The facility may provide services to patients either directly or by written agreement with outside resources as specified in Section 77109.

The facility shall have a clinical director who shall be a licensed mental health professional and qualified in accordance with section 77093 of these regulations.

The clinical director may also serve as the administrator. The clinical director shall designate a clinical psychologist or psychiatrist to review and approve interdisciplinary treatment plans.

A physician shall be on-call at all times for the provision of physical health care and those services which can only be provided by a physician. The person in charge of patient care services on each shift shall be provided with the names(s) and means of locating and contacting the available physician. Patients requiring general acute physical health care shall be diverted from admission or transferred to a general acute care hospital.

A prospective patient may be admitted to a psychiatric health facility if the patient's medical condition could ordinarily be managed on an outpatient basis. by a reasonably competent individual.

If the clinical director is not a physician, responsibility for those aspects of an individual treatment plan which may only be performed by a physician., shall be assumed by a physician.

During the absence of any staff required in subsection (h)(1) below there shall be a substitute person with the required qualifications to provide the number of hours of services required.

Community practitioners who are approved to admit and/or attend patients in the facility may be calculated as part of the staffing pattern only if they are retained by written contract to provide services for a specified number of hours to the patients at the facility.

Each facility shall meet the following full-time equivalent staff to census ratio, in a 24 hour period:

In patient Census:

• 1-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 91-100
• Licensed 1 2 3 4 5 6 7 8 9 10

Mental Health Professional

• Nursing Staff 4 5 6 8 10 12 14 16 18 20
• Mental Health 3 5 8 10 13 15 18 20 23 25

Worker

• Totals 8 12 17 22 28 33 39 44 50 55

Weekend and holiday staffing must include adequate nursing and professional staff to provide coverage for the unit, arrange admissions and discharges, attend rounds and patient activities as necessary at each PHF, but not necessarily at the same level as on weekdays.

For facilities in excess of 100 beds, staffing shall be provided in the ratios as in (1) above.

A registered nurse shall be employed 40 hours per week.

The registered nurse time may count as part of the total requirement for licensed nursing personnel.

There shall be a registered nurse, a licensed vocational nurse, or a psychiatric technician awake and on duty in the facility at all times.

The required staffing ratio shall be calculated based upon the inpatient census and shall provide services only to psychiatric health facility patients.

Regardless of the minimum staffing required in subsection (h)(1) above, the facility shall employ professional and other staff on all shifts in the number and with the qualifications to provide the necessary services for those patients admitted for care.

Psychiatric services shall be provided by licensed physicians with training and/or experience in psychiatry.

Psychological services shall be provided by clinical psychologists in accordance with Business and Professions code, Section 2903 and Health and Safety Code, Section 1316.5.

Counseling services shall be provided by licensed clinical social workers in accordance with Business and Professions Code, Sections 4996 and 4996.9 or licensed marriage, family and child counselors in accordance with Business and Professions Code, Sections 4980 and 4980.02.

Counseling services may be provided by staff not included in the above cited sections. All counseling services will be limited by the authority to treat or diagnose as provided by the individual's expertise, certification or licensure.

Psychiatric nursing services shall be designed to meet the objectives of each patient's interdisciplinary treatment plan.

Policies and procedures for the administration of medications shall be implemented by the psychiatric nursing service.

Nursing services shall include the development of a nursing care plan based upon an initial written and continuing assessment with input from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed with 72 hours after admission.

Nursing care plans may be included as a part of the interdisciplinary treatment plan or may occupy a unique section of the patient record.

Written nursing services policies and procedures shall be developed which include:

• A current nursing procedure manual appropriate to the patient served by the facility.
• Provision for the inventory and identification of patients' personal possessions, equipment and valuables.

Screening of all patients for tuberculosis upon admission. A tuberculosis screening procedure may not be required if there is satisfactory written evidence available that a tuberculosis screening procedure has been completed with 90 days of the date of admission to the facility. Subsequent tuberculosis screening procedures shall be determined by a physician.

Notification of practitioner regarding sudden or marked adverse change in a patient's condition.

Conditions under which restraints are used, the application of restraints, and the mechanism used for monitoring and controlling their use.

A planned and systematic process for the monitoring and evaluation of the quality and appropriateness of patient care and for resolving identified problems.

Psychiatric nursing policies and procedures may be integrated into a single manual with general services which set forth all policies and procedures for the various functions of the facility. If the policies and procedures are contained in a general manual, a separate section must be devoted to nursing policies and procedures.

There shall be a written staffing pattern which shall show:

• Total numbers of staff including full-time and full-time equivalents.
• The available nursing care hours for each nursing unit.
• The categories of staff available for patient care.

The psychiatric nursing service shall be under the direction of a registered nurse who shall meet at least the following qualifications:

• Master's degree in psychiatric nursing or related field with experience in administration
• Baccalaureate degree in nursing or related field with experience in psychiatric nursing and two years of experience in nursing administration
• Four years of experience in nursing administration or supervision and with experience in psychiatric nursing.

The provisions of this subsection are not intended to require that nursing services be organized as a department under the guidelines of the "Director of Nurses." Nursing services are to be integrated into the psychiatric health facility interdisciplinary model.

Psychiatric health facility policies and procedures must specify how a registered nurse will exercise authority and carry out the responsibility of supervising nursing activities such as, but not limited to pouring, dispensing, and recording of medication(s); the documentation of patient's nursing care needs in the interdisciplinary treatment plan; the implementation of nursing procedures; the provision of inservice education related to nursing activities.

Social services shall be designed to meet the objectives of each patient's interdisciplinary treatment plan in accordance with established policies and procedures.

Social services shall be organized, directed and supervised by a licensed clinical social worker.

This section does not require that a Licensed Clinical Social Worker (LCSW) directly carry out social service functions. The facility may contract, for no less than 4 hours monthly, with a LCSW to periodically monitor and supervise social services.

Rehabilitation services mean those activities provided by occupational therapists, physical therapists or recreation therapists under the general direction of the clinical director to restore, establish and maintain optimum levels of social, vocational and physical functioning and to minimize residual disabilities of patients.

Rehabilitation services provided in a psychiatric health facility are to be designed to meet the needs of acute psychiatric inpatients. Because PHF stays are generally quite brief, the need for traditional rehabilitation services is limited.

In accordance with established policies and procedures, the scope of these activities shall include at least the following:

• Social activities which involve group participation.
• Recreational activities, both indoor and outdoor.
• Opportunity to participate in activities outside of the facility if appropriate.
• Exercises.
• A physician shall prescribe in the health record the level of physical activity in which a patient may engage.

Prior to or at the time of discharge, each patient shall be evaluated concerning the patient's need for aftercare services with the result of that evaluation noted in the patient's health record.

Aftercare services are those services to, and on behalf of, a patient following discharge from the psychiatric health facility for the purpose of enabling the patient to achieve an optimum level of functioning.

Aftercare services shall include but not be limited to the following:

• Arranging for out of home placement if necessary.
• Arranging for medication supervision if indicated.
• Obtaining community social, vocational and educational services if appropriate.

If a licensed psychiatric health facility does not provide its own aftercare service through its employed staff, it shall affiliate or have an agreement with a recognized aftercare agency in the facility's service area to provide aftercare services to patients who could benefit from such services upon discharge from the facility.

A member of the interdisciplinary team designated by the clinical director, shall be responsible for ensuring that the referral of,the patient to the appropriate aftercare service has been completed and documented in the patient's health record.

In accordance with Health and Safety Code, Section 1284 and Welfare and Institutions Code, Section 5622, Aftercare plans shall be transmitted to the local director of mental health services in the county of residence for any patient placed in the facility under a county Short-Doyle plan.

The local director of mental health services may designate an alternative site as to where the aftercare plan is to be transmitted and filed.

The content of the aftercare plan shall conform to the requirements of Welfare and Institutions Code, Section 5622.

A written interdisciplinary treatment plan shall be developed and implemented by the interdisciplinary treatment team for each patient as soon as possible after admission but no longer than 72 hours following the patient's admission, Saturdays, Sundays and holidays excepted.

The interdisciplinary treatment plan shall include as a minimum:

• A statement of the patient's physical and mental condition, including all diagnoses.
• Specific goals of treatment with interventions and actions, and observable, measurable objectives.
• Methods to be utilized, the frequency for conducting each treatment method and the person(s) or discipline(s) responsible for each treatment method.

The interdisciplinary treatment plan shall be reviewed and modified as frequently as the patient's condition warrants, but at least weekly.

This section requires the interdisciplinary treatment plan (ITP) to be actively used as the instrument for setting the plan for treating a given patient. Short and long-term goals should be well thought out and reasonable in light of patient diagnosis, anticipated length of stay, treatment requirements and the economic and social environment available to the patient upon discharge.

A transfer summary shall accompany the patient upon transfer to another health facility. The transfer summary shall include  information relative to the patient's diagnosis, known residual behaviors or symptoms of mental disorder, medications, treatments, dietary requirements, rehabilitation potential, and known allergies and shall be signed by the clinical director or the clinical director's designee as specified in Section 77061 ©.

The total daily diet for patients shall be of the quality and in the quantity necessary to meet the needs of the patients and shall meet the "Recommended Dietary Allowances," 9th edition, 1980, or most current edition, adopted by the Food and Nutrition Board of the National Research council of the National Academy of Science, adjusted to the age, activity and environment of the group involved. All food shall be of good quality and be selected, stored, prepared and served in a safe and healthful manner. The following shall apply:

Arrangements shall be made so that each patient has available at least three meals per day. not more than fourteen (14) hours shall elapse between the third and first meal. A facility may choose to purchase, store and prepare the required food for its patients, or it may choose to purchase prepared meals from other appropriate sources, through a written contract.

When a non-inpatient program exceeds four hours, nourishment or snacks shall be available.

A person shall be designated by the administrator to be responsible for the management and operation of the food service.

This may be provided by a full-time or part-time employee with the facility, or through a written contract with an outside supplier or food service. If this person is not a dietitian, provision shall be made for consultation at least four hours every three months. If total food service is by contract, a staff member will be designated to monitor the operation of the food service within the facility.

A registered dietitian will provide at least four hours of consultation and oversight every three months.

If patients participate in food preparation and/or service to inpatients as part of their interdisciplinary treatment plan, they shall comply with the same policies and procedures as those required for food service employees.

Pesticides and other toxic substances shall not be stored in the food store rooms, kitchen areas, or where kitchen equipment or utensils are stored, or accessible to patients.

Supplies of staple foods for a minimum of two days shall be maintained on the premises.

All kitchen equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips.

All utensils used for eating and drinking and in the preparation of food and drink shall be cleaned and sanitized after each usage.

The facility shall maintain a written plan to provide patients' food service in emergencies.

Provisions shall be made to provide patients with access to beverages and nourishments at times when the main dietary service is not in operation.

The reviewer will examine meals as closely as possible during the review, observing whether the food served iswholesome and edible.

Arrangements shall be made with pharmacists licensed by the California Board of Pharmacy to assure that pharmaceutical services are available to provide patients with prescribed drugs and biologicals.

Dispensing, labeling, storage, disposal and administration of drugs and biologicals shall be in conformance with state and federal laws.

If a pharmacy is located on the premises, the pharmacy shall be approved by the Department. The pharmacy shall not serve the general public unless a separate public entrance or a separate public serving window is utilized. Pharmacies located on the licensed premises of the facility shall be opened for inspection upon the request of an authorized Department representative.

The facility shall not accept money, goods or service free or below cost from any pharmacist or pharmacy as compensation or inducement for referral of business to any pharmacy.

Pharmaceutical service shall include, but no be limited to the following:

• Obtaining necessary drugs including the availability of 24 hour prescription service on a prompt and timely basis as follows:
  • Drugs ordered "STAT" that are not available in the facility emergency drug supply shall be available and administered within one hour of the time ordered during normal pharmacy hours. For those hours during which the pharmacy is closed, drugs ordered "STAT" shall be available and administered within two hours of the time ordered. Drugs ordered "STAT" which are available in the emergency drug supply shall be administered immediately.
  • Anti-infectives and drugs used to treat severe pain, nausea, agitation, diarrhea or other severe discomfort shall be available and administered within four hours of the time ordered.

Except as indicated above, all new drug orders shall be available on the same day ordered unless the drug would not normally be started until the next day.

Refill of prescription drugs shall be available when needed.

Dispensing of drugs and biologicals.

Monitoring the drug distribution system which includes ordering, dispensing and administering of medication.

Provision of consultative and other services furnished by pharmacists which assist in the development, coordination, supervision and review of the pharmaceutical services within the facility.

Containers which are cracked, soiled or without secure closures shall not be used. Drug labels shall be legible.

All drugs obtained by prescription shall be labeled in compliance with state and federal laws governing prescription dispensing. No person other than the dispenser or prescriber of the drug shall alter any prescription label.

Nonlegend drugs shall be labeled in conformance with state and federal food and drug laws.

Test reagents, germicides, disinfectants and other household substances shall be stored separately from drugs and shall not be accessible to patients.

External use drugs in liquid, tablet, capsule or powder form shall be stored separately from drugs for internal use.

Drugs shall be stored at appropriate temperatures. Drugs required to be stored at room temperature shall be stored at a temperature between 15° C (59°F) and 30°C (80°F). Drugs requiring refrigeration shall be stored in a refrigerator between 2°C (36°F) and 8°C (46°F). When drugs are stored in the same refrigerator with food, the drugs shall be kept in a closed container clearly labeled "drugs".

Drugs shall be stored in an orderly manner in cabinets, drawers or carts of sufficient size to prevent crowding.

Dose preparation and administration areas shall be well lighted.

Drugs shall be accessible only to personnel designated in writing by the licensee.

Medication shall not be kept at the patient's bedside.

Drugs shall not be kept in stock after the expiration date on the label and no contaminated or deteriorated drugs shall be available for use.

The drugs of each patient shall be kept and stored in their originally received containers. No drug shall be transferred between containers.

Discontinued drug containers shall be marked, or otherwise identified, to indicate that the drug has been discontinued, or shall be stored in a separate location which shall be identified solely for this purpose. Discontinued drugs shall be disposed of within 90 days of the date the drug order was discontinued. unless the drug is reordered within that time.

Written policies shall be established and implemented limiting the duration of new drug orders in the absence of a prescriber's specific indication for duration of therapy. The prescriber shall be contacted for new orders prior to the termination time established by the policy. Such policies shall include all categories of drugs.

No drugs shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illness.

All drug orders shall be written, dated, and signed by the person lawfully authorized to give such an order. The name, quantity or specific duration of therapy, dosage and time or frequency of administration of the drug and route of administration if other than oral shall be specified shall be specified. "PRN" orders shall also include the indication for the use of the drug.

Verbal orders for drugs and treatment shall be received only by licensed nurses, psychiatric technicians, pharmacists, physicians and physician's assistants from their supervising physicians only. Such orders shall be recorded immediately in the patient's health record by the person receiving the order and shall include the date and time of the order. The order shall be signed by the prescriber within 24 hours excluding weekends and holidays.

The signing of orders shall be by signature or a personal computer key. Signature stamps shall not be used.

Signed orders for drugs shall be transmitted to the issuing pharmacy within 48 hours, either by written prescription of the prescriber or by an order form with produces a direct copy of the order or by an electronically reproduced facsimile.

Facilities shall maintain a record which includes, for each drug ordered by prescription, the name of the patient, the drug name, and strength, the date ordered, the date and amount received and the name of the issuing pharmacy. The records shall be kept at least one year.

Medications brought by or with the patient on admission to the facility shall not be used unless the contents of the containers have been examined and positively identified after admission by the patient's physician or a pharmacist retained by the facility.

The facility may use drugs transferred from other licensed health facilities or those drugs dispensed or obtained after admission from any licensed or governmental pharmacy and may accept the delivery of those drugs by any agent of the patient or pharmacy without the necessity of identification by a physician or pharmacist.

Drugs listed in Schedules II, III, and IV of the Federal Comprehensive Drug Abuse Prevention and Control Act of 1970, Title 21, United States Code, Section 801 et seq., shall not be accessible to other than licensed nursing, pharmacy ;and medical personnel designated by the licensee. Drugs listed in Schedule II of the above Act shall be stored in a locked cabinet or a locked drawer separate from noncontrolled drugs unless they are supplied on a scheduled basis as a part of a unit dose medication system.

Separate records of use shall be maintained on all Schedule II drugs. Such records shall be maintained accurately and shall include the name of the patient, the prescription number, the drug name, strength and dose administered, the date and time of administration and the signature of the person administering the drug. Such records shall be reconciled at least daily and shall be retained at least one year. If such drugs are supplied on a scheduled basis as part of a unit dose medication system, such records need not be maintained separately.

Drug records shall be maintained for drugs listed in Schedules III and IV of the above Act in such a way that the receipt and disposition of each dose of any such drug may be readily traced. Such records need not be separate from other medication records.

Drugs which have been dispensed for individual patient use and are labeled in conformance with state and federal law for outpatient use shall be furnished to patients on discharge on the order of a physician. If the discharge orders do not include provisions for drug disposition, drugs shall be furnished to patients unless:

• A physician's order specifies otherwise, or
• The patient leaves or is discharged without a physician's order or approval, or
• The patient is discharged to a general acute care hospital or acute psychiatric hospital, or
• The drug was discontinued prior to discharge, or

The labeled directions for use are not substantially the same as most current orders for the drug in the patient's health record.

A record of the drugs sent with the patient shall be made in the patient's health record.

Patient's drugs supplied by prescription which have been discontinued and those which remain in the facility after discharge of the patient shall be destroyed by the facility in the following manner:

• Drugs listed in Schedules II, III, and IV of the Federal Comprehensive Drug Abuse Prevention and Control Act of 1970, Title 21, United States Code, Section 801 et seq., shall be destroyed by the facility in the presence of a pharmacist and a registered nurse employed by the facility. The name of the patient, the name and strength of the drug, the prescription number, the amount destroyed, the date of destruction and the signature of the witnesses required above shall be recorded in the patient's health record or in a separate log. Such log shall be retained for at least three years.
• Drugs not listed under Schedules II, III, or IV of the above Act shall be destroyed by the facility in the presence of a pharmacist or licensed nursing personnel. The name of the patient, the name and strength of the drug, the prescription number (if applicable), the amount destroyed, the date of destruction and the signature of the person named above and one other person shall be recorded in the patient's; health record or in a separate log. Such log shall be retained for at least three years.

Unless otherwise prohibited under applicable federal or state laws, individual patient drugs supplied in sealed containers may be returned, if unopened, to the issuing pharmacy for disposition provided that; No drugs covered under the Federal Comprehensive Drug Abuse Prevention and Control Act of 1970 are returned.

All such drugs are identified as to lot or control number.

The signatures of the receiving pharmacist and a licensed nurse employed by the facility are recorded in a separate log which lists the name of the patient, the name, strength, prescription number (if applicable), the amount of the drug returned and the date of return.

In facilities utilizing a unit dose medication system, there shall be at least a 24 hour supply of all patient medications on hand at all items, except those drugs which are to be discontinued within the 24 hour period. Drugs that are part of a unit dose medication system shall not exceed a 48 hour supply.

Facilities may utilize a floor stock medication system in lieu of a unit dose medication system.

Facilities shall retain a consulting pharmacist who devotes a sufficient number of hours during a regularly scheduled visit, for the purpose of coordinating, supervising and reviewing the pharmaceutical service at least quarterly. The report shall include a log or record of time spent in the facility. There shall be a written agreement between the pharmacist and the facility which includes the duties and responsibilities of both.

A pharmacist shall review the drug regimen of each patient at least monthly and prepare appropriate reports. The review of the drug regimen of each patient shall include all drugs currently ordered, information concerning the patient's condition relating to drug therapy, medication administration records, and where appropriate, physician's progress notes, nurse's notes, and laboratory test results. The pharmacist shall be responsible for reporting, in writing, irregularities in the dispensing and administration of drugs and other matters relating to the review of the drug regimen to the clinical director and the director of nursing service.

Facilities may allow drug regimen reviews of a 10% random sample of patient records to meet the requirements of this section.

There shall be adequate equipment and supplies necessary for the provision of pharmaceutical services within the facility including at least the following:

• Refrigerator with an accurate thermometer.
• Lockable drug cabinets, drawers, closets or rooms.
• Drug service trays and/or carts.
• Drug preparation counter area and convenient water source.

Reference materials containing drug monographs on all drugs in use in the facility. Such monographs shall include information concerning generic and brand names, if applicable, available strength, and dosage forms and pharmacological data including indication and side effects.

Emergency supplies shall be readily available at each facility. Emergency drug supplies shall meet the following requirements:

• Legend drugs shall not be stored in the emergency supply, except under the following conditions:
  • Injectable supplies of legend drugs shall be limited to a maximum of three single doses in ampules or vials or one container of the smallest available multi-dose vial and shall be in sealed, unused containers.
  • Sublingual or inhalation emergency drugs shall be limited to single sealed containers of the smallest available size.
  • Not more than six emergency drugs in solid, oral dosage form or suppository dosage form for anti-infective, anti-diarrheal, anti-nausea, or analgesic use may be stored if in sealed containers. Not more than four doses of any one drug may be so stored.

The emergency drug supply shall be stored in a portable container which is sealed in such a manner that the tamper proof seal must be broken to gain access to the drugs. The registered nurse or charge nurse or charge nurse shall notify the pharmacist when drugs have been used from the emergency kit or when the seal has been broken. Drugs used from the kit shall be replaced within 72 hours and the supply resealed by the pharmacist.

The contents of the supply shall be listed on the outside of the container.

The supply shall be checked at least monthly by the pharmacist.

Separate records of use shall be maintained for drugs administered from the supply. Such records shall include the name and dose of the drug administered, name of the patient, the date and time of administration and the signature of the person administering the dose.