Wyo. Code R. 048-0026-15
Effective Date: 06/18/1999 to Current
Rule Type: Current Rules & Regulations
Reference Number: 048.0026.15.06181999
FOR LICENSURE OF PSYCHIATRIC HOSPITALS
Section 1. Authority. These rules are promulgated by the Department of Health pursuant to the Health Facilities Act at W.S. §35-2-901 et seq. and the Wyoming Administrative Procedures Act at W.S. §16-3-101 et seq.
Section 2. Purpose. These rules have been adopted to protect the health, safety and welfare of patients and employees in Psychiatric Hospitals.
Section 3. Severability. If any portion of these rules is found to be invalid or unenforceable, the remainder shall continue in effect.
Section 4. Definitions.
The following definitions shall apply in the interpretation and enforcement of these rules. Where the context in which words are used in these rules indicates that such is the intent, words in the singular number shall include the plural and visa versa. Throughout these rules gender pronouns are used interchangeable. The drafters have attempted to utilize each gender pronoun in equal numbers, in random distribution. Words in each gender shall include individuals of the other gender.
For purpose of these rules, the following shall apply:
(a) "Acceptable Plan of Correction" means the Licensing Division approved the Psychiatric Hospital's plan to correct the deficiencies identified during an on-site survey conducted by the Survey Division or its designated representative. The plan of correction shall be a written document and shall provide, but not be limited to, the following information:
(iv) An appropriate date, not to exceed sixty (60) days after the last day of survey, for the correction of deficiencies.
(b) "Certified Occupational Therapy Assistant" means a person licensed to assist in the practice of occupational therapy, and who works under the supervision of a registered occupational therapist pursuant to W.S. §33-40-102.
(c) “Clinical Director” means a physician who is licensed by the Wyoming Board of Medicine to practice medicine in Wyoming. The clinical director shall meet the training and other requirements for examination by the American Board of Psychiatry and Neurology or the American Osteopathic Board of Neurology and Psychiatry.
(d) “Clinical Laboratory” means a facility for the microbiological, serological, chemical, hematological, immunohematological, cytological or pathological examination of materials derived from a human body for the purpose of obtaining information for the diagnosis, prevention or treatment of disease or assessment of medical conditions.
(e) “Complaint Investigations” means those investigations required to be performed by the Licensing Division.
(f) “Dietitian” means a person who is registered by the American Dietetic Association and provides nutritional and dietary services.
(g) “Dietetic Manager/Supervisor” means an individual who has at a minimum a high school education or equivalent and has completed courses in food service supervision, but is not a registered dietitian.
(h) “Director of Psychiatric Nursing Services” shall be a registered nurse who has a master’s degree in psychiatric or mental health nursing, or its equivalent from a school of nursing accredited by the National League for Nursing, or be qualified by education and experience in the care of the mentally ill.
(i) “Drug Administration” means an act in which a single dose of an identified drug is given to a patient.
(j) “Drug Dispensing” means the issuance of one or more doses of a prescribed medication in containers that are correctly labeled to indicate the name of the patient, the contents of the containers, and all other vital information needed to facilitate correct patient usage and drug administration.
“Facility” means a Psychiatric Hospital.
(l) “Governing Body” means the individual(s), group or corporation that is legally responsible for the Psychiatric Hospital.
(m) “Health Care Services” includes but is not limited to nursing, physical therapy, speech therapy, occupational therapy, respiratory therapy, social services, nurse assistant, and dietary services. Staff shall be licensed or registered in accordance with Wyoming State Statutes.
(n) “Hospital” means an institution or a unit in an institution providing one (1) or more of the following to patients by or under the supervision of an organized medical staff.
(i) Diagnostic and therapeutic services for medical diagnosis, treatment and care of injured, disabled or sick persons;
(ii) Rehabilitation services for the rehabilitation of injured, disabled or sick persons;
(iii) Acute care;
(iv) Psychiatric care;
(vi) Swing beds.
(o) “Laboratory Director” means a person who is qualified by CLIA (federal) and state standards (e.g.; pathologist, medical doctor, or PhD, MS, BS degrees).
(p) “License” means the authority granted by the Licensing Division to operate a Psychiatric Hospital.
(q) “Licensee” means any person, association, partnership, or corporation holding a Psychiatric Hospital license.
(r) “Licensing Division” means the Department of Health, Office of Health Quality.
(s) “Licensed Practical Nurse (LPN)” means a person who is licensed to practice as a licensed practical nurse by the Wyoming Board of Nursing pursuant to W.S. §33-21-120.
(t) “LSC” means NFPA 101 Life Safety Code cited in the Department of Health, Chapter III Construction Rules for Health Facilities.
(u) “Medical Record Administrator” means Accredited Record Technician (A.R.T.) who has passed the appropriate accreditation examination conducted by the American Medical Record Association, or who has the equivalent of such education and training.
(v) “Medical Technologist” means a person who is a graduate of a program in medical technology approved by the Council on Medical Education of the American Medical Association, or has the equivalent of such education and training.
(w) “NEC” means the National Electric Code.
(x) “NFPA” means the National Fire Protection Association.
(y) “Nursing Service” means patient care services pertaining to the curative, restorative, and preventive aspects of nursing that are performed and/or supervised by a registered nurse pursuant to the psychiatric care plan of the practitioner and the nursing care plan.
(z) “Occupational Therapist” means a person who is licensed by the Wyoming Board of Occupational Therapy to practice as a Registered Occupational Therapist pursuant to W.S. §33-40-102.
(aa) “Pharmacist” means a person licensed as a Pharmacist in Wyoming.
(bb) “Physical Therapy Assistant” means a person who is licensed by the Wyoming Board of Physical Therapy to practice as a physical therapy assistant under the supervision of a registered Physical Therapist pursuant to §33-25-101.
(cc) “Physical Therapy Services” means services provided by a physical therapist or a physical therapy assistant licensed pursuant to W.S. §33-25-101.
(dd) “Physical Therapist” means a person who is licensed to practice physical therapy in the State of Wyoming pursuant to W.S. §33-25-101.
(ee) “Physician” means a person who is licensed by the Wyoming Board of Medicine to practice medicine in Wyoming.
(ff) “Quality Management Program” means a program developed and implemented by a Psychiatric Hospital to evaluate and improve patient care and services.
(gg) “Registered Nurse” means a person who is a graduate of an approved school of professional nursing, and who is currently licensed to practice as a registered nurse by the Wyoming Board of Nursing pursuant to W.S. §33-21-120.
(hh) “Speech Language Pathologist” means a person who is licensed in the State of Wyoming to practice speech language pathology.
(ii) “Speech Pathology” means the application of principles, methods, and procedures for the evaluation, monitoring, instruction, habilitation, or rehabilitation related to the development and disorders of speech, voice, or language for preventing, identifying, evaluating and reducing the effects of such disorders and conditions.
(jj) “Survey” means a periodic on-site evaluation conducted by the Survey Division or its designated representative to determine compliance with State Licensure Rules and Regulations for Psychiatric Hospitals.
(kk) “Survey Division” means the Department of Health, Office of Health Quality or its designated representative.
(ll) “Therapy Service” means physical therapy, occupational therapy, and speech language therapy.
Section 5. Licensure. Applicants must demonstrate full compliance with paragraphs (a) and (b) of this section.
(i) For an initial license to be issued, the Licensing Division shall receive:
(A) A completed application form as supplied by the Licensing Division.
(B) Each completed application shall be accompanied by the required licensure fee identified in Chapter 1, Rules and Regulations for Health Care Facilities Licensure Fees. The check or money order shall be made payable to the Treasurer, State of Wyoming.
(C) Applicant shall demonstrate full compliance with the licensure requirements in paragraph (b) of this section.
(ii) For renewal of a full license for one year beginning July 1st, and unless suspended or revoked, expiring on June 30th of the following year, the Licensing Division shall receive:
(A) A completed application form by the date stated in the application cover letter supplied by the Licensing Division; and
(B) The license fee as required in paragraph (a) (i) (B) of this section.
(i) Initial and annual renewal licensure survey deficiencies cited by the Survey Division;
(ii) Life Safety Code deficiencies cited by the Survey Division;
(iii) Complaint investigations and resolutions;
(iv) Compliance with all laws and standards relating to communicable and reportable diseases as required by the Department of Health, State Health Officer and Public Health Division; and
(v) The effectiveness of the quality management program to evaluate and improve patient care and services.
(c) Transfer of license.
(i) No license granted shall be assigned or transferred by the licensee without prior approval of the Licensing Division.
(A) Requests to assign or transfer a Psychiatric Hospital license shall be submitted in writing by the licensee to the Licensing Division at least thirty (30) days prior to the planned date of assignment or transfer.
(B) Any license approved for assignment or transfer by the Licensing Division shall be subject to the plan of correction for licensure submitted by the previous owner.
(ii) If the Psychiatric Hospital's name is changed, the Licensing Division shall be advised in writing, before the name is changed, by the current licensee and a new license will be issued upon the receipt of an application and licensure fee.
(d) Conditions for Denying, Revoking, or Suspending a License.
(i) Denial, revocation, or suspension of a license may occur for noncompliance with any provisions of these licensure rules.
(e) Suspension of Admissions.
(i) The Licensing Division may suspend new admissions or re-admissions to the Psychiatric Hospital when conditions are such that patient needs cannot be met. Conditions in a Psychiatric Hospital shall not jeopardize the patient's health or safety.
(f) Monitor.
(i) The Licensing Division shall place a Department of Health approved monitor at the Psychiatric Hospital's expense when conditions are such that patients' needs are not being met by the Psychiatric Hospital. The monitor shall insure that neither the health nor the safety of the patients is jeopardized.
(g) Hearings.
(i) Any Psychiatric Hospital aggrieved by a decision of the Licensing Division may request a hearing by submitting a written request to the Licensing Division within ten (10) days of receipt of the adverse action.
(ii) Except in matters concerned with the spread of communicable disease, the Licensing Division (Nurse Administrator or designated representative) shall present the preliminary decisions and reasons for the decision to the parties concerned and shall provide an opportunity for a hearing. Any request for hearing shall adhere to the time frames of (i) above.
(iii) In matters concerned with the spread of communicable disease, the Wyoming State Health Officer or designated representative shall present the preliminary decisions and reasons for the decision to the parties concerned and shall provide an opportunity for a hearing. Any request for a hearing shall adhere to the time frames in (i) above.
(iv) Hearings requested under the terms of these licensure rules shall be held in accordance with the provisions of the Wyoming Administrative Procedures Act.
(h) Posting of License.
(i) The current license issued by the Licensing Division shall be displayed in a public area within the Psychiatric Hospital.
(i) Surveys for Licensure.
(i) The Survey Division or its designated representative shall perform initial and periodic surveys for the renewal of licensure.
(A) These surveys shall be based on the current Licensure Rules and Regulations for Psychiatric Hospitals as promulgated by the Wyoming Department of Health.
(B) The Survey Division shall provide, within ten (10) working days after the last day of survey, copies of its cited deficiencies to the Psychiatric Hospital.
(C) The Psychiatric Hospital shall provide an acceptable plan of correction for all cited deficiencies, within ten (10) working days after receipt of the deficiencies, to the Licensing Division.
(ii) At the time of survey, all records, including patient medical records, pertaining to matters involved in the survey shall be made available to members of the survey team in their assigned disciplines.
(j) Voluntary Closure.
(i) If a Psychiatric Hospital voluntarily ceases to operate, it shall notify the Licensing Division in writing at least thirty (30) working days prior to closure.
(ii) The first working day after closure, the Psychiatric Hospital’s license shall be hand carried to or sent by certified mail to the Office of Health Quality; 2020 Carey Avenue, Eighth Floor; Cheyenne, WY 82002.
Section 6. Governing Body. There shall be a governing body legally responsible for the management and operation of the Psychiatric Hospital.
(a) Bylaws shall be adopted by the governing body in accordance with legal requirements.
(i) The bylaws shall:
(A) Stipulate the basis upon which members are selected, term of office, and duties.
(B) Specify to whom responsibilities for the operation and management of the Psychiatric Hospital, including evaluation of Psychiatric Hospital practices, shall be delegated.
(b) Medical staff members shall be appointed by the governing body. (i) There shall be a formal procedure established, governed by written rules and regulations, covering the application for medical staff membership and the method of processing applications.
(c) The Psychiatric Hospital Administrator, appointed by the governing body, shall be the executive officer of the hospital and shall be an individual qualified in hospital administration either by sufficient education or experience. He/She shall be responsible directly to such governing entities and shall execute all policies established by the governing body.
(d) All hospitals must receive and maintain formal designation through the Department of Health's Trauma System Enhancement Program (W.S. §35-1-801). The level of designation shall be at the discretion of the hospital.
(i) The administrator shall:
(A) Keep the governing body fully informed on the operation of the hospital through annual or monthly written or oral reports and by attendance at meetings of the governing body.
(B) Be responsible for developing current written personnel policies and for establishing continuing inservice programs as indicated by personnel needs.
(C) Maintain current employee records containing evidence of adequate health examinations and absence of active communicable disease.
(D) Insure that all unusual accidents and deaths are immediately reported verbally and in writing to the Licensing Division.
Section 7. Medical Staff. The hospital shall have a medical staff organized under bylaws approved by the governing body and be primarily engaged in providing psychiatric services for the diagnosis and treatment of mentally ill patients.
Section 8. Special Requirements For Inpatient Psychiatric Services.
(a) Staff Requirements. Psychiatric Hospitals shall have staff adequate in number and qualifications to carry out an active program of treatment for individuals who are furnished services in the facility.
(i) Inpatient psychiatric facilities (Psychiatric Hospitals, distinct parts of Psychiatric Hospitals or inpatient components of community mental health centers) shall be staffed with the number of qualified professional, technical, supporting personnel, and consultants required to carry out an intensive and comprehensive treatment program that shall include: evaluation of individual needs; establishment of treatment and rehabilitation goals; and implementation, directly or by arrangement, of a broad range of therapeutic programs including professional psychiatric, medical, surgical, nursing, social work, psychological and activity therapies required to carry out an individual treatment plan for each patient.
(A) Qualified professional, technical and consultant personnel shall be available to evaluate each patient at the time of admission. The evaluation shall include diagnosis of any inter-current disease. Services necessary for such evaluation shall include laboratory, radiological, and other diagnostic tests, psycho-social data, psychiatric and psychological evaluations, and a physical examination which includes a complete neurological examination when indicated, shortly after admission.
(B) The number of qualified professional personnel, consultants, technical and supporting personnel shall be adequate to assure representation of the disciplines necessary to establish short-range and long-term goals; to plan, carry out and periodically revise a written individualized treatment program for each patient based on scientific interpretation of:
(I) Degree of physical disability and indicated remedial or restorative measures (including nutrition, nursing, physical medicine and pharmacological therapeutic interventions).
(II) Degree of psychological impairment and appropriate measures to be taken relieving treatable distress and compensation for nonreversible impairments.
(III) Capacity for social interaction and appropriate nursing measures and milieu therapy to be undertaken (including group living experiences, occupational and recreational therapy and other prescribed rehabilitative activities to maintain or increase each patients capacity to manage activities of daily living).
(IV) Environmental and physical limitations required to safeguard each patient’s health and safety.
(b) Director of Inpatient Psychiatric Services-Medical Staff.
(i) Inpatient psychiatric services shall be under the supervision of a clinical director, service chief or equivalent who shall be qualified to provide the leadership required for an intensive treatment program. The number and qualifications of physicians shall be adequate to provide essential psychiatric services.
(ii) The medical staff shall be qualified legally, professionally and ethically for the positions to which they are appointed.
(iii) Residency training shall be under the direction of a qualified psychiatrist.
(c) Nursing Service.
(i) Nursing services shall be under the direct supervision of a registered nurse who shall be qualified by education and experience for the position. The number of registered nurses, licensed practical nurses and other nursing personnel shall be adequate to formulate and carry out the nursing components of the individualized treatment plan for each patient.
(ii) The number of registered nurses, including nurse consultants, shall be adequate to formulate in writing, that a nursing care plan for each patient is carried out.
(iii) Registered nurses and other nursing personnel shall be prepared by continuing inservice and staff development programs for active participation in interdisciplinary meetings affecting the planning or implementation of nursing care plans for patients (including diagnostic conferences, treatment planning sessions, and meetings held to consider alternative facilities and community resources).
(d) Psychological Services.
(i) Psychology services shall be under the supervision of a psychologist with a doctoral degree in psychology from an American Psychological Association approved program in clinical psychology or its equivalent.
(i) The psychology staff, including consultants shall be adequate in numbers and by qualifications to plan and carry out assigned responsibilities.
Note: Where a psychologist who does not hold the doctoral degree directs the program, he/she shall have attained recognition of competency through the American Board of Examiners for Professional Psychology, state certification or licensing, or through endorsement by his/her state psychological association.
(iii) Psychologists, consultants and supporting personnel shall be adequate in number and by qualifications to assist in essential diagnostic formulations, and to participate in program development and evaluation of program effectiveness, in training and research activities, in the therapeutic interventions such as milieu, individual or group therapy, and in interdisciplinary conferences and meetings held to establish diagnoses, goals and treatment programs.
(e) Social Services.
(i) Social services shall be under the supervision of a qualified social worker. The social work staff shall be adequate in numbers and by qualifications to fulfill responsibilities related to the specific needs of individual patients and their families, the development of community resources and consultation to other staff and community agencies.
(ii) Social work staff, including other social workers, consultants, and other assistants or case aides, shall be qualified and numerically adequate to conduct pre-hospitalization studies. They shall provide psychological data for diagnosis and treatment planning, direct therapeutic services to patients, patient groups or families, to develop community resources, including family or foster care programs. They shall conduct appropriate social work research and training activities; and participate in interdisciplinary conferences and meetings concerning diagnostic formulation and treatment planning, including identification and utilization of other facilities and alternative forms of care and treatment.
(f) Qualified Therapists, Consultants, Volunteers, Assistants and Aides.
(i) Qualified therapists, consultants, volunteers, assistants or aides shall be sufficient in number to provide comprehensive therapeutic activities. They shall include occupational, recreational, and physical therapists to assure that appropriate treatment shall be rendered for each patient, and to establish and maintain a therapeutic milieu.
(ii) Occupational therapy services shall be under the supervision of a graduate of an occupational therapy program approved by the Council on Education of the American Medical Association and who has passed or is eligible for the National Registration Examination of the American Occupational Therapy Association.
Note: In the absence of a full-time, fully qualified occupational therapist, a certified occupational therapy assistant as defined in W.S. §33-40-102 may function as the director of the activities program with consultation from a fully qualified occupational therapist.
(iii) When physical therapy services are offered, the services are given by or under the supervision of a qualified physical therapist who is a graduate of a physical therapy program approved by the Council on Medical Education of the American Medical Association or its equivalent. In the absence of a full time, fully qualified physical therapist, physical therapy services shall be available by arrangement with a licensed and certified hospital or by consultation or part-time services furnished by a fully qualified physical therapist.
(iv) Recreational or activity therapy services shall be available under the direct supervision of a member of the staff who has demonstrated competence in therapeutic recreation programs.
(v) Other occupational, recreational, activity and physical therapy assistants or aides shall be directly responsible to qualified supervisors and shall be provided special on-the-job training to fulfill assigned functions.
(vi) The total number of occupational, recreational, activity and rehabilitation personnel, including consultants, shall permit adequate representation and participation in the interdisciplinary conference and meetings affecting the planning and implementation of activity and rehabilitation programs, including diagnostic conferences. All daily schedule and prescribed activities including maintenance of appropriate progress records of individual patients shall be maintained.
(vii) Voluntary services workers shall be: under the direction of a paid professional supervisor of volunteers; provided appropriate orientation and training; and available daily in sufficient numbers to be of assistance to patients and their families in support of therapeutic activities.
(g) Physical and Therapeutic Environment.
(i) Areas for private conversations, group activities or therapy sessions, recreational and hobby activities and dining shall be provided commensurate with the number and characteristics of the patient population.
(ii) If staff members do not eat with the patients, dining areas shall be adequately supervised.
(iii) There shall be a written policy regarding any activities involving travel and use of facilities away from the hospital of which the service or unit is a part. This policy shall address the manner in which security of patients and staff will be ensured and shall also include a description of the way in which community law enforcement and other community resources will be informed when patient elopement occurs.
(iv) A minimum of one detention room shall be provided.
(v) Recreational equipment, games, books and magazines shall be provided in accordance with the backgrounds and needs of the patients.
(vi) Therapeutic Environment.
(A) Written policies and procedures shall be in place which govern the use of seclusion, restraints, psycho surgery, electroconvulsive therapy, behavior modification procedures that use painful stimuli, scheduled drugs and experimental treatment activities. These policies shall require specific written justification to be made and entered in the patient's record for the use of such treatment.
(B) The Psychiatric Hospital Administrator, or his/her designee, shall be the authorizing official for the use of mechanical restraints. The order to use the restraints and the reasons why they were used shall be documented in the patient's clinical record and signed by the Psychiatric Hospital Administrator, or his/her designee. The patient's clinical record shall also contain documentation of what restraints were used, and the time they were applied and released. Frequent monitoring of patients in restraints shall ensure that patients are safe and that restraints are used for the minimum amount of time clinically indicated.
(C) Written policies and procedures shall be in place regarding elopement and the use of discipline. Such policies and procedures shall include a detailed description of staff action to be taken when elopement occurs and how community law enforcement shall be informed and involved.
(D) Rehabilitation therapy shall be provided by the facility or by arrangement with other service providers, as appropriate, to meet the needs of the patient population. Rehabilitation therapy includes:
(I) Activities which shall be provided daily, including evenings and weekends;
(II) Education services;
(III) Speech and hearing services which shall be provided to assess, as well as treat; and
(IV) Vocational services.
(E) Patients shall be encouraged to take responsibility for maintaining their own living quarters.
(I) Except for the responsibilities identified in (vi)(E) above, patients may not be required to work unless it is part of the individual treatment plan and fair compensation is paid. Any such work arrangement shall be documented and included in the patient’s record.
(h) Patient’s Rights.
(i) Every effort shall be made to insure that the patient or the person responsible for the patient’s care or custody understands at the time of admission the policies relating to the patient’s rights and responsibilities during hospitalization. This shall include the patient’s rights and an explanation of the facility’s policies regarding seclusion and restraints, discipline, and elopement. A copy of the written policy concerning patient’s rights and responsibilities shall be provided to the patient or person responsible for the patient’s care or custody at the time of admission.
(ii) A written policy shall be in place which describes the rights of patients, including a description of the circumstances under which, and to what extent, rights may be limited. Patient’s rights include, but are not necessarily limited to:
(A) Communicate by sealed mail or otherwise with persons, including official agencies, inside or outside the hospital;
(B) Receive visitors;
(C) Make and receive telephone calls within reasonable limits;
(D) Wear his/her own clothing;
(E) An independent or in-house medical review, upon written request;
(F) Review the proceedings involving his/her commitment; and
(G) An explanation and a written copy of these rights.
(iii) A copy of these rights shall be posted in a prominent location that is available to the patients.
(iv) Any limitation of the patients rights shall be documented in the patient’s record by the Psychiatric Hospital Administrator, or his/her designee, and explained to the patient.
(v) The patient’s right to communicate with an attorney by sealed mail shall not in any way be subject to limitation.
(i) The written grievance procedure shall establish a system of reviewing complaints and allegations of patient's right violations to include, but not limited to:
(A) How to voice grievances;
(B) Documentation of the provider's response to verbal and written patient grievances;
(C) List of agencies, with addresses and telephone numbers for patients to contact if grievances are not addressed satisfactorily; and
(D) Written reports of the grievances and resolutions shall be provided to the Licensing Division within ten (10) days after the grievance is filed.
(ii) The written grievance procedure shall be posted in a conspicuous place, and there shall be documentation in each patient's medical record that the resident has read or had such policy for handling grievances explained upon admission.
(j) Complaint Investigations.
(i) Patient complaints and grievances shall be referred in writing to the Licensing Division.
(ii) Written reports of investigations and the status of the resolutions shall be provided to the Licensing Division, within thirty (30) days after the investigation.
(l) Special Administrative Requirements.
(i) Inpatient psychiatric services shall be included in the program evaluation, quality assurance and utilization review policies and procedures of the Psychiatric Hospital.
(ii) Designated inpatient psychiatric services shall have a written policy regarding the contents, filing and distribution of reports required by the Department of Health and those reports required to be filed with the court pursuant to W.S. §25-10-110 et. seq. for involuntarily hospitalized patients.
(iii) At least every six (6) months the Psychiatric Hospital Administrator, or his/her designee, shall reexamine every patient involuntarily hospitalized to determine if the patient should be released, released on convalescent leave or remain hospitalized.
Section 9. Dietary Services. The Psychiatric Hospital shall have an organized dietary services directed by qualified personnel.
(a) The Psychiatric Hospital shall provide dietetary services that meet the nutritional needs of patients according to the science of nutrition.
(i) Dietetary service must operate with safe food handling practices in accordance with the most current edition of FOOD CODE from the U.S. Public Health Service, Food and Drug Administration from receipt through production and service.
(b) Dietary Supervision.
(i) Overall supervisory responsibility for dietary service shall be assigned to a full time qualified dietary supervisor.
(A) If the qualified supervisor is not a registered dietitian, she/he shall be a graduate of a dietetic technician program approved by the American Dietetic Association or a dietary managers educational program approved by the Wyoming Dietary Managers' Association. Training and experience in food service supervision and nutrition equivalent in content to the approved educational programs are acceptable.
(ii) Visits of a consultant dietitian shall be scheduled to assure that the professional dietetic service needs of the facility are met. These visits shall be scheduled for at least eight (8) hours every other week, so that adequate time is allowed for observation of more than one (1) meal per visit. Visits shall not be limited to evenings and weekends only.
(iii) Reports of the consultant dietitian shall be made verbally and in writing to the Psychiatric Hospital Administrator. The reports shall be kept on file with notations made of actions taken by the facility.
(A) The report shall include dates, length of time on-site, functions performed, and recommendations.
(iv) The consultant or staff dietitian shall:
(A) Develop written plans and conduct or supervise inservice programs for dietary personnel on a monthly basis;
(B) Participate in the development of policies and procedures, as well as the development and approval of all menus;
(C) Provide assistance and advice, as needed, regarding the dietary service budget; and
(D) Maintain interdisciplinary communication and to act as the dietetic service's chief liaison to the medical and nursing staffs.
(v) The dietetary supervisor shall be responsible for:
(A) Orientation, training, scheduling, and work assignments for all dietetary service personnel;
(B) Menu planning, ordering or recommending the purchase of supplies, monitoring the dietary service budget, controlling costs, maintaining associated records, etc; and
(C) Development of dietary policies and procedures. These policies shall be maintained in a manual and reviewed at least annually. Reviews and revisions shall be dated and signed by the supervisor and the consultant dietitian.
(vi) If the dietetary supervisor has responsibility for cooking, adequate time shall be allowed for supervisory management.
(c) Hygiene of Dietetary Personnel.
(i) Food service personnel shall be in good health and shall practice safe food handling techniques in accordance with the current edition of FOOD CODE published by the U.S. Public Health Service, Food and Drug Administration.
(ii) Personnel having symptoms of a communicable disease that can reasonably be expected to be transmitted through food, a boil, an infected wound, or an acute respiratory infection shall not be permitted to work until medical clearance is received from a physician.
(iii) Personnel returning to work after an absence due to illness shall receive clearance from a physician. Written clearance shall be maintained in the employee’s file.
(iv) An up-to-date manual of regimens shall be available for all therapeutic diets, as approved by the medical staff and the dietitian.
(d) Menus shall be planned and written in advance for regular and therapeutic diets. When changes in the menu are necessary, substitutions shall provide equal nutritive value.
(a) The Psychiatric Hospital shall have a well organized CLIA of 1988 (Clinical Laboratory Improvement Act of 1988) certified, supervised clinical laboratory with the necessary space, facilities, equipment and suitable location to perform those services commensurate with the Psychiatric Hospital’s needs for its patients. Laboratory service may be provided by a certified, contracting laboratory.
(b) Anatomical and/or clinical pathology services and blood bank services shall be available either in the Psychiatric Hospital or by other arrangements with a CLIA certified laboratory.
Section 11. Radiology Services. The Psychiatric Hospital shall maintain or have radiological services readily available.
(a) Personnel adequate to supervise and conduct radiology services shall be provided; interpretation of radiological examinations shall be made by physicians competent to make such interpretation.
(b) Written policies and procedures concerning the operation of equipment, the use of radium or other radio-active isotopes, safety precautions, and radiation exposure shall be in place.
(c) Yearly inspection of x-ray equipment shall be made by competent personnel trained in radiation physics. Annual documentation must be kept on-site.
Section 12. Pharmacy. The Psychiatric Hospital shall have a pharmacy directed by a registered pharmacist. The pharmacy shall be administered in accordance with accepted professional principles.
(a) The pharmacist shall be responsible to the Psychiatric Hospital Administrator for developing, supervising and coordinating pharmacy activities.
(b) Prescription medications shall be compounded in a proper location by a qualified pharmacist.
(c) Facilities shall be provided for storing, safeguarding, preparing and dispensing of drugs.
(i) Drugs shall be issued to floor units in accordance with approved policies and procedures.
(ii) Drug cabinets on the nursing units shall be routinely checked by the pharmacist and all floor stocks shall be controlled.
(d) Provisions shall be made for emergency pharmaceutical services.
Section 13. Medical Library. The Psychiatric Hospital shall have a medical library.
(a) The medical library shall be located in or adjacent to the Psychiatric Hospital building; its contents shall be organized, easily accessible and available at all times to the medical and nursing staffs.
(b) The library shall contain modern textbooks in basic sciences and other current textbooks, journals and magazines pertinent to the clinical services maintained in the Psychiatric Hospital.
Section 14. Medical Records. Medical records shall stress the psychiatric component, history of findings, and the treatment rendered to patients.
(a) Preferably, a Registered Record Administrator (RRA) or Accredited Record Technician (ART) supervises the medical records function. If such a professionally qualified person is not in charge of Medical Records, a qualified RRA or ART on a consultant or part-time basis shall organize the function, train the personnel, and make periodic visits to evaluate the records and the operation.
(b) Disclosure of psychiatric patient records can be made only when:
(i) The patient or guardian consents in writing; or
(ii) The patient’s parent or guardian consents in writing, if the patient is a minor or incompetent; or
(iii) It is necessary to effect treatment; or
(iv) It is necessary for continuing treatment in the event of transfer or referral to another facility or service; or
(v) It is necessary for a pending court disposition or commitment proceeding.
(c) Records of Psychiatric Hospitals shall be preserved, either in the original form or on microfilm, for a period of time determined by the Psychiatric Hospital Administrator and the Archives, Records Management, and centralized Microfilm Division of the State of Wyoming Archives and Historical Department. If any records are to be destroyed, final legal authority must be granted by the State of Wyoming Archives and Historical Department Records Committee.
(d) A system of identification and filing to ensure the prompt location of a patient’s medical records shall be maintained.
(i) Indexing shall be current within three (3) months following discharge of the patient.
(e) Medical records shall contain at least the following information:
(i) Identification Data and Legal Status;
(ii) Admitting/Intercurrent Diagnosis;
(iii) Reasons for Admission;
(iv) Social Service Reports;
(v) Neurological Examinations;
(vi) Psychiatric evaluations; (vii) Medical History; (viii) Treatment Plans; (ix) Treatment notes; (x) Progress notes; and (xi) Discharge Summary.
Section 15. Infection Control Program. An Infection Control Program shall be established to prevent, identify, and control infections and communicable diseases.
(a) The infection control program shall be coordinated by the Psychiatric Hospital Administrator, the medical staff, and Director of Nursing Services, in conjunction with the Hospital's quality assurance and inservice training programs.
(b) Problems identified shall be reported to the medical staff, nursing and administration, and addressed in the Hospital's quality assurance management and inservice training programs.
(c) Documentation concerning corrective actions and outcomes shall be maintained.
Section 16. Sanitary Environment. The Psychiatric Hospital shall provide for housekeeping, maintenance, and laundry services.
(a) There shall be written policies and procedures for each of these services to ensure the use of approved practices, procedures, and products.
(i) A designated person shall be responsible for plant maintenance, laundry and general housekeeping.
(ii) Housekeeping shall be responsible for keeping the Psychiatric Hospital free of offensive odors, accumulations of dirt, rubbish, dust, insects and rodents.
(iii) Laundry facilities shall have physical separation of clean and dirty areas, adequate ventilation and temperature control.
(iv) Oxygen tubing and humidifiers shall be replaced after each usage and the length of continuous usage shall not exceed twenty-four (24) hours.
(v) There shall be written policies and procedures covering the disinfectants used on various types of equipment, surfaces, and instruments.
(vi) There shall be a written policy covering the cleaning and disinfecting of ice machines.
(vii) All garbage and kitchen refuse shall be kept in leakproof, nonabsorbent containers with tight fitting covers. All garbage containers kept within the Hospital buildings shall be washed, inside and out, daily. Other dry waste materials, normally designated “Trash”, may be stored in plastic bags.
Section 17. Other Hospital Services. Psychiatric Hospitals which provide one (1) or more of the hospital services listed in W.S. 35-2-901(a)(xiii), in addition to psychiatric care, shall meet the State’s Rules and Regulations for Licensure of Hospitals.
Section 18. Physical Environment. The Psychiatric Hospital buildings shall be designed, constructed, arranged, equipped and maintained to ensure the safety of patients, personnel and visitors and to provide adequate and efficient care and treatment to the patients. Fire safety in Psychiatric Hospitals shall be in accordance with the requirements of NFPA Life Safety Code 101, Section 31-4.4.
Section 19. Disaster Plan. Psychiatric Hospitals shall develop and adopt a written disaster preparedness plan in accordance with NFPA 99, Standards for Health Care Facilities, 1996 edition, Chapter 11.
Section 20. Construction and Remodeling. Department of Health, Chapter III Construction Rules for Health Facilities apply.
Section 21. Life Safety and Electrical Safety. Department of Health, Chapter III Construction Rules for Health Facilities apply.
(a) Psychiatric Hospitals operating prior to the effective date of these rules, shall meet the Life Safety Code of the National Fire Protection Association that was in effect at the time the facility was licensed as a Psychiatric Hospital.