2005, “Baker Act Service Eligibility,” which is incorporated herein by reference for all individuals receiving services and available at HYPERLINK "http://www.flrules.org/Gateway/reference.asp?No=Ref-08945" http://www.flrules.org/Gateway/reference.asp?No=Ref-08945 and from the department’s website at https://eds.myflfamilies.com/DCFFormsInternet/Search/DCFFormSearch.aspx; and,
21. If the individual receiving services has a community case manager, documentation of contacts between the community case manager and CSU or SRT staff and the person receiving service.
(7) Admission and Discharge Criteria. Each CSU and SRT shall develop and utilize policies and procedures pursuant to Chapter 394, F.S., for the intake, screening, admission, referral, disposition, and notification of the individual or their guardians, representatives, or others as specified by the individual seeking treatment. There shall be adequate intake procedures to ensure that individuals being received from an emergency room, agency, facility, or other referral source shall have all the required paperwork and documentation for admission. If an individual has a case manager, the case manager shall be notified and shall provide appropriate information and participate in the development of the discharge plan. Individuals receiving services, guardians, or others as specified by the individual receiving services shall be informed of their eligibility or ineligibility status for publicly funded CSU or SRT services, either at admission or shortly thereafter.
(8) Protection of Individuals Receiving Services. Unless abridged by a court of law, the rights of individuals who are admitted to CSU and SRT programs shall be assured as mandated under Chapter 394, Part I, F.S., and Chapter 65E-5, F.A.C. Each CSU and SRT shall be operated in a manner that protects the individual’s rights, life, and physical safety while receiving evaluation and treatment. In addition to all rights granted under Chapter 394, Part I, F.S., individuals receiving services shall be:
(b) Assured that any search or seizure is carried out in a manner consistent with program policies and procedures to ensure safety and security and is consistent with therapeutic practices.
1. Searches and Seizures. Whenever there is a reason to believe that the security of a facility or the health of anyone is endangered or that contraband or objects which are illegal to possess are present on the premises, a search of an individual’s room, locker, or possessions shall be conducted if authorized by the program director or designee, as defined in program policies and procedures.
2. Presence of Individual. Whenever feasible, the individual receiving services shall be present during a search.
3. Absence of Individual. When it is impossible for the individual to be physically present during the search, they shall be given prompt written notice of the search and of any article confiscated.
4. Documentation. Written reports of all searches shall be documented in the individual’s clinical record. A written inventory of items confiscated shall be forwarded to the program director or designee.
(9) Quality Assurance Program. Every CSU and SRT shall comply with the requirements of Section 394.907, F.S.
(a) Inclusions. Every CSU and SRT shall have, or be an active part of, an established multidisciplinary quality assurance program and develop a written plan which addresses the minimum guidelines to ensure a comprehensive integrated review of all programs, practices, and facility services, including the following: facilities safety and maintenance; care and treatment practices; resource utilization review; peer review; infection control; records review; maintenance of clinical records; pharmaceutical review; professional and clinical practices; curriculum, training and staff development; and incidents with appropriate policies and procedures. The quality assurance program must include:
1. Composition of quality assurance review committees and subcommittees, purpose, scope, and objectives of the quality assurance committee and each subcommittee, frequency of meetings, minutes of meetings, and documentation of meetings;
2. Procedures to ensure selection of both difficult and randomly selected cases for review;
3. Procedures to be followed in reviewing cases and incident reports;
4. Criteria and standards used in the review process and procedures for their development;
5. Procedures to be followed to assure dissemination of the results and verification of corrective action;
6. Tracking capability of incident reports, pertinent issues and actions; and,
7. Procedures for measuring and documenting progress and outcome of individuals receiving services.
(b) Process. The quality assurance program shall conduct two separate complementary review processes on a monthly basis to include peer review and utilization review. The effects of the peer and utilization reviews shall ensure the following.
1. The admission is necessary and appropriate.
2. The services are the least restrictive means of intervention.
3. Rights are being protected.
4. Family or significant others are involved in the treatment and discharge planning process as much as feasible with the consent of the individual receiving services.
5. The service plan is comprehensive, relative to the full range of the needs of the individual receiving services at the CSU or SRT.
6. Minimal standards for clinical records and consent to treatment are being met as required by subsections 65E-12.106(5) and (6), F.A.C., of this rule.
7. Medication is prescribed and administered appropriately. All medication errors shall be reported under the CSU or SRT’s incident reporting system and subject to internal review by the quality assurance program.
8. There has been appropriate handling of medical emergencies.
9. Special treatment procedures, for example, seclusion and restraints, emergency treatment orders, and medical emergencies, are conducted according to facility policy.
10. High risk situations and special cases are reviewed within 24 hours. These shall include suicide attempts, death, serious injury, violence, sexual assaults, and abuse of any individual.
11. All incident reports are reviewed by the facility director within 3 working days.
12. The length of stay is supported by clinical documentation.
13. Supportive services are ordered and obtained as needed.
14. Continuity of care is provided through care coordination activities.
15. Delay in receiving services is minimal.
(10) Critical Incident Reporting.
(b) Every CSU and SRT shall report critical events within one (1) business day of the incident occurring.
(VII) Unknown. The manner of death was not identified or made known.
2. Child Arrest. The arrest of a child.
3. Child Death. An individual who is less than 18 years of age whose life terminates:
a. While receiving services, or
b. When it is known that a child died within 30 days of discharge from a CSU or SRT;
c. The final classification of a child’s death is determined by the medical examiner. In the interim, the manner of death will be reported as one of the following:
(VII) Unknown. The manner of death was not identified or made known.
4. Child-on-Child Sexual Abuse. Any sexual behavior between children less than 18 years of age which occurs without consent, without equality, or because of coercion.
5. Elopement. An unauthorized absence of any individual.
6. Employee Arrest. The arrest of an employee for a civil or criminal offense.
7. Employee Misconduct. Work-related conduct or activity of an employee that results in potential liability for the Department or the Agency for Health Care Administration (Agency); death or harm to an individual receiving services; abuse, neglect or exploitation of an individual receiving services; or which results in a violation of statute, rule, regulation, or policy. This includes falsification of records; failure to report suspected abuse or neglect; contract mismanagement; or improper commitment or expenditure of state funds.
8. Missing Child. When the whereabouts of a child in the custody of the Department are unknown and attempts to locate the child have been unsuccessful.
9. Security Incident – Unintentional. An unintentional action or event that results in compromised data confidentiality, a danger to the physical safety of personnel, property, or technology resources; misuse of state property or technology resources; or, denial of use of property or technology resources. This excludes instances of compromised information of individuals in treatment.
10. Sexual Abuse/Sexual Battery. Any unsolicited or non-consensual sexual activity by one individual receiving services to another individual receiving services; or, sexual activity by a service provider employee or other person to an individual receiving services, or an individual receiving services to an employee regardless of the consent of the individual receiving services. This may include sexual battery, as defined in Chapter 794, F.S.
11. Significant Injury to Individuals in Treatment. Any severe bodily trauma received by an individual in a CSU or SRT that requires immediate medical or surgical evaluation or treatment in a hospital emergency department to address and prevent permanent damage or loss of life.
12. Significant Injury to Staff. Any serious bodily trauma received by a staff member as result of a work-related activity that requires immediate medical or surgical evaluation or treatment in a hospital emergency department to prevent permanent damage or loss of life.
13. Suicide Attempt. A potentially lethal act which reflects an attempt by an individual to cause his or her own death as determined by a licensed mental health professional or other licensed healthcare professional.
14. Other. Any major event not previously identified as a reportable critical incident but has, or is likely to have, a significant impact on individuals receiving services, on the Department, or on the Agency, such as:
a. Human acts that jeopardize the health, safety, or welfare of individuals receiving services, such as kidnapping, riot, or hostage situation;
b. Bomb or biological/chemical threat of harm to personnel or property involving an explosive device or biological/chemical agent received in person, by telephone, in writing, via mail, electronically, or otherwise;
c. Theft, vandalism, damage, fire, sabotage, or destruction of state or private property of significant value or importance;
d. Death of an employee or visitor while on the grounds of the CSU or SRT;
e. Significant injury of a visitor while on the grounds of the CSU or SRT that requires immediate medical or surgical evaluation or treatment in a hospital emergency department to prevent permanent damage or loss of life, or
f. Events regarding individuals receiving services or providers that have led to or may lead to media reports.
1. Adult Death. An individual 18 years old or older whose life terminates:
a. While receiving services, or
b. When it is known that an adult died within thirty (30) days of discharge from a CSU or SRT.
c. The final classification of an adult’s death is determined by the medical examiner. In the interim, the manner of death shall be reported as one of the following:
(c) Seclusion and Restraint Event Reporting.
All public and private designated Baker Act receiving facilities and all SRTs shall develop policies and procedures for reporting seclusion and restraint events into the statewide designated electronic system specific to seclusion and restraints.
(12) Health and Safety.
(a) Disaster Preparedness.
(XI) Provision for annual review and revision of the fire safety manual and plan.
b. The plan shall be made available to all facility staff and posted in appropriate areas within the facility.
c. There shall be records indicating the nature of disaster training and orientation programs offered to staff.
1. Each CSU and SRT shall have, or operate under, a safety committee with a safety director or officer who is familiar with the applicable local, state, federal and National Fire Protection Association safety standards. The committee’s functions may be performed by an already existing committee with related interests and responsibilities.
2. Each CSU and SRT shall have, or be a part of, a written internal and external disaster plan, developed with the assistance of qualified fire, safety and other experts.
a. The plan and fire safety manual shall identify the availability of fire protection services and provide for the following:
(d) Health and Sanitation.
1. Appropriate health and sanitation inspections shall be obtained before occupying any new physical facility or addition. A report of the most recent inspections must be on file and accessible to authorized individuals.
2. Hot and cold running water under pressure shall be readily available in all washing, bathing and food preparation areas. Hot water in areas used by individuals being served shall be at least 100 degrees Fahrenheit but not exceed 120 degrees Fahrenheit.
3. Garbage, Trash and Rubbish Disposal.
a. All garbage, trash, and rubbish from residential areas shall be collected daily and taken to storage facilities. Garbage shall be removed from storage facilities frequently enough to prevent a potential health hazard or at least twice per week. Wet garbage shall be collected and stored in impervious, leak proof, fly tight containers pending disposal. All containers, storage areas and surrounding premises shall be kept clean and free of vermin.
b. If public or contract garbage collection service is available, the facility shall subscribe to these services unless the volume makes on-site disposal feasible. If garbage and trash are disposed of on premises, the method of disposal shall not create sanitary nuisance conditions. Facilities must comply with the Florida Department of Health’s garbage, trash, and rubbish disposal requirements, as stated in Chapter 62-701, F.A.C.
(13) Food Services.
(14) Housekeeping and Maintenance. Every CSU and SRT shall have housekeeping and maintenance standards which meet the following criteria:
(17) Pharmaceutical Services.
(18) Emergency Medical Services. Every CSU or SRT shall have written policies and procedures for handling medical emergency cases which may arise subsequent to an individual’s admission. All staff shall be familiar with the policies and procedures.
(a) Emergency Treatment Orders. Policies and procedures shall be written to address the use of emergency treatment orders as specified in Section 394.459, F.S., and Chapter 65E-5, F.A.C. They shall address the following:
1. Emergency treatment orders shall be initiated only upon direct order of a physician or psychiatrist;
2. The clinical justification shall be documented in the clinical record; and,
3. The use of standing, pro re nata (PRN), or routine orders for emergency treatment orders is prohibited.
(19) Protection of Individuals Receiving Services.
(b) Control of potentially injurious items.
1. Policies and procedures shall prohibit the transmittal onto or carrying onto the unit sharps, flammables, toxins, weapons, caustic chemicals, rope, or other items potentially injurious to individuals on the unit.
2. Therapeutic activity materials shall also exclude similarly potentially hazardous items such as bats, paddles, mallets, knives, ropes, cords, wire clothes hangers, wire, sharp pointed scissors, luggage straps, and sticks.
3. Housekeeping supplies and chemicals shall, whenever practical, be non-toxic or non-caustic. The unit shall implement procedures to avoid access by individuals receiving services during use or storage.
4. Nursing and medical supplies including drugs, sharps, and breakables shall be safeguarded from access by individuals receiving services through storage, use, and disposal processes.
(d) Suicide Precaution.
1. Suicide precaution is for the protection of individuals who have been assessed to be potentially suicidal and require a higher level of supervision.
2. The modification or removal of suicide precautions shall require clinical justification determined by an assessment and shall be specified by the attending physician or psychiatric nurse and documented in the clinical record. A registered nurse, clinical psychologist or other mental health professional may initiate suicide precautions prior to obtaining a psychiaric nurse’s, physician’s or psychiatrist’s order, but in all instances must obtain an order within 1 hour of initiating the precautions. Telephone orders shall be reviewed and signed by a psychiatric nurse or physician within 24 hours of their initiation.
3. Each CSU shall develop policies and procedures for implementing suicide precautions addressing: assessment, staffing, levels of observation and documentation. Policies and procedures shall require constant visual observation of individuals clinically determined to be actively suicidal.
(20) Nursing Services.
(23) Collocation.
(24) Passes.
Rulemaking Authority 394.457, 394.46715, 394.879(1), 394.907(8) FS. Law Implemented 394.455, 394.457, 394.4572, 394.459, 394.4615, 394.463, 394.77, 394.875, 394.879, 394.907 FS. History–New 2-27-86, Amended 7-14-92, Formerly 10E-12.106, Amended 9-1-98, 10-4-00, 4-8-18.