The governing body shall:

Assure that all services including care and treatment provided to patients, is adequate and safe at all times.

Establish and implement written bylaws in accordance with legal requirements and its responsibility to the community and to the patients served which shall include, but not be limited to, provisions for:

Identification of the purposes of the facility and the means of fulfilling them.

Ensuring the fitness, adequacy and quality of the clinical and medical care rendered.

The appointment and reappointment of clinical staff who provide treatment, care and consultation to patients in the facility.

Approval of policies and procedures for appropriate practices to be observed in the facility. In this connection, the practice of division of fees, under any guise whatsoever, shall be prohibited and any such division of fees shall be cause for exclusion from the staff.

Identification of the requirements for health and treatment records.

Requiring the interdisciplinary staff to establish controls that are designed to ensure the achievement and maintenance of high standards of professional ethical practices.

Appoint a clinical director and administrator whose qualifications, authority and duties shall be defined in a written statement adopted by the governing body.

Provide for the control and use of appropriate physical and financial resources and personnel required to meet the needs of the patients.

Assure that the facility and its operation conforms to all applicable federal, state and local laws and regulations, including those relating to licensure and fire inspections.

The organized clinical staff shall be composed of all licensed mental health professionals as included in section 77012 or other licensed practitioners who have admitting and/or treatment privileges in the facility and shall be responsible for the following:

A formal peer review process which, in order to improve the quality of care, will review and evaluate the adequacy, appropriateness, and effectiveness of the care and treatment planned for, or provided to, facility patients;

In conjunction with the pharmacist's monthly drug regimen review, a medication monitoring system that will assess the prescribing practices of the professional staff of the facility with respect to appropriateness and cost effectiveness of the medications ordered for the patients of the facility.

The medication monitoring requirements specified in subsection (a)(2) must include findings of the pharmacist's monthly drug regimen review

A utilization review program which shall be a system of policies and procedures designed to ascertain and assure the clinical necessity of acute inpatient psychiatric services for patients using the facility.

The clinical staff shall meet at least monthly. Minutes of each meeting shall be maintained for at least one year and shall be available for review by the Department.

Patients shall be admitted only upon the order and under the care of a member of the clinical staff who is lawfully authorized to diagnose, prescribe and treat patients. The patient's condition and provisional diagnosis shall be established at time of admission by the admitting practitioner subject to the provisions of Section 77073.

In order to carry out the functions as specified in this section, professionals who are not members of the organized clinical staff may be utilized. These professionals include, but are not limited to, pharmacists, dietitians, occupational therapists, physical therapists, recreation therapists, registered record administrators or licensed nursing staff.

All facilities shall have a current written agreement for medical services with one or more general acute care hospitals and shall maintain a current copy of such agreements for review by the Department. The agreements shall include, but not be limited to:

• Whether the general acute care hospital agrees to medically screen and conduct physical examinations of patients of admission to the psychiatric health facility and the procedure by which such screening and examination will be provided.
• The procedure for patient transfer from the psychiatric health facility to the hospital for inpatient medical or psychiatric care.
• The availability of medical services for patients of the psychiatric health facility, and the procedure by which such service will be provided.
• The specific means by which patients who require such medical services will be transported to the hospital or medical facility.

Each facility shall have an administrator who has primary responsibility for business and support services for the clinical program.

The administrator shall be accountable to the clinical director.

The administrator shall have direct access to the clinical director for the purpose of communicating the status of business and support services of the psychiatric health facility.

Each facility shall have a clinical director who shall direct the clinical program, provide general direction to professional and nonprofessional staff, and be responsible for the quality of clinical services performed in the facility. The clinical director shall be a licensed mental health professional. The clinical director shall have at least three years of postgraduate direct clinical experience with the mentally disordered.

The clinical director shall be administratively accountable to the governing body.

When the clinical director is part of the overall structure of a county mental health program, the county organization chart must show a line of reportability to the director of mental health.

The interdisciplinary treatment team shall be composed of those persons who work directly with the patient in each of the professions, disciplines or service areas that provide service to the patient, including direct treatment staff, the patient's attending or consulting psychiatrist, the clinical psychologist, the licensed nurse or the psychiatric technician, the clinical director, or the clinical director's designee and any other persons whose participation is relevant to the treatment and care of the patient.

The interdisciplinary treatment team shall be responsible for the development and implementation of the patient's individual treatment plan in consultation with the patient and members of the patient's family pursuant to Welfare and Institutions Code, Section 5328.

The governing body shall adopt and implement written policies regarding patients' right to ensure compliance with 5325, 5325.1, 5326, 5326.1 5326.9, 5326.95 and 5520 through 5550 of the Welfare and Institutions Code.

A list of these patients' rights shall be posted in English and in the predominant language of the community, if other than English, in appropriate places with within psychiatric health facility so that such rights may be read by patients.

No physical restraints with locking devices shall be used or be available for use in the facility unless approved by the State Fire Marshal.

Seclusion as defined in Section 77029 is considered to be a physical restraint.

Exclusion timeout as defined in Section 77010 is considered to be a physical restraint.

Treatment restraint, as defined in Section 77033, shall be accomplished by a soft tie only, so as not to cause harm to the patient and shall only be used during medically prescribed treatment or diagnostic procedures.

Behavioral restraint and seclusion shall only be used as a measure to protect the patient from injury to self or others.

Behavioral restraint and seclusion shall only be used upon a physician's or clinical psychologist's written or verbal order, except under emergency circumstances. Under emergency circumstances behavioral restraint may be applied and then an order obtained as soon as possible, but at least within one hour of application. Telephone orders shall be received only by authorized professional staff, shall be recorded immediately in the patient's health record and, within twenty-four (24) hours, weekends and holidays excepted, and signed by the prescriber.

Behavioral restraint and seclusion shall not be used as punishment or as a substitute for more effective programming or for the convenience of the staff.

Orders for behavioral restraint and seclusion shall be in force for not longer than 24 hours.

There shall be no PRN orders (as needed orders) for behavioral restraint and seclusion.

Patients in restraint shall remain in staffs' line of vision and shall be afforded protection from other patients who may be in the area.

A patient placed in behavioral restraint or seclusion shall be checked at least every 15 minutes by professional staff to assure that the restraint remains properly applied or that the patient has not harmed him/herself. A written record shall be kept of these checks and maintained in the individual patient's health record.

Facilities shall have written policies and procedures concerning the use of postural supports.

Postural supports shall be designed and applied for speedy removal in case of emergency.

Postural supports shall be designed and applied:

• Under the supervision of a physical or occupational therapist.
• In accordance with principles of proper body alignment, with concern for circulation and allowance for change of position.
• To improve a patient's mobility and independent functioning.

Prior to implementing any research projects involving human subjects that were not approved with the initial program plan, a supplemental patient care program plan shall be submitted to the Department of Mental Health for approval or denial. All research projects involving human subjects shall meet the requirement of all applicable state and federal laws and regulations.

When patients of school age, between the ages of 6 and 18 are expected to remain in the facility for 30 days or more, the facility shall arrange for appropriate educational services pursuant to Sections 48200 and 48400 of the Education Code and the applicable federal regulations.

If a facility does not employ qualified personnel to render a specific service to be provided by the facility, there shall be arrangement through a written agreement and/or contract with outside resources. Outside resources shall meet the standards and requirements of these and all other applicable regulations before an agreement and/or contract may be entered into and shall continue to meet these and all other applicable regulations during the term of the agreement and/or contract. Outside resources may include other facilities, organizations, individuals or public or private agencies.

Signed and dated copies of agreements, contracts or written arrangement for advice, consultation, services, training or transportation, with outside resources shall be on file in the facility. These agreements and/or contracts shall be readily available for inspection and review by the Department. The agreements and/or contracts shall include, but not be limited to, a description of the services to be provided, the financial arrangements, the methods by which the services are to be provided, and the conditions upon which the agreement or contract can be terminated.

The governing body shall be responsible and accountable for all services provided by agreements and/or contracts.

No facility that receives any financial assistance from the State of California shall discriminate against or deny admission to any person, otherwise qualified, based on sex, age, race, color, religion, ancestry or national origin, or physical or mental handicap.

Facility policies shall so state and apply to the appointment of the treatment staff, hiring of facility employees and the admission, housing and treatment of patients.

While a facility may not discriminate against any group identified in 77111. (a), the facility may not admit a minor for whom it cannot provide protection from adult patients, appropriate treatment and educational services when applicable.

Any bona fide nonprofit religious, fraternal or charitable organization which can demonstrate to the satisfaction of the Department that its primary or substantial purpose is not to evade this section, may establish admission policies limiting or giving preference to its own members or adherents. Such policies shall not be construed as a violation of (a) above. Any admission of nonmembers or nonadherents shall be subject to (a) above.

Facilities shall comply with the Americans with Disabilities Act (ADA), public Law 101-336 of 1990 (42 U.S.C. §12101 et seq.) which guarantees equal opportunity for persons with disabilities.

Each facility shall have and implement written admission and discharge policies encompassing which licensed health professionals may admit patients, the types of diagnoses for which patients may be admitted, limitations imposed by law or licensure, staffing limitations, rules governing emergency admissions, policies concerning advance deposits, rates of charge for care, charges for extra services, limitations of services, termination of services, refund policies, insurance agreements and other financial considerations, discharge of patients and other relevant functions. These policies shall be made available to patients or their agents upon admission and upon request, and shall be made available to the public upon request.

The types of diagnoses for which patients may be admitted are to be identified by the appropriate name and numbering system as described in the most current edition of the Diagnostic and Statistical Manual.

Psychiatric health facilities shall not admit and treat patients with the primary diagnosis of an eating disorder as defined in Section 1254.5(b) of the California State Health and Safety code.

Psychiatric health facilities shall not admit and treat patients with the primary diagnosis of chemical dependency, chemical intoxication or chemical withdrawal. Individuals who abuse chemicals may also suffer from other psychiatric
pathology which requires acute inpatient admission. However, once the psychiatric symptoms are stabilized, leaving the individual with the primary diagnosis of chemical dependency, the patient must be discharged.

Individuals with severe psychiatric pathology shall not be admitted to a psychiatric health facility if their treatment requires medical interventions beyond the level appropriate to a PHF, including, detoxification from substance abuse, treatment for delirium tremens, or autonomic disturbances.

A facility shall accept and retain only those patients for whom it can provide adequate care.

A minor shall not be detained in a facility against the will of his or her parent or legal guardian. In those cases where law permit minors to contract for or consent to the type of medical care provided by the facility, without the consent of their parent or guardian, they shall not be detained in the facility against their will. This provision shall not be construed to preclude or prohibit attempts to persuade patients to remain in the facility in their own interest, nor the temporary detention of patients for the protection of themselves or others under the provisions of the Lanterman-Petris-Short Act (Welfare and Institutions Code, Section 5000 et seq.), if the facility has been designated by the county as a treatment facility pursuant to said act, nor to prohibit minors legally capable of contracting for or consenting to medical care from assuming responsibility for their discharge.

Within 24 hours after admission or immediately before admission, every patient shall have a complete history and physical examination unless a history and physical examination has been completed within the previous 30 days and is determined by the attending physician to be current.

No inpatient shall be transferred or discharged for purposes of effecting a transfer, from a facility to another facility, unless arrangements have been made in advance for admission to such health facility and the person legally responsible for the patient has been notified or, in the case of an emergency, documented attempts to contact such person have been made and a responsible person cannot be reached. A transfer or discharge shall not be carried out if in the opinion of the clinical director such transfer or discharge would be contraindicated, unless there exists no legal basis to do so. This section shall not be construed to prohibit the transfer or discharge of a patient pursuant to court orders.

There shall be a method of prompt and accurate identification of each patient admitted to the facility.

Written administrative policies and procedures for services provided shall be developed and implemented by appropriate staff members. These policies and procedures shall be reviewed and approved at least annually by the clinical director and administrator.

The facility shall have policies and procedures for the provision of first aid and life saving measures that shall be implemented in emergency situations.

The facility shall have a policy which shall ensure the obtaining of the patient's written consent prior to photographing that patient.

Each facility shall adopt and implement written policies and procedures to properly manage outbreaks or prevalence of infectious and communicable disease whether or not such disease is required to be reported by Title 17, California Administrative Code, Section 2500.

Each facility shall adopt and implement written personnel policies concerning qualification, responsibilities and conditions of employment for each classification employed which shall be available to all personnel. Such policies shall include but not be limited to: Hours of work.

A plan for orientation for all new staff members that shall ensure that all new staff providing program services shall receive at least 20 hours of orientation and training within 60 days of employment. Staff attendance shall be documented. Initial training shall include, but not be limited to, the following:

• Orientation to all policies, procedures and objectives of the facility.
• Orientation to overall concepts of programs to meet the special needs of the mentally disordered.
• Orientation and training in specific program techniques being used in the facility to meet the identified program needs of the patients.
• A plan for at least annual evaluation of employee performance.
• The facility shall provide for a continuing inservice education program designed to improve patient care and employee efficiency. This training shall include, but not be limited to, suicide prevention techniques. All staff members shall attend and attendance shall be documented.
• Personnel policies shall require that employees and other persons working in or for the facility familiarize themselves with these regulations and such other regulations as are applicable to their duties.
• The facility shall recruit qualified personnel. Mental health workers shall work under the direct supervision of qualified mental health professionals.
• If language or communication barriers exist between facility staff and patients, arrangements shall be made for interpreters or for the use of other means to ensure adequate communications between patients and personnel.
• All personnel shall wash their hands before and after coming in direct contact with any linen or food.

All facilities shall maintain personnel records of all employees. Such records shall be retained for at least three years following termination of employment.

The record shall include the employee's full name, Social Security number, the license or registration number, if any, brief resume of experience, employment classification, date of beginning employment and date of termination of employment.

Records of hours and dates worked by all employees during at least the most recent six month period shall be kept on file at the place of employment.

A health examination, performed by a person lawfully authorized to perform such an examination shall be performed as a prerequisite for employment within six months prior to employment or within one week after employment. Written examination reports, signed by the person performing the examination, shall verify that employees are able to perform assigned duties and do not have any health condition that would create a hazard for the employee, fellow employees, patients or visitors.

The initial health examination shall include a tuberculosis screening test consisting of a purified protein derivative intermediate strength intradermal skin test and a chest x-ray if the skin test is positive. The facility shall establish a policy regarding subsequent health examinations and tuberculosis screening test based on an assessment of the following:

The risk of a previously infected person developing tuberculosis and then possibly infecting others.

The risk of a non-infected person becoming infected and developing a disease.

The facility shall develop policies which ensure that reasonable precautions are taken to prevent the spread of infectious disease between persons within the facility.

Employee health records shall be maintained by the facility and shall include the records of all required health examinations. Such records shall be kept a minimum of three years following terminations of employment.

Contract employees are exempt from the requirement of health examination.

Equipment and supplies adequate in quality and quantity shall be available as necessary to provide patient services related to the scope and nature of the services offered.

No facility shall make or disseminate any false or misleading statement, or advertise by any manner or means any false or misleading claims regarding services provided by the facility.

A written fire and internal disaster program, incorporating evacuation procedures, shall be developed with the assistance of local fire, safety and other appropriate experts. A copy of the program shall be available on the premises or review by the Department.

The written program shall be implemented in the event of a fire or internal disaster and shall include but not be limited to the following:

• Plans for the assignment of personnel to specific tasks and responsibilities.
• Instructions relating to the use of alarm systems and signals.
• Information concerning methods of fire containment.
• Systems for notification of appropriate persons.
• Information concerning the location of fire fighting equipment.
• Identification of evacuation routes and procedures.
• Other provisions as the local situation dictates.
• Fire and internal disaster drills shall be held at least quarterly for each shift of facility personnel and under various conditions.
• Actual evacuation of patients during a drill is optional.

The evacuation plan shall be posted throughout the facility and shall include but not be limited to the following:

• Evacuation routes.
• Location of fire alarm boxes.
• Location of fire extinguishers.

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the prevention of fire and for the protection of life and property against fire and panic. All facilities shall secure and maintain a clearance relative to fire safety from the State Fire Marshal.

Each facility shall develop a written plan to be implemented when a discontinuance or disruption of service occurs.

The clinical director shall be responsible for informing the Department, via telephone, telegraph or Emergency radio network, immediately upon being notified of the intent of the discontinuance or disruption of services or upon the threat of a walkout of a substantial number of employees, or upon occurrence of earthquake, fire, power outage or other calamity that causes damage to the facility or threatens the safety or welfare of patients.

Persons with a communicable disease that is required to be reported by Title 17, California Administrative Code, Section 2500, shall not be admitted to the facility.

A patient who after admission is diagnosed as having a reportable communicable disease or being a carrier shall be promptly transferred to a facility capable of accommodating such patients.

Psychiatric health facilities are to develop alternative treatment settings for patients with communicable diseases.
When a patient's particular disease would ordinarily be treated on an outpatient basis absent the mental condition, the facility may admit the patient only if the facility has appropriate policies, procedures and resources to ensure safety of the staff and other patients from the disease.

Unusual occurrences shall be reported by the facility, within 24 hours, either by telephone with written confirmation, or by telegraph to the county mental health director and the Department.

An unusual occurrence report shall be retained on file by the facility for three years.

The facility shall furnish other pertinent information related to such occurrences as the county mental health director or the Department may require.

A facility admitting a patient exhibiting a physical injury or presenting a condition caused by neglect shall immediately notify a physician and request a physical examination of the patient. If, in the opinion of the examining physician, the injury or condition appears to be the result of neglect or abuse, the facility shall report such fact by telephone, and in writing, within 24 hours of the patient's admission, to the Department, the local police authority having jurisdiction, and the county mental health department. Written reports in the patient's health record shall state the character and extent of the physical injury or condition.

Every fire or explosion which occurs in or on the premises shall be reported immediately to the local fire authority, or in areas not having an organized fire service to the State Fire Marshal.

All suspected criminal acts in or on the premises by or against patients, employees or visitors shall be reported to the local police authority and the Department within 24 hours.

The facility shall maintain a health record service in accordance with accepted professional standards and practices. The health record service shall have sufficient staff, facilities and equipment and be conveniently located to facilitate the accurate processing, checking, indexing and filing of all health records.

The health record service shall be under the direction of a staff member who has training and experience in records administration. This designated staff member shall be assisted by such qualified personnel as are necessary to conduct the service. A registered record administrator or accredited records technician shall provide consultation as necessary to designated staff members responsible for record administration.

If a facility, in addition to inpatient services, is providing outpatient or day treatment or crisis intervention, a unit health record system shall be established.

The facility shall have a continuing system of collecting and recording data that describe patients served in such form as to provide for continuity of care, programming services, and data retrieval for program, patient care evaluation, and research. Health records shall be stored and systematically organized to facilitate retrieving of information.

Policies and procedures shall be established and implemented to ensure the confidentiality of an authorized access to patient health information, in accordance with federal, state and local laws and acceptable standards of practice.

Each patient's health record shall consist of at least the following:

Admission and discharge record identification data including, but not limited to, the following:

• Name
• Address on admission
• Patient identification number
• Social Security number
• Date of birth
• Sex
• Marital status
• Legal status.
• Religion (optional on part of patient)
• Date of admission
• Date of discharge
• Name, address and telephone number of person or agency responsible for patient.
• Initial diagnostic impression
• Discharge or final diagnosis.
• Disposition, including aftercare arrangements, plus a copy of the aftercare plan prepared pursuant to Section 1284, Health and Safety code, if the patient was placed in the facility under a county Short-Doyle plan
• Mental status
• Medical history and physical examination
• Dated and signed observations and progress notes recorded as often as the patient's condition warrants by the person responsible for the care of the patient
• Any necessary legal authorization for admission.
• Consultation reports
• Medication treatment and diet orders
• Social service evaluation, if applicable
• Psychological evaluations, if applicable
• Dated and signed patient care notes including, but not limited to, the following:
• Concise and accurate records of nursing care provided.
• Records of pertinent nursing observations of the patient and the patient's response to treatment.
• The reasons for the use of and the response of the patient to PRN medication administered and justification for withholding scheduled medications.
• Record of type of restraint, including time of application and removal as outlined in Section 77103.
• Rehabilitation evaluation, if applicable.
• Interdisciplinary treatment plan.
• Progress notes including the patient's response to medication and treatment rendered and observation(s) of patient by all members of treatment team providing services to the patient.
• Medication records including name, dosage and time of administration of medications and treatments given. The route of administration and site of injection shall be recorded if other than by oral administration.
• Treatment records including group and individual psychotherapy, occupational therapy, recreational or other therapeutic activities provided.
• Vital sign sheet.
• Consent forms as required, signed by patient or person responsible for patient.
• All dental records, if applicable.
• Reports of all laboratory tests ordered.
• Reports of all cardiographic or encephalographic tests performed.
• Reports of all X-ray examinations ordered
• All reports of special studies ordered.
• Acknowledgment in writing of patient's rights, as required in Section 77099, signed by patient or person responsible for the patient.
• Denial of patient rights documentation.
• A discharge summary prepared by the admitting practitioner which shall briefly recapitulate the significant findings and events of the patient's treatment, his/her condition on discharge and the recommendation and arrangements for future care.

Records shall be kept on all patients admitted or accepted for treatment. All required records, either as originals or as accurate reproductions of the contents of such originals, shall be maintained in a confidential manner, legible and readily accessible upon request of persons authorized by law to have access to such records including, but not limited to, persons authorized pursuant to Health and Safety Code, Section 25250 et seq., those professional persons who are providing services to the patient and authorized representatives of the Department.

The facility shall safeguard the information in the record against loss, defacement, tampering or use by unauthorized persons.

Patient health records or reproductions thereof, shall be safely preserved for a minimum of seven years following discharge of the patient, except that the records of unemancipated minors shall be kept at least one year after such minor has reached the age of 18 years and, in any case, not less than seven years.

If a facility ceases operation, the Department shall be informed, within 48 hours prior to cessation, of the arrangements made for safe preservation of patient health records.

If ownership of a licensed facility changes, both the previous licensee and the new licensee shall, prior to the change of ownership, provide the Department with written documentation that arrangements have been made for the retention and preservation of all patient records.

Patient records shall be filed in an easily accessible manner in the facility or in an approved health record storage facility off the facility premises.

Patient records shall be completed within 14 days following the patient's discharge.

All information and records obtained in the course of providing services under Division 5 (commencing with Section 5000), Division 6 (commencing with Section 6000), or Division 7 (commencing with Section 7000) of the Welfare and Institutions Code to either voluntary or involuntary recipients of services shall be confidential and may be disclosed only in accordance with Sections 5328 through 5330 of the Welfare and Institutions Code.

No licensee shall use patients' monies or valuables as its own or mingle them with its own. Patients' monies and valuables shall be separate, intact and free from any liability the licensee incurs in the use of the licensee's or the facility's funds and valuables.

Each licensee shall maintain accurate records of patients' monies and valuables entrusted to its care. Such records shall include but not be limited to:

A control account for all recipients and expenditures kept current with columns for debits, credits and balances.

An account for each patient with supporting vouchers filed in chronological order and kept current with columns for debits, credits and balances.

Records of patients' monies and other valuables entrusted to the licensee for safe keeping shall include a copy of the receipt furnished to the patient or to the person responsible for the patient.

Patients' monies entrusted to the psychiatric health facility shall be kept in a fireproof safe on the premises of the psychiatric health facility or deposited in a demand trust account in a local bank authorized to do business in California and whose deposits are insured by the Federal Deposit Insurance Corporation. A county psychiatric health facility may deposit such funds with the county treasurer.