Rule 111-8-2-.08. Admission and Discharge, Care, and Services

1. (1) Admission Criteria.

   1. (a) Mental Illness. In order to be admitted to a program, a client must meet the definition of a mentally ill person. Mentally ill persons applying for admission and thereafter receiving services from a program are referred to within these rules and regulations as "clients," or "clients receiving services" or similar designation.
   2. (b) Referral Required. Clients may be admitted to a program only by referral from an inpatient psychiatric hospital that is discharging a patient to a program or following a determination by a licensed psychiatrist that admission is required to provide stabilization, treatment, and care of the condition for which an inpatient admission to a psychiatric hospital is not required.
   3. (c) Length of Stay. Length of stay shall be redetermined on a periodic basis through a mental health evaluation to include treatment goals and progress from the initial admission. Such mental health evaluation shall determine medical necessity for continued stay in the program with a maximum length of stay of six (6) months unless a client case waiver is approved by the department.

2. (2) Admission Agreement. Each ARMHP must utilize a written admission agreement signed by an individual with authority to bind the program and the client receiving services. The admission agreement must meet the following minimum requirements:

   1. (a) The admission agreement is written in plain and understandable language and is consistent with the information contained in the client's clinical record.
   2. (b) Contain a current statement of all fees and daily, weekly or monthly charges; the services covered by those basic fees and any other services which the program provides on an additional fee basis.
   3. (c) Contain a statement that clients and their representatives or legal surrogates shall be informed, in writing, at least 30 days prior to any increase in established charges related to the provision of personal services and at least 60 days prior to any increase in charges for room and board.
   4. (d) Contain provisions regarding the administrator's continuous assessment of the client's needs, referral for appropriate services as may be required if the client's condition changes and referral for transfer or discharge if required due to a change in the client's condition.
   5. (e) Contain a description of how the program responds to formal complaints received from clients and their representatives and how to file a complaint within the program.
   6. (f) Contain provisions regarding transportation of clients for shopping, recreation, rehabilitation, medical services. Such transportation service may be provided by the program as either a basic service or on a reimbursement basis, with transportation for emergency use available at all times.
   7. (g) Contain provisions regarding the program's refund policy when a client dies, is transferred or discharged.
   8. (h) Contain a statement that a client may not be required to perform services for the program.
   9. (i) Contain the program policies and procedures for clients receiving treatment.
   10. (j) Contain disclosures of how and by what level of staff medications are handled in the program. The agreement must also specify who is responsible for initial acquisition and refilling of prescribed medications utilizing unit or multidose packaging for the client. Either this responsibility will remain with the client, representative or legal surrogate, if any, or be assigned to the program operating through the administrator.
   11. (k) The program must provide each client, representative or legal surrogate with an opportunity to read the complete agreement prior to the execution of the admissions agreement. In the event that a client, representative or legal surrogate is unable to read the agreement, the administrator or a manager must take steps to assure communication of the contents of the admission agreement to be signed. Each client, representative, or legal surrogate must be given an opportunity to ask questions prior to signing the admission agreement. The administrator or a manager must be present prior to execution to answer any questions regarding the admissions agreement.
   12. (l) The program must provide the client and representative or legal surrogate, if any, with a signed copy of the agreement. A copy signed by both parties (client and administrator or on-site manager) must be retained in the client's file and maintained by the administrator of the program.
   13. (m) The program must not use a written admission agreement, or any other written agreement signed by the client or the client's legal representative, which waives or attempts to waive any of the client's rights these rules protect. Any such provision of an admission agreement purporting to waive these rules is void.
3. (3) Nursing Assessment and Physical Examination. All clients shall be given a nursing assessment and physical examination as soon as possible but no more than 48 hours after admission to a program. The physical examination shall include a complete medical history and documentation of significant medical problems. It must contain specific descriptive terms and not the phrase, "within normal limits," or similar statement. If the client received a physical examination at an inpatient psychiatric hospital or from a psychiatrist within 72 hours prior to admission to the program, no further physical examination will be necessary unless clinically indicated or if the physical examination does not meet the requirements of this section. General findings must be written in the client's clinical record within 48 hours.

4. (4) Emotional and Behavioral Assessment. Upon admission to a program and on a monthly basis thereafter, an emotional and behavioral assessment shall be completed and entered into the client's clinical record. The assessment shall be made by a mental health professional. If the client received an assessment at a crisis stabilization unit or an inpatient acute care or psychiatric hospital prior to discharge to the program, another assessment is not required unless clinically indicated, the assessment does not meet the requirements of this section, or the assessment occurred more than 7 days prior to admission to the program. The assessment shall include the following:

   1. (a) A history of previous emotional, behavioral, and substance abuse problems and treatment.
   2. (b) An initial social assessment shall be completed upon a client's admission which must include a determination of the need for participation of family members or significant others in the client's treatment; the social, peer group, and environmental setting from which the client comes; family circumstances; current living situation; employment history; social, ethnic, cultural factors; and childhood history. Additionally, a comprehensive assessment shall be conducted within thirty days of admission by a licensed or certified staff member and reviewed by the program's multidisciplinary team and signed by a licensed or certified supervisor.
   3. (c) A direct psychiatric evaluation of each client shall be completed by a physician or psychiatrist upon admission to include a mental status examination which includes detailed behavioral descriptions, including symptoms (not summary conclusions), and concise evaluation of cognitive functioning. A diagnosis, made by the physician or psychiatrist in accordance with the current edition of the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders shall be recorded in the client's clinical record.
   4. (d) Specifications of the behaviors that will be demonstrated in order for the client to return to a less restrictive setting and recommended intervention strategies.
   5. (e) When indicated, the assessment shall also include intellectual, projective, and personality testing, and other functional evaluations of language, self-care, and social-affective and visual-motor functioning.
   6. (f) A determination of medical necessity for continued stay in the program and treatment goals and progression.

5. (5) Medical Care.

   1. (a) The program shall adopt medical care policies and procedures regarding medical care applicable to all types of mental health professionals at the program which have been approved by the medical director. The policies and procedures for medical care shall include the procedures that may be initiated by a registered nurse in order to alleviate a life-threatening situation. Medication or medical treatment shall be administered by a mental health professional with appropriate authorization and qualification, and orders for medications and treatments shall be written and signed by the physician or psychiatrist.
   2. (b) There shall be no standing orders for any medication used primarily for the treatment of mental illness.
   3. (c) All oral orders shall be received and recorded immediately only by a nurse with the physician's or psychiatrist's name and signed by the physician or psychiatrist within 24 hours. Such orders shall include a progress note that an order was made orally, the content of the order, justification, time, date and completion of medication reconciliation.
   4. (d) Upon admission and as additional medication or treatment is prescribed or discontinued, the nurse, physician, psychiatrist, or other qualified staff member shall reconcile the client's medication.
6. (6) Treatment Plans. The program shall work with the client to develop a treatment plan which has objectives and action steps written for the client in behavioral terms. The objectives shall be related directly to one or more goals in the client's treatment plan. The treatment plan shall be initiated with documented input from the client receiving services and signed by the responsible physician or psychiatrist or other mental health professional privileged by policies and procedures within 48 hours of admission. The treatment plan shall be fully developed within 10 days of admission and must contain short-term treatment objectives stated in behavioral terms, relative to the long-term view and goals in the treatment plan, and a description of the type and frequency of services to be provided in relation to treatment objectives. The plan shall be reviewed with the client and updated at least every 30 days. A copy of the plan shall be signed by and provided to the client. A new aftercare plan shall be developed with and shared with the client prior to discharge from the program.
7. (7) Previous Record. For clients who enter the program following discharge from an inpatient psychiatric hospital, the previously completed intake interview, physical examination, medication log, progress notes, discharge or aftercare plan, and forms required for admission to the program attended by the client shall be made a part of the program clinical record.

8. (8) Required ARMHP Services.

   1. (a) Services. Each ARMHP shall provide the following services on a 24-hour-a-day, 7-day-a-week basis:

      1. 1. Twenty-four hour per day supervision;
      2. 2. Client, group, and family counseling services directed toward alleviating the symptomatic behavior which required admission to a program;
      3. 3. Medical and psychiatric treatment provided by a licensed physician or psychiatrist;
      4. 4. Social and recreational activities, inside and outside the context of the program;
      5. 5. Referral arrangements with crisis stabilization units, other psychiatric treatment facilities, and hospital emergency services, which include but are not limited to, a written process and adequate staff to facilitate transfer of a client to such facilities and referral to less restrictive, nonresidential treatment services, when appropriate, and
      6. 6. Provision of or access to transportation in order to accomplish emergent and non-emergent transfers and to meet the service needs of clients served.
   2. (b) Optional Services. A program may provide therapeutic modalities and complementary services beneficial to the treatment of and supports for adult mentally ill persons, as determined by the Medical Director. Notwithstanding the foregoing, such services may only be provided to a client upon the express written consent of the client or legal surrogate.
   3. (c) Routine Activities. Basic routine activities for clients admitted to a program shall be delineated in program policies and procedures which shall be available to all staff. The daily activities shall be planned to provide a consistent, well structured, yet flexible, framework for daily living and shall be periodically reviewed and revised as the needs of clients or the group change. Basic daily routine shall be coordinated with special requirements of each treatment plan. A schedule of daily activities shall be posted or otherwise available to all clients receiving services.

   4. (d) Laboratory Services.

      1. (1) Requirement. Every ARMHP shall provide or contract for certified laboratory services commensurate with the client's needs.

         1. (i) Emergency. Provision shall be made for the availability of emergency licensed laboratory services on a 24-hour-a-day, 7-day-a-week basis including holidays.
         2. (ii) Orders. All laboratory tests and services shall be ordered by a mental health professional pursuant to authority granted by his or her scope of license.
         3. (ii) Record. All laboratory reports shall be filed in the client's clinical record.
         4. (iii) Specimens. Each ARMHP shall have written policies and procedures governing the collection, preservation, and transportation of specimens to ensure adequate stability of specimens.
      2. (2) Contracts. Where the program depends on an outside laboratory for services, there shall be a written contract detailing the conditions, procedures, and availability of work performed. The contract shall be reviewed and approved by the program director or administrator.

   5. (e) Discharge and Continuity of Care.

      1. (1) Discharge Preparation. Prior to discharge from the program, the staff shall work with the client and, with the client's written consent, shall work with the client's support system including family, friends, employers, and case manager, as appropriate, to ensure that all efforts are made to prepare the client for returning to a less restrictive setting.
      2. (2) Referral Services. All ARMHP facilities shall develop and maintain written referral agreements with licensed general or psychiatric hospitals. Such agreements shall ensure that referred clients are admitted as soon as necessary.
      3. (3) Discharge Summary. The discharge summary shall include the initial formulation and diagnosis, clinical summary, final formulation, and final primary and secondary diagnoses, the psychiatric and physical categories. The final formulation shall reflect the general observations and understanding of the client's condition initially, during appraisal of the fundamental needs of the client. All relevant discharge diagnoses should be recorded and coded in the standard nomenclature of the current "Diagnostic and Statistical Manual of Mental Disorders," published by the American Psychiatric Association, and the latest edition of the "International Classification of Diseases," regardless of the use of other additional classification systems. Records of discharged clients shall be completed following discharge within a reasonable length of time, and not to exceed fifteen (15) days. In the event of death, a summation statement shall be added to the record either as a final progress note or as a separate statement. This final note shall take the form of a discharge summary and shall include circumstances leading to death. All discharge summaries must be signed by a physician who treated the client.

Authority: O.C.G.A. §§ 37-3-204, 37-3-205, 31-2-4, 31-2-7, 31-2-8, 31-7-2.1.

History. Original Rule entitled "Admission and Discharge, Care, and Services" adopted. F. Dec. 10, 2024; eff. Dec. 30, 2024.