Authority: IC 12-21-2-3; IC 12-25-1-2; IC 12-25-1-4

Affected: IC 12-25

Sec. 2. (a) Before an entity may operate as a private mental health institution, the entity must be licensed by the division under this article.

(b) A private mental health institution shall be accredited by an accrediting agency approved by the division.

(c) The following components are required for licensure as a private mental health institution:

1. (1) A governing board.
2. (2) Medical or professional staff organization.
3. (3) A quality assessment and improvement program.
4. (4) Dietetic service.
5. (5) An infection control program.
6. (6) Medical record services.
7. (7) Nursing service.
8. (8) Physical plant, maintenance, and environmental services.
9. (9) Intake and treatment services.
10. (10) Discharge planning services.
11. (11) Pharmacy services.
12. (12) A plan for special procedures.

(d) The private mental health institution shall have a written plan that clearly defines the facility's course of action and arrangements for emergency services.

(e) The facility shall make a verbal report to the division within twenty-four (24) hours of an occurrence of any of the following:

1. (1) The death or kidnapping of a consumer occurring after admission.
2. (2) Any consumer death that occurs while the consumer is in restraint or seclusion.
3. (3) Any death of a consumer that occurs within twenty-four (24) hours after the consumer has been removed from restraint or seclusion.

4. (4) Any death of a consumer known to the facility that occurs within one (1) week after restraint or seclusion where it is reasonable to assume that the use of restraint or placement in seclusion contributed directly or indirectly to that consumer's death. For purposes of this subdivision, "reasonable to assume" includes, but is not limited to, deaths related to:

   1. (A) restrictions of movement for prolonged periods of time;
   2. (B) chest compression;
   3. (C) restriction of breathing; or
   4. (D) asphyxiation.
5. (5) The admission of a child, fourteen (14) years of age or younger, to an adult unit, as prescribed by 440 IAC 1.5-3-9(g) and 440 IAC 1.5-3-9(h).

6. (6) A disruption, exceeding four (4) hours, in the continued safe operation of the facility or in the provision of consumer care, caused by:

   1. (A) internal or external disasters;
   2. (B) strikes by health care workers; or
   3. (C) unscheduled revocation of vital services.
7. (7) Any fire or explosion.

(f) In addition, a facility shall submit a written report, as required in subsection (h), to the division within ten (10) working days of any occurrence listed in subsection (e).

(g) The facility shall also submit a written report, as required in subsection (h), to the division within ten (10) working days of the occurrence of any of the following:

1. (1) A serious injury to a consumer with the actual or potential loss of function or a marked deterioration in a consumer's condition occurring under unanticipated or unexpected circumstances.
2. (2) Chemical poisoning occurring within the facility resulting in actual or potential harm to a consumer.
3. (3) An unexplained loss or theft of a controlled substance.

4. (4) A consumer who:

   1. (A) is missing; or
   2. (B) cannot be located;
5. for more than twenty-four (24) hours.

(h) A written report required under subsection (f) or (g) shall include the following information:

1. (1) An explanation of the circumstances surrounding the incident.
2. (2) Summaries of all findings, conclusions, and recommendations associated with a review of the incident.

3. (3) A summary of actions taken to:

   1. (A) resolve identified problems;
   2. (B) prevent recurrence of the incident; and
   3. (C) improve overall consumer care.

(i) In the event of flood, fire, or other disaster, when significant damage has occurred to the facility, the governing board, or the governing board's designee, or the director shall suspend the use of all, or an affected part, of the facility as may be necessary to ensure the safety and well-being of consumers. The director shall issue a permit to reoccupy the facility, or an affected part thereof, after an inspection and approval for reoccupation of the facility by the:

1. (1) Indiana state department of health; or
2. (2) division of fire and building safety, department of homeland security;

as applicable.

(j) A private mental health institution that has:

1. (1) applied for a license; or
2. (2) been licensed;

shall supply any information reasonably requested by the division. A facility's failure to comply with the division's request may result in revocation or denial of a private mental health institution's license.

(k) As the licensing body, the division may conduct inspections and investigate complaints and incidents in a private mental health institution.

(l) A private mental health institution's license shall be posted in a conspicuous place in an area of the facility open and accessible to consumers and to the public.

(Division of Mental Health and Addiction; 440 IAC 1.5-2-2; filed Oct 11, 2002, 11:26 a.m.: 26 IR 734; filed Aug 11, 2008, 3:40 p.m.: 20080910-IR-440070875FRA; readopted filed Nov 5, 2008, 3:50 p.m.: 20081119- IR-440080742RFA; readopted filed Aug 11, 2014, 11:21 a.m.: 20140910-IR-440140240RFA; readopted filed Nov 9, 2020, 3:09 p.m.: 20201209-IR-440200502RFA)