WSR 12-15-074

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Aging and Disability Services Administration)

[ Filed July 18, 2012, 9:35 p.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 11-20-101.

Title of Rule and Other Identifying Information: New sections WAC 388-865-0800 Triage facility -- Definitions, 388-865-0810 Triage facility -- General requirements for certification, 388-865-0820 Triage facility -- Memo of understanding and other requirements, 388-865-0830 Triage facility -- Seclusion and restraint, 388-865-0840 Triage facility -- Admission, assessment, and clinical record requirements for voluntary and involuntary admissions, 388-865-0850 Triage facility -- Triage stabilization plan, 388-865-0860 Triage facility -- Discharge services for voluntary and involuntary admissions, 388-865-0870 Triage facility -- Staff requirements, and 388-865-0880 Triage facility -- Posting of individual rights.

Hearing Location(s): Office Building 2, Lookout Room, DSHS Headquarters, 1115 Washington, Olympia, WA 98504 (public parking at 11th and Jefferson. A map is available at http://www1.dshs.wa.gov/msa/rpau/RPAU-OB-2directions.html), on September 4, 2012, at 10:00 a.m.

Date of Intended Adoption: Not earlier than September 5, 2012.

Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504, e-mail DSHSRPAURulesCoordinator@dshs.wa.gov, fax (360) 664-6185, by 5 p.m. on September 4, 2012.

Assistance for Persons with Disabilities: Contact Jennisha Johnson, DSHS rules consultant, by August 25, 2012, TTY (360) 664-6178 or (360) 664-6094 or by e-mail at jennisha.johnson@dshs.wa.gov.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: These rules meet the requirements of chapter 148, Laws of 2011 (SHB 1170) which directs the department to add "triage facilities" to the types of facilities to which a law enforcement officer may take an individual who is suffering from a mental disorder and who either presents an imminent likelihood of serious harm, is in imminent danger because of being gravely disabled, or has committed a nonfelony offense that is not a serious offense. The rules will establish state minimum standards for certification of triage facilities.

Reasons Supporting Proposal: See Purpose above.

Statutory Authority for Adoption: RCW 71.05.020, 71.05.150, 71.05.153, and 71.24.035, chapter 148, Laws of 2011 (SHB 1170).

Statute Being Implemented: RCW 71.05.020, 71.05.150, 71.05.153, and 71.24.035.

Rule is not necessitated by federal law, federal or state court decision.

Name of Proponent: Department of social and health services, governmental.

Name of Agency Personnel Responsible for Drafting: Kathy Sayre, P.O. Box 45330, Olympia, WA 98504-5330, (360) 725-1342; Implementation and Enforcement: Pete Marburger, P.O. Box 45330, Olympia, WA 98504-5330, (360) 725-1513.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The preparation of a small business economic impact statement is not required, as no new costs will be imposed on small businesses or nonprofits.

A cost-benefit analysis is not required under RCW 34.05.328. These rules are exempt under RCW 34.05.328 (5)(b)(v) as they are explicitly and specifically dictated by statute.

July 13, 2012

Katherine I. Vasquez

Rules Coordinator

4353.3SECTION EIGHT--CERTIFICATION OF TRIAGE FACILITIES
NEW SECTION
WAC 388-865-0800   Triage facility--Definitions.   The following definitions apply to this chapter:

"Designated mental health professional (DMHP)" See WAC 388-865-0150.

"Mental health professional (MHP)" See WAC 388-865-0150.

"Peace officer" means a law enforcement official of a public agency or governmental unit, and includes persons specifically given peace officer powers by any state law, local ordinance, or judicial order of appointment.

"Triage facility" is a short-term facility or a portion of a facility licensed by the department of health and certified by the department of social and health services under RCW 71.24.035, which is designed as a facility to assess and stabilize an individual or determine the need for involuntary commitment of an individual. A triage facility must meet department of health residential treatment facility standards and may be structured as a voluntary and/or involuntary placement facility.

"Triage involuntary placement facility" is a triage facility that has elected to operate as an involuntary facility and may, at the direction of a peace officer, hold an individual for up to twelve hours. A peace officer or designated mental health professional may take or cause the person to be taken into custody and immediately delivered to the triage facility. The facility may ask for an involuntarily admitted individual to be assessed by a mental health professional for potential for voluntary admission. The individual has to agree in writing to the conditions of the voluntary admission.

"Triage voluntary placement facility" is a triage facility wherein the individual may elect to leave the facility of their own accord, at anytime. A triage voluntary placement facility may only accept voluntary admissions.

"Short-term facility" is a facility licensed by the department of health and certified by the department of social and health services under RCW 71.24.035 which has been designed to assess, diagnose, and treat individuals experiencing an acute crisis without the use of long-term hospitalization. Length of stay in a short-term facility is less than fourteen days from the day of admission.

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NEW SECTION
WAC 388-865-0810   Triage facility--General requirements for certification.   Under chapter 71.05 RCW, the department certifies facilities to provide triage services that assess and stabilize an individual, or determine the need for involuntary commitment.

(1) To obtain and maintain certification as a triage facility (defined in WAC 388-865-0800), a facility must:

(a) Be licensed by the department of health (DOH) as a residential treatment facility;

(b) Meet the requirements for voluntary admissions under this chapter;

(c) Meet the requirements for involuntary admissions under this chapter if it elects to operate and be certified as a triage involuntary placement facility;

(d) Ensure that the facility and its services are accessible to individuals with disabilities, as required by applicable federal, state, and local laws; and

(e) Successfully complete a provisional and annual on-site review administered by the department's division of behavioral health and recovery (DBHR) and be determined by DBHR to be in compliance with the standards of this chapter and chapter 72.06 RCW.

(2) If a triage facility is collocated in another facility, there must be a physical separation. Physically separate means the triage facility is located in an area with no resident foot traffic between the triage facility and other areas of the building, except in case of emergencies.

(3) A triage facility must have, at a minimum:

(a) A written organizational structure that describes clear lines of authority of administrative oversight and clinical supervision.

(b) A designated person in charge of administration of the triage unit.

(c) A mental health professional (MHP) on-site twenty-four hours a day, seven days a week.

(d) A written program description that includes:

(i) Program goals;

(ii) Identification of service categories to be provided;

(iii) Length of stay criteria;

(iv) Identification of the ages or range of ages of individual populations to be served;

(v) A statement that only an individual eighteen years of age or older may be admitted to the triage facility; and

(vi) Any limitation or inability to serve or provide program services to an individual who:

(A) Requires acute medical services;

(B) Has limited mobility;

(C) Has limited physical capacity for self care; or

(D) Exhibits physical violence.

(e) A quality management plan to ensure the facility monitors, collects appropriate data, and develops improvements to meet the requirements of this chapter.

(f) Written procedures to ensure a secure and safe environment. Examples of these procedures are:

(i) Visual monitoring of the population environment by line of sight, mirrors or electronic means;

(ii) Having sufficient staff available twenty-four hours a day, seven days a week to meet the behavioral management needs of the current facility population; and

(iii) Having staff trained in facility security and behavioral management techniques.

(g) Written procedures to ensure that an individual is examined by an MHP within three hours of the individual's arrival at the facility.

(h) Written procedures to ensure that a designated mental health professional (DMHP) evaluates a voluntarily admitted individual for involuntary commitment when the individual's behavior warrants an evaluation.

(i) Written procedures that are in accordance with WAC 246-322-180, 246-337-110, 246-320-271, and WAC 388-865-0545, if the triage facility declares any intent to provide seclusion and/or restraint.

(j) Written procedures to facilitate appropriate and safe transportation, if necessary, for an individual who is:

(i) Not being held for police custody and/or police pick up;

(ii) Denied admission to the triage facility; or

(iii) Detained for transfer to a certified evaluation and treatment facility.

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NEW SECTION
WAC 388-865-0820   Triage facility--Memo of understanding and other requirements.   This section applies to a facility that elects to operate as a triage involuntary placement facility.

(1) Memo of understanding requirements. The facility must have a memo of understanding developed in consultation with local law enforcement agencies, which details the population that the facility has capacity to serve. The memo of understanding must include, at a minimum, a description of the facility's:

(a) Capacity to serve individuals with medication, medical and/or accommodation needs;

(b) Capacity to serve individuals with behavioral management needs;

(c) Ability to provide seclusion and/or restraint to individuals (see WAC 388-865-0830);

(d) Notification procedures for discharge of individuals (see WAC 388-865-0850); and

(e) Procedures for notifying the appropriate law enforcement agency of an individual's release, transfer, or hold for up to twelve hours to allow the peace officer to reclaim the individual.

(2) Individuals brought to a triage involuntary placement facility by a peace officer. The facility must have written procedures to assure the following:

(a) An individual detained by the designated mental health professional (DMHP) under chapter 71.05 RCW with a confirmed admission date to an evaluation and treatment facility, may remain at the triage facility until admitted to the evaluation and treatment facility.

(i) The individual may not be detained to the triage facility; and

(ii) An individual who agrees to a voluntary stay must provide a signature that documents the agreement.

(b) The individual is examined by a mental health professional (MHP) within three hours of the individual's arrival at the facility, and the examination includes an assessment to determine if a designated mental health professional (DMHP) evaluation is also required.

(c) If it is determined a DMHP evaluation is required, the DMHP must evaluate the individual within twelve hours of arrival. The DMHP determines whether the individual:

(i) Meets detention criteria under chapter 71.05 RCW; or

(ii) Agrees to accept voluntary admission. The individual must provide a signature agreeing to voluntary treatment.

(3) Individuals involuntarily admitted to a triage involuntary placement facility based on a peace officer-initiated twelve-hour hold. The facility must ensure each involuntarily admitted individual's clinical record:

(a) Documents the date and time the individual arrived at the facility and the date and time the examination by the mental health professional (MHP) occurred. The examination must occur within three hours of the individual's arrival to the facility (see WAC 388-865-0840(2)).

(b) Documents the peace officer's:

(i) Determination for cause to have the individual transported to the facility;

(ii) Request to be notified if the individual leaves the facility and how the peace officer is to be contacted, or documentation of other person(s) permitted to be contacted, such as the shift supervisor of the law enforcement agency or dispatcher; and

(iii) Request that the individual be held for the duration of the twelve hours to allow the peace officer sufficient time to return and make a determination as to whether or not to take the individual into custody.

(c) Contains a copy of the evaluation if the individual is determined by a designated mental health professional (DMHP) to meet detention criteria under chapter 71.05 RCW.

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NEW SECTION
WAC 388-865-0830   Triage facility--Seclusion and restraint.   A triage facility must declare to the department any intention to provide seclusion and/or restraint (see WAC 388-865-0810 (3)(i)).

(1) The seclusion and/or restraint may only be used:

(a) To the extent necessary for the safety of the individual or others and in accordance with WAC 246-322-180 and 246-337-110, 246-320-271, and WAC 388-865-0545; and

(b) When all less restrictive measures have failed.

(2) The facility must clearly document in the clinical record:

(a) The threat of imminent danger;

(b) All less restrictive measures that were tried and found to be ineffective; and

(c) A summary of each seclusion and/or restraint event, including a debriefing with staff members and the individual regarding how to prevent the occurrence of similar incidents in the future.

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NEW SECTION
WAC 388-865-0840   Triage facility--Admission, assessment, and clinical record requirements for voluntary and involuntary admissions.   A triage facility must ensure the requirements in this section are met for each voluntary and involuntary admission. See WAC 388-865-0820(2) for additional requirements for an individual brought to a triage involuntary placement facility by a peace officer. See WAC 388-865-0820(3) for additional requirements for an individual involuntarily admitted to a triage involuntary placement facility based on a peace officer-initiated twelve-hour hold.

(1) Each individual must be assessed for chemical dependency and/or a co-occurring mental health and substance abuse disorder as measured by the global appraisal on individual need-short screen (GAIN-SS) as it existed on the effective date of this section, or such subsequent date consistent with the purposes of this section. The clinical record must contain the results of the assessment.

(2) Each individual must be assessed by a mental health professional (MHP) within three hours of the individual's arrival at the facility.

(a) The assessment must include, at a minimum:

(i) A brief history of mental health or substance abuse treatment; and

(ii) An assessment of risk of harm to self, others, or grave disability.

(b) The MHP must request:

(i) The names of treatment providers and the treatment provided; and

(ii) Emergency contact information.

(c) The MHP must document in the individual's clinical record:

(i) All the information obtained in (a) and (b) of this subsection.

(ii) Sufficient information to demonstrate medical necessity. Medical necessity is defined in the state plan as "A term for describing a requested service which is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent the worsening of conditions in the recipient that endanger life, or cause suffering or pain, or result in illness or infirmity, or threaten to cause or aggravate a handicap, or cause of physical deformity or malfunction, and there is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the person requesting service. For the purpose of this chapter "course of treatment" may include mere observation, or where appropriate, no treatment at all."

(iii) Sufficient clinical information to justify a provisional diagnosis using criteria in the:

(A) Diagnostic and Statistical Manual of Mental Disorders (2000) (American Psychiatric Association (DSM-IV-TR), 2000), as it existed on the effective date of this section; then

(B) DSM-5 as it exists when published and released in 2013, consistent with the purposes of this section. Information regarding the publication date and release of the DSM-5 is posted on the American Psychiatric Association's public website at www.DSM5.org.

(3) Each individual must receive a health care screening to determine the individual's health care needs.

(a) The health care screening instrument must be provided by a licensed health care provider (defined in WAC 246-337-005(22)). A licensed health care provider must be available to staff for staff consultation twenty-four hours a day, seven days a week.

(b) The individual's clinical record must contain the results of the health care screening.

(4) A qualified staff member (see WAC 388-865-0870) must coordinate with the individual's current treatment provider, if applicable, to assure continuity of care during admission and upon discharge.

(5) Each individual's clinical record must:

(a) Contain a statement regarding the individual circumstances and events that led to the individual's admission to the facility.

(b) Document the admission date and time.

(c) Contain the results of the health care screening required in (3) of this section.

(d) Document the date and time of a referral to a designated mental health professional (DMHP), if a referral was made.

(e) Document the date and time of release, or date and time the twelve-hour hold ended.

(f) Document any use of seclusion and/or restraint and include:

(i) Documentation that the use of seclusion and/or restraint occurred only due to the individual being an imminent danger to self or others; and

(ii) A description of the less restrictive measures that were tried and found to be ineffective.

(6) A triage facility that declares any intent to provide seclusion and/or restraint to an individual may do so only to the extent necessary for the safety of others and in accordance with WAC 246-322-180, 246-337-110, 246-320-271, and WAC 388-865-0545. See also WAC 388-865-0830.

(7) A triage facility must document the efforts and services provided to meet the individual's triage stabilization plan.

(8) A triage facility must document the date, time, and reason an individual's admission status changed from involuntary to voluntary.

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NEW SECTION
WAC 388-865-0850   Triage facility--Triage stabilization plan.   A triage stabilization plan must be developed for each individual voluntarily or involuntarily admitted to a triage facility for longer than twenty-four hours. For an individual admitted twenty-four hours or less, the facility must document the results of the assessment performed by a mental health professional (MHP) required under WAC 388-865-0840.

(1) The triage stabilization plan must:

(a) Be developed collaboratively with the individual within twenty-four hours of admission.

(b) Improve and/or resolve the individual's crisis in the least restrictive manner possible.

(c) Be written in a language that is understandable to the individual and/or the individual's support system if applicable.

(d) Be mindful of the individual's culture, life style, economic situation, and current mental and physical limitation.

(e) Have goals that are relevant to the presenting crisis and demonstrate how they impact the crisis by improving the individual's ability to function.

(f) Include any recommendation for treatment from the mental health professional (MHP) assessment provided with three hours of the individual's arrival at the facility.

(g) Include:

(i) The date and time the designated mental health professional (DMHP) evaluated the individual in accordance with the detention criteria under chapter 71.05 RCW; and

(ii) The DMHP's determination of whether the individual should be detained.

(2) The individual's clinical record must:

(a) Contain a copy of the triage stabilization plan;

(b) Contain charting that demonstrates how requirements of the individual's triage stabilization were met; and

(c) Document the services provided to the individual.

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NEW SECTION
WAC 388-865-0860   Triage facility--Discharge services for voluntary and involuntary admissions.   A triage facility must:

(1) Provide discharge services for each individual:

(a) Voluntarily admitted to the facility; or

(b) Involuntarily admitted to the facility if the individual is not transferred to another facility.

(2) Coordinate with the individual's current treatment provider, if applicable, to transition the individual back to the provider.

(3) Develop a discharge plan and follow-up services from the triage facility that includes:

(a) The name, address, and telephone number of the provider;

(b) The designated contact person; and

(c) The appointment date and time for the follow-up services, if appropriate.

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NEW SECTION
WAC 388-865-0870   Triage facility--Staff requirements.   A triage facility must ensure each staff member providing services to individuals is qualified to perform the duties within the scope of their position.

(1) The triage facility must document that each staff member has the following:

(a) A current job description.

(b) A current Washington state department of health license or credential as required for performing the job duties and meeting the specific responsibilities of the position.

(c) A Washington state patrol background check consistent with chapter 43.43 RCW.

(d) An annual review and evaluation of work performance.

(e) An individualized annual training plan that assures the employee is provided, at a minimum:

(i) Training relevant to the skills required for the job and the population served by the facility.

(ii) Adequate training regarding the least restrictive alternative options available in the community and how to access them.

(iii) Training that meets the requirements of this chapter and RCW 71.05.720.

(iv) Training that meets the requirements of RCW 71.05.705 if the triage facility is performing outreach services.

(f) Adequate training regarding methods of health care as defined in WAC 246-337-005(19).

(g) Adequate training regarding the proper and safe use of seclusion and/or restraint procedures if the triage facility employs these techniques. See WAC 388-865-0810 (3)(i) and 388-865-0830.

(2) The triage facility must ensure:

(a) Each clinical supervisor and each clinical staff member meets the qualifications of a mental health professional as defined in WAC 388-865-0800; and

(b) A clinical staff member who does not meet the qualifications for an MHP as defined in WAC 388-865-0800 is supervised by an MHP if the staff member provides direct services to individuals.

(c) A contracted staff member who provides direct services to individuals meets the requirements of this section.

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NEW SECTION
WAC 388-865-0880   Triage facility--Posting of individual rights.   (1) A triage facility must ensure the individual rights outlined in WAC 388-865-0410 are:

(a) Prominently posted within the facility;

(b) Available to any individual on request; and

(c) Provided to each individual being assessed and admitted to the facility.

(2) A triage facility that has elected to operate as an involuntary placement facility must meet the requirements in subsection (1) of this section and, in addition, ensure the individual rights outlined in WAC 388-865-0561 are:

(a) Prominently posted within the facility; and

(b) Provided in writing to an individual during the admission process.

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Washington State Code Reviser's Office