(1) The definitions in this subsection apply throughout this section, unless the context clearly requires otherwise:

(a) "Admission," "admitting," and "admit" means acceptance into outpatient treatment services provided by a 23-hour crisis relief center.

(b) "Adolescent" means the same as in RCW 71.34.020.

(d) "Minor" means any person ages eight through 17 years of age.

(e) "Parent" has the same meaning as defined in RCW 26.26A.010, including:

(i) Either parent if custody is shared under a joint custody agreement; or

(ii) A person or agency judicially appointed as legal guardian or custodian of the minor; or

(iii) For purposes of treatment of a minor, without the minor's consent, at the request of a parent, "parent" also includes a person to whom a parent, defined in (e)(i) and (ii) of this subsection, has given a signed authorization to make health care decisions for the minor, a stepparent who is involved in caring for the minor, a kinship caregiver who is involved in caring for the minor, or another relative who is responsible for the health care of the minor, who may be required to provide a declaration under penalty of perjury stating that they are a relative responsible for the health care of the minor pursuant to chapter 5.50 RCW. If a dispute arises between individuals authorized to act as a parent for the purpose of consenting to care of the minor at a 23-hour crisis relief center, the disagreement must be resolved according to the priority established under RCW 7.70.065 (2)(a).

(2) An agency certified for 23-hour crisis relief center services provides services to address mental health and substance use crisis issues which may include treatment of chemical withdrawal symptoms. 23-hour crisis relief center services under this certification include:

(a) Adult crisis relief services; and

(b) Minor crisis relief services.

(3) General requirements: An agency certified for 23-hour crisis relief center services must:

(a) Follow requirements for outpatient crisis services in WAC 246-341-0901;

(b) Provide services to address mental health and substance use crisis issues which may include treatment of chemical withdrawal symptoms;

(c) Limit ((patient)) stays to a maximum of 23 hours and 59 minutes, except in the following circumstances in which the ((patient))person may stay up to a maximum of 36 hours when:

(i) ((A patient))The admitted person is waiting on a designated crisis responder evaluation; or

(ii) ((A patient))The admitted person is making an imminent transition to another setting as part of an established aftercare plan. This may include, but is not limited to, a minor who is:

(A) Allegedly abandoned according to RCW 13.34.030, and is receiving support from the department of children, youth, and families (DCYF);

(B) Transitioning to an alternative placement option; or

(d) Be staffed 24 hours a day, seven days a week, with a multidisciplinary team capable of meeting the needs of ((individuals))persons experiencing all levels of crisis in the community including, but not limited to, nurses, department-credentialed professionals who can provide mental health and substance use disorder assessments, peers, and access to a prescriber;

(e) Offer walk-in options and drop-off options for first responders and persons referred through the 988 system, without a requirement for medical clearance for these ((individuals))persons;

(f) Have staff serving minors with documented training, experience, or credentials in pediatric care applicable to the services they are providing;

(g) Only accept emergency medical services drop-offs of ((individuals))persons determined to be medically stable by emergency medical services in accordance with department guidelines on transport to behavioral health service facilities developed pursuant to RCW 70.168.170 ((())and published as form DOH 530-262. Copies of the guidelines are available at https://doh.wa.gov/BHA or by contacting the department at ochsfacilities@doh.wa.gov or 360-236-2957.

(((g)))(h) Only accept for admission, walk-ins, first responder drop-offs, and referrals through the 988 system of minors who are able to consent to their own care or who are accompanied by a person legally able to consent to treatment;

(i) Have a no refusal policy for law enforcement drop-offs, including tribal law enforcement;

(((h)))(j) Provide the ability to dispense medications and provide medication management in accordance with WAC 246-337-105, except that references to residential treatment facilities (RTF) in WAC 246-337-105 shall be understood to mean behavioral health agency (((BHA)));

(((i)))(k) Maintain capacity to deliver minor wound care for nonlife-threatening wounds, and provide care for most minor physical or basic health needs that can be identified and addressed through a nursing assessment;

(((j)))(l) Identify pathways to transfer ((individuals))persons to more medically appropriate services if needed;

(((k)))(m) If restraint or seclusion are used, follow requirements in WAC 246-337-110 (3) through (19) except that references to RTF in WAC 246-337-110 shall be understood to mean behavioral health agency (((BHA)));

(((l)))(n) Establish and maintain relationships with entities capable of providing for reasonably anticipated ongoing service needs of ((clients))admitted persons, unless the licensee itself provides sufficient services:

(i) For ((individuals))admitted persons identifying as American Indian/Alaska Native (AI/AN), relationships will ((be with))include tribal behavioral health systems;

(ii) For ((individuals))admitted persons identifying as veterans, relationships will ((be with))include the local/regional Veterans Administration Medical Center (VAMC) or the Washington state department of veterans affairs (WDVA) or both;

(iii) For facilities serving minors, relationships will include the DCYF;

(((m)))(o) When appropriate, coordinate connection to ongoing care; and

(((n)))(p) Have an infection control plan inclusive of:

(i) Hand hygiene;

(ii) Cleaning and disinfection;

(iii) Environmental management; and

(iv) Housekeeping functions.

(((2)))(4) Orientation and initial screening: An agency certified for 23-hour crisis relief center services must:

(a) Orient all ((walk-ins and drop-offs))persons who present for admission upon arrival including the person(s) presenting a minor for admission;

(b) Screen all ((individuals))persons for:

(i) Suicide risk and, when clinically indicated, engage in comprehensive suicide risk assessment and planning;

(ii) Violence risk and, when clinically indicated, engage in comprehensive violence risk assessment and planning;

(iii) Nature of the crisis; and

(iv) Physical and cognitive health needs((,)) including, for persons over the age of 30, dementia screening;

(i) Document and make available to the department instances of declined admissions, including those that were not eligible for admission, declined due to no capacity, or those declined for any other reason;

(ii) Provide support to the ((individual))person to identify and, when appropriate, access services or resources necessary for the ((individual's))person's ongoing health and safety.

(((3)))(5) Admission: An agency certified for 23-hour crisis relief center services must:

(a) Accept eligible admissions 90 percent of the time when the facility is not at its full capacity; and

(b) Provide an assessment appropriate to the nature of the crisis to each ((individual))person admitted to a recliner. The assessment must be age appropriate and inform the person of the interval for monitoring the ((individual))person based on their medical condition, behavior, suspected drug or alcohol misuse, and medication status.

(((4)))(6) For the purposes of this section:

(a) Eligible admission includes individuals ((18))eight years of age or older who:

(i) Do not require a secure facility as described in WAC 246-341-1131 (2)(b);

(ii) Are able to consent to their own treatment, or are accompanied by a person that may provide legal consent to treat;

(iii) Are identified upon screening as needing behavioral health crisis services((,)); and ((whose))

(iv) Have physical health needs that can be addressed by ((the))23-hour crisis relief center services in accordance with subsection (((1)(i)))(3)(k) of this section;

(b) Full capacity means all certified recliners are occupied by ((individuals))persons receiving 23-hour crisis relief center services;

(c) An agency may temporarily exceed the number of certified recliners only to comply with the no refusal policy for law enforcement, up to the maximum occupancy allowed by the local building department for ((patient)) care spaces within the licensed unit;

(d) A recliner means a piece of equipment used by ((individuals))persons receiving 23-hour crisis relief center services that can be in a sitting position and fully reclined.

(((5)))(7) An agency certified to provide 23-hour crisis relief center services must be constructed in such a way to be responsive to the unique characteristics of the types of interventions used to provide care for all levels of behavioral health acuity and accessibility needs. These rules are not retroactive and are intended to be applied as outlined below.

(a) The construction review rules in subsections (((6)))(8) and (((7)))(9) of this section will be applied to the following agencies who are providing 23-hour crisis relief center services:

(i) New buildings to be certified to provide 23-hour crisis relief center services;

(ii) Conversion of an existing building, or portion of an existing building certified, or to be certified to provide 23-hour crisis relief center services;

(iii) Additions to an existing building certified, or to be certified, to provide 23-hour crisis relief center services;

(iv) Alterations to an existing building certified, or to be certified, to provide 23-hour crisis relief center services;

(v) Buildings or portions of buildings certified to provide 23-hour crisis relief center services and used for providing 23-hour crisis relief center services; and

(vi) Excludes ((nonpatient))noncare care buildings used exclusively for administration functions.

(b) The requirements of this chapter in effect at the time the complete construction review application and fee are received by the department, apply for the duration of the construction project.

(((6)))(8) Standards for design and construction.

Facilities constructed and intended for use under this section shall comply with:

(a) The following sections of the 2022 edition of the Guidelines for Design and Construction of Hospitals as developed by the Facility Guidelines Institute and published by the Facility Guidelines Institute, 9750 Fall Ridge Trail, St. Louis, MO 63127 (copies available at https://www.fgiguidelines.org or by contacting the department at ochsfacilities@doh.wa.gov or 360-236-2957):

(i) 1.1 Introduction;

(ii) 1.2 Planning, Design, Construction, and Commissioning;

(iii) 2.1 Common Elements for Hospitals;

(iv) 2.2 - 3.2 Specific Requirements for General Hospitals, Behavioral Health Crisis Unit;

(v) Part 4: Ventilation of Health Care Facilities; and

(b) The following specific requirements:

(i) A public walk-in entrance;

(ii) A designated area for first responder drop-off;

(iii) A bed in a private space for ((individuals))persons who are admitted for greater than 24 hours per subsection (((1)))(3)(c) of this section;

(iv) A system or systems within the building that give staff awareness of the movements of ((individuals))admissions within the facility. If a door control system is used, it shall not prevent an ((individual))admission from leaving the licensed space on their own accord, except temporary delays. Such systems include:

(A) Limited egress systems consistent with state building code, such as delayed egress;

(B) Appropriate staffing levels to address safety and security; and

(C) Policies and procedures that are consistent with the assessment of the ((individual's))person's care needs and plan and do not limit the rights of a voluntary ((individual))admission;

(v) Access to a telephone for ((individuals))persons receiving services; and

(vi) A facility used for both minor and adult services must include separate internal entrances, spaces, and treatment areas such that no contact occurs between minor and adult 23-hour crisis relief center services admitted persons.

(((7)))(9) Construction review process.

(a) Preconstruction. The applicant or licensee must request and attend a presubmission conference with the department for projects with a construction value of $250,000 or more. The presubmission conference shall be scheduled to occur at the end of the design development phase or the beginning of the construction documentation phase of the project.

(b) Construction document review. The applicant or licensee must submit accurate and complete construction documents for proposed new construction to the department for review within 10 business days of submission to the local authorities. The construction documents must include:

(i) A written functional program outlining the types of services provided, types of ((individuals))persons to be served, and how the needs of the ((individuals))person will be met including a narrative description of:

(A) Program goals;

(B) Staffing and health care to be provided, as applicable;

(D) Safety and security efforts;

(E) Restraint and seclusion, if used;

(F) Medication storage; and

(G) Housekeeping;

(ii) Drawings prepared, stamped, and signed by an architect or engineer licensed by the state of Washington under chapter 18.08 RCW. The services of a consulting engineer licensed by the state of Washington may be used for the various branches of the work, if appropriate;

(iii) Drawings with coordinated architectural, mechanical, and electrical work drawn to scale showing complete details for construction;

(iv) Specifications that describe with specificity the workmanship and finishes;

(v) Shop drawings and related equipment specifications;

(vi) An interim life safety measures plan to ensure the health and safety of occupants during construction and renovation; and

(vii) An infection control risk assessment indicating appropriate infection control measures, including keeping the surrounding occupied area free of dust and fumes during construction, and ensuring rooms or areas are well ventilated, unoccupied, and unavailable for use until free of volatile fumes and odors.

(((8)))(10) Copies of the reference material listed in subsections (((1)(f)))(3)(g) and (((6)))(8)(a) of this section are available for public inspection at the department's office at Department of Health, Town Center 2, 111 Israel Road S.E., Tumwater, WA 98501.

(11) An agency providing 23-hour crisis relief center services for minors must follow these additional requirements. The agency must:

(a) Adopt and implement policies defining how differing age groups will be appropriately separated;

(b) Ensure all staff members that interact with minors are trained in techniques for dealing with a minor's behavior, including:

(i) Verbal de-escalation;

(ii) Crisis intervention;

(iii) Emotional regulation;

(iv) Suicide assessment and intervention;

(v) Conflict management and problem-solving skills;

(vi) Management of assaultive behavior;

(vii) Proper use of therapeutic physical intervention techniques; and

(viii) Emergency procedures.

(c) Inform all employees, consultants, and contractors of mandatory reporting responsibilities and requirements in accordance with state law, including WAC 246-341-0605, and require documentation in the individual service record when an oral or written report has been made. Documentation must include:

(i) The date and time that the report was made;

(ii) The entity or entities to which the report was made; and

(iii) The signature of the person making the report; and

(d) Develop and implement policies and procedures for the temporary detention of the person for evaluation regarding involuntary commitment in compliance with RCW 71.34.445.

(12) Admission of minors:

(a) When admitting a minor age eight through 12 years of age, the 23-hour crisis relief center services must:

(i) Obtain legal consent to treat for admission and provision of behavioral health care in accordance with RCW 7.70.065.

(ii) Require those who are consenting to treatment of the minor, to either stay at the facility with the minor during treatment, be available by phone, or sign consents regarding alternative discharge plans or custody arrangements.

(b) When admitting an adolescent age 13 years through 17 years of age the agency must:

(i) Obtain documented consent from either the parent of the adolescent or the adolescent themselves in accordance with RCW 71.34.530.

(ii) Only offer 23-hour crisis relief center services to an adolescent, without the need for parental consent, if, following the initial screening performed pursuant to subsection (4) of this section, a professional person, as defined in RCW 71.34.020, agrees with the need for either:

(A) Mental health care;

(B) Substance use care; or

(iii) Immediately consult the information that the Washington state patrol makes publicly available under RCW 43.43.510(2) if an adolescent is offered and consents to receiving 23-hour crisis relief center services without parental consent. If the adolescent is publicly listed as missing, the agency must immediately notify the Washington state patrol's missing persons unit of its contact with the adolescent listed as missing.

(iv) Only offer 23-hour crisis relief center services to an adolescent, presented to the agency by a parent requesting an initial screening pursuant to RCW 71.34.650, if, following the initial screening performed pursuant to subsection (4) of this section, a professional person, as defined in RCW 71.34.020, agrees with the need for mental health care, substance use care, or both. If the adolescent declines admission, the declination is to be reported in accordance with subsection (4)(c) of this section.

(13) Discharge of minors:

(a) When discharging minors, the 23-hour crisis relief center must develop and implement policies and procedures that include, but are not limited to:

(i) Only permitting discharge or transfer of a minor to another health care facility if the minor is in need of a higher level of behavioral health treatment or needs medical attention that is beyond the scope of 23-hour crisis relief center services;

(ii) Requiring DCYF contact for assistance if a parent has expressed, either through statement or conduct, that they are unwilling to exercise their parental rights and responsibilities, including an unwillingness to take custody of the minor upon discharge from the facility;

(iii) How the agency will begin seeking alternative discharge options and notification of law enforcement if the minor is not a dependent of the state, and alternative discharge options cannot be found;

(iv) How the agency will contact DCYF if the minor is found to be a dependent of the state as soon as feasible, but no longer than two hours of the agency becoming aware;

(v) Contacting alternative legal guardians, as appropriate;

(vi) How the agency will coordinate with local law enforcement, including tribal law enforcement;

(vii) Identifying and contacting specific placement options of the dependent child; and

(viii) Requiring documentation of all discharge efforts made.

(b) When discharging a minor age eight through 12 years of age, the 23-hour crisis relief center must, in addition to the policies and procedures listed in (a) of this subsection, also develop and implement a policy that discharge may only be to a parent or custodial guardian unless the parent has signed consent for an alternative or otherwise permitted by law.

(c) When discharging an adolescent age 13 through 17 years of age, the 23-hour crisis relief center must develop and implement the following policies and procedures in addition to those listed in (a) of this subsection:

(i) Requiring referral to DCYF's youth and young adult housing response team for adolescents experiencing homelessness; and

(ii) Discharge of adolescents consenting to their own treatment who request to be discharged without the supervision of a parent.