902 KAR 20:180. Psychiatric hospitals; operation and services

Link to law: http://www.lrc.ky.gov/kar/902/020/180.htm
Published: 2015

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      902 KAR 20:180.

Psychiatric hospitals; operation and services.



216B.010-216B.131, 216B.175, 216B.990, 311.560(3), (4), 314.011(8), 320.240(14)


KRS 202B.060, 216B.042(1)(a), 216B.175(4)


AND CONFORMITY: KRS 216B.042 require the Kentucky Cabinet for Health Services

to regulate health facilities and health services. This administrative

regulation establishes minimum licensure requirements for the operation and services

of psychiatric hospitals and for the provision of psychiatric services in

general hospitals which have a psychiatric unit.


      Section 1.

Definitions. (1) "Governing authority" means the individual, agency,

partnership, or corporation in which the ultimate responsibility and authority

for the conduct of the institution is vested.


"Professional staff" means psychiatrists and other physicians,

psychologists, psychiatric nurses and other nurses, social workers and other

professionals with special education or experience in the care of persons with

mental illness and who are involved in the diagnosis and treatment of patients

with mental illness.


"Psychiatric unit" means a department of a general acute care

hospital consisting of eight (8) or more psychiatric beds organized for the purpose

of providing psychiatric services.


"Restraint" means the application of a physical device, the application

of physical body pressure by another person in such a way as to control or

limit physical activity, or the intravenous, intramuscular, or subcutaneous

administration of a pharmacologic or chemical agent to a patient with a mental

illness, with the sole or primary purpose of controlling or limiting the

physical activities of the patient.


"Seclusion" means the confinement of a patient with a mental illness

or mental retardation alone in a locked room.


      Section 2.

Applicability. (1)(a) A general acute care hospital with a psychiatric unit


      1. Designate the

location and number of beds for which licensure is sought;

      2. Meet the requirements

of 902 KAR 20:016;

      3. Meet the

requirements of this administrative regulation.

      (b) A facility

requesting licensure as an exclusively psychiatric hospital is subject to this

administrative regulation.

      (2)(a) A facility

shall not be licensed as, or be called, a psychiatric hospital unless it

provides the full range of services required by Section 5 of this

administrative regulation and provides for the treatment of a variety of mental


      (b)1. A facility

with a certificate of need that is licensed after the effective date of this

administrative regulation and that has a mean daily census of patients whose

primary illness is chemical dependency exceeding ten (10) percent of the

licensed bed capacity shall apply for a certificate of need in order to convert

the necessary number of beds to chemical dependency services.

      2. Licensure

requirements are established in 902 KAR 20:160.

      3. Mean daily census

shall be as reported in the last Annual Hospital Utilization Report.


      Section 3.

Administration and Operation. (1) General requirements. A hospital shall comply


      (a) This section;

      (b) 902 KAR 20:016,

Section 3; and

      (c) KRS Chapters

202A and 202B.

      (2) Professional

staff. A facility requesting licensure as an exclusively psychiatric hospital

that operates with an organized professional staff shall comply with the

staffing requirements in this subsection rather than those in 902 KAR 20:016,

Section 3(8):

      (a) A hospital shall

have a professional staff:

      1. Organized under

bylaws approved by the governing authority;

      2. Responsible to

the governing authority for the quality of clinical care provided to patients;


      3. Responsible for

the ethical conduct and professional practice of its members.

      (b) The professional

staff shall develop and adopt bylaws, subject to the approval of the governing

authority, which shall:

      1. Require that a

licensed physician be responsible for admission, diagnosis, all medical care

and treatment, and discharge;

      2. State the

necessary qualifications for professional staff membership;

      3. Define and

describe the responsibilities and duties of each category of professional staff

(e.g., active, associate, courtesy, consulting, or honorary), delineate the

clinical privileges of staff members, and establish a procedure for granting

and withdrawing staff privileges, to include credentials review;

      4. Provide a

mechanism for appeal of decisions regarding staff membership and privileges;

      5. Provide a method

for the selection of officers of the professional staff;

      6. Establish

requirements regarding the frequency of, and attendance at, general staff and

department or service meetings of the professional staff;

      7. Provide for the

appointment of standing and special committees, and include requirements for

composition and organization, and the minutes and reports which shall be part

of the permanent records of the hospital. Committees may include: executive committee,

credentials committee, medical audit committee, medical records committee, infections

control committee, pharmacy and therapeutic committee, utilization review

committee, and quality assurance committee; and

      8. Establish a

policy requiring a physician, or other member of the professional staff

permitted to order diagnostic testing and treatment, to sign telephone orders

for diagnostic testing and treatment within seventy-two (72) hours of the time

the order was given.

      (c) A hospital shall

develop a process of appointment to the professional staff which will assure

that the person requesting staff membership is appropriately licensed,

certified, registered, or experienced, and qualified for the privileges and

responsibilities sought.

      (3) Policies.

      (a) A hospital's

written admission and discharge policies shall be consistent with the

requirements of KRS Chapters 202A and 202B.

      (b) A hospital shall

have written policies pertaining to patient rights and the use of restraints

and seclusion, consistent with KRS Chapters 202A and 202B.

      (c) A hospital shall

have written policies concerning the use of special treatment procedures that

may have abuse potential, or be life-threatening, and shall specify the

qualifications required for professional staff using special treatment


      (4) Patient rights.

A hospital shall assure that patient rights are provided for pursuant to KRS

Chapters 202A and 202B.

      (5) Medical records.

      (a) Patient

information shall be released only on written consent of the patient or the

patient's authorized representative, or as otherwise authorized by law. The

written consent shall contain the following information:

      1. The name of the

person, agency or organization to which the information is to be disclosed;

      2. The specific

information to be disclosed;

      3. The purpose of

disclosure; and

      4. The date the

consent was signed and the signature of the individual witnessing the consent.

      (b) In addition to

the requirements of 902 KAR 20:016, Section 3(11)(d) the medical record shall


      1. Appropriate court

order or consent of patient, authorized family member or guardian for

admission, evaluation, and treatment;

      2. A provisional or

admitting diagnosis which includes a physical diagnosis, if applicable, and a

psychiatric diagnosis;

      3. Results of the

psychiatric evaluation;

      4. A complete social


      5. An individualized

comprehensive treatment plan;

      6. Progress notes,

dated and signed by physician, nurse, social worker, psychologist, or other

individuals involved in treatment of patient. Progress notes shall document

services and treatments provided and the patient's progress in response to the

services and treatments;

      7. A record of the

patient's weight;

      8. Special clinical

justification for the use of special treatment procedures specified in Section

5(3) of this administrative regulation;

      9. A discharge

summary which includes a recapitulation of the patient's hospitalization and

recommendations from appropriate services concerning follow-up or after care,

and a brief summary of the patient's condition on discharge;

      10. If a patient

dies, a summation statement in the form of a discharge summary, including

events leading to the death, signed by the attending physician; and

      11. If an autopsy is

performed, a provisional anatomic diagnosis shall be included in the patient's

record within seventy-two (72) hours, with the complete summary and pathology

report, including cause of death, recorded within three (3) months.


      Section 4. Patient

Management. (1) Assessment. A hospital shall be responsible for conducting a

complete assessment of each patient.

      (a) A provisional or

admitting diagnosis, which includes the diagnosis of physical diseases, if

applicable, and the psychiatric diagnosis, shall be made for each patient at

the time of admission.

      (b) A history and

physical examination shall

be conducted according to the requirements of KRS 216B.175(2).

      1. The history and physical examination

shall include:

      a. A description of the patient's chief

complaint, the major reason for hospitalization;

      b. A history of the patient's:

      (i) Present illness;

      (ii) Past illnesses;

      (iii) Surgeries;

      (iv) Medications;

      (v) Allergies;

      (vi) Social history;

      (vii) Immunizations;

      c. A review of the patient's anatomical

systems and level of function at the time of the exam;

      d. A patient's vital signs;

      e. A general observation of the


      (i) Alertness;

      (ii) Debilities; and

      (iii) Emotional behavior.

      2. The results of the history and

physical examination shall be recorded, reviewed for accuracy, and signed by

the practitioner conducting the examination.

      (c) A psychiatric

evaluation for each patient shall be completed within seventy-two (72) hours of

admission. It shall include a medical history; a record of mental status;

details regarding onset of illness and circumstances leading to admission; a

description of attitudes and behavior; an estimate of intellectual functioning,

memory functioning, and orientation; and an inventory of the patient's assets

in a descriptive, not interpretative, fashion.

      (d) A social

assessment of each patient shall be recorded.

      (e) An activities

assessment of each patient shall be prepared and shall include information

relating to the patient's current skills, talents, aptitudes, and interest.

      (f) When

appropriate, nutritional, vocational, and legal assessments shall be conducted.

The legal assessment shall be used to determine the extent to which the

patient's legal status will influence progress in treatment.

      (2) Treatment plans.

Each patient shall have a written individualized treatment plan that is based

on assessments of his clinical needs and approved by the patient's attending

physician. Overall development and implementation of the treatment plan shall

be assigned to appropriate members of the professional staff.

      (a) Within

seventy-two (72) hours following admission, a designated member of the

professional staff shall develop an initial treatment plan that is based on an

assessment of the patient's presenting problems, physical health, emotional and

behavioral status, and other relevant factors. Appropriate therapeutic efforts

shall begin before a master treatment plan is finalized.

      (b) A master

treatment plan shall be developed by a multidisciplinary team within ten (10)

days for any patient remaining in treatment beyond the initial evaluation. It

shall be based on a comprehensive assessment of the patient's needs and include

a substantiated diagnosis and the short-term and long-range treatment needs and

address the specific treatment modalities required to meet the patient's needs.

      1. The treatment

plan shall include referrals for services not provided directly by the


      2. The treatment

plan shall contain specific and measurable goals for the patient to achieve.

      3. The treatment

plan shall describe the services, activities, and programs to be provided to

the patient, and shall specify staff members assigned to work with the patient

and also the time and frequency for each treatment procedure.

      4. The treatment

plan shall specify criteria to be met for termination of treatment.

      5. The patient shall

participate to the maximum extent feasible in the development of his treatment

plan, and such participation shall be documented in the patient's record.

      6. A specific plan

for involving the patient's family or significant others shall be included in

the treatment plan when indicated.

      7. The treatment

plan shall be reviewed and updated through multidisciplinary case conferences

as clinically indicated, but in no case shall this review and update be

completed later than thirty (30) days following the first ten (10) days of

treatment and every sixty (60) days thereafter for the first year of treatment.

      8. Following one (1)

year of continuous treatment, the review and update may be conducted at three

(3) month intervals.

      (3) Special

treatment procedures.

      (a) Special

documentation shall be included in the patient's medical record concerning the

use of restraints, seclusion and other special treatment procedures which may

have abuse potential or be life threatening.

      (b) The

documentation shall include:

      1. The written order

of a physician, advanced practice registered nurse, or physician's assistant;

      2. Justification for

the use of the procedure;

      3. The required

consent forms;

      4. A description of

procedures employed to protect the patient's safety and rights; and

      5. A description of

the procedure used.

      (c) The use of

physical restraints and seclusion shall be governed by the following:

      1. Restraint or

seclusion shall be used only to prevent a patient from injuring himself or

others, or to prevent serious disruption of the therapeutic program;

      2. A written,

time-limited order from a physician, advanced practice registered nurse, or

physician assistant shall be required for the use of restraint or seclusion;

      3. The head of the

medical staff shall give written approval when restraint or seclusion is

utilized for longer than twenty-four (24) hours;

      4. PRN orders shall

not be used to authorize the use of restraint or seclusion;

      5. The head of the

medical staff or his designee shall review daily all uses of restraint or

seclusion and shall investigate unusual or possibly unwarranted patterns of


      6. Restraint or

seclusion shall not be used in a manner that causes undue physical discomfort,

harm, or pain to the patient;

      7. Appropriate

attention shall be paid every fifteen (15) minutes to a patient in restraint or

seclusion, especially in regard to regular meals, bathing, and use of the

toilet; and staff shall document in the patient's record that the attention was

given to the patient.

      (d) Locking

restraints may be used in the circumstances outlined in subparagraph 5 of this

paragraph, if the cabinet has previously found that the facility has instituted

policies which comply with the provisions of paragraph (c) of this subsection

and the following requirements:

      1. Keys. A

facility's direct care nursing staff shall:

      a. Have in their

possession at least two (2) keys to a locking restraint so that the restraint

can be removed immediately in the case of an emergency;

      b. A plan

designating nursing staff responsible for the keys; and

      c. An explanation of

how the keys are to be used.

      2. Orders for the

locking restraints shall be time-limited as follows:

      a. Four (4) hours

for adults up to a maximum of twenty-four (24) hours, during which time the

continued need for the restraint shall be evaluated at fifteen (15) minute

intervals until the maximum time is reached;

      b. Two (2) hours for

children and adolescents ages nine (9) to seventeen (17) up to a maximum of

twenty-four (24) hours, during which time the continued need for the restraint

shall be evaluated at fifteen (15) minute intervals until the maximum time is


      c. One (1) hour for

patients under the age of nine (9) up to a maximum of twenty-four (24) hours,

during which time the continued need for the restraint shall be evaluated at

fifteen (15) minute intervals until the maximum time is reached; and

      d. Orders pursuant

to this paragraph shall specify the restraint type and criteria for release in

the patient's medical record.

      3. If, after

twenty-four (24) hours, a patient still appears to need restraint, the patient

shall receive a face-to-face reassessment by a licensed physician. If the

physician determines that continued restraint is necessary, the physician shall

write a time-limited order according to the time frames set out in subsection

(2) of this section;

      4. A facility may

reinstitute the use of a restraint that has been discontinued if the time frame

limited order for the restraint has not expired; and

      5. A facility found

to be in compliance with this section may use locking restraints only under the

following circumstances:

      a. For the transport

of forensic or other impulsively violent patients;

      b. For the crisis

situation stabilization of forensic and other impulsively violent patients;

      c. To prevent a

patient who has demonstrated the ability to escape from a nonlocking restraint

on one (1) or more occasions; or

      d. For a patient

requiring ambulatory restraints as approved by a behavioral health management



      Section 5. Provision

of Services. (1) Psychiatric and general medical services.

      (a) Psychiatric

services shall be under the supervision of a clinical director, service chief,

or equivalent, who is qualified to provide the leadership required for an

intensive treatment program.

      1. The clinical

director, or equivalent, shall be certified by the American Board of Psychiatry

and Neurology, or shall meet the training and experience requirements for

examination by the board.

      2. If the

psychiatrist in charge of the clinical program is not board certified, there

shall be evidence that consultation is given to the clinical program on a

continuing basis by a psychiatrist certified by the American Board of

Psychiatry and Neurology.

      (b) General medical

services provided in the hospital shall be under the direction of a physician

member of the professional staff in accordance with staff privileges granted by

the governing authority.

      1. The attending

physician shall assume full responsibility for diagnosis and care of his or her

patient. Physician assistants and advanced practice registered nurses may

provide services in accordance with their scope of practice and the hospital's

protocols and bylaws.

      2. Incidental

medical services necessary for the care and support of patients shall be

provided by in-house staff or through agreement with outside resources. If a

patient's condition requires services not available in the hospital, the

patient, on physician's orders, shall be transferred promptly to an appropriate

level of care. A physician's order is not necessary in the case of an emergency.

      3. There shall be a

written plan delineating the manner in which emergency services are provided by

the hospital or through clearly defined arrangements with another facility. The

plan shall clearly specify the following:

      a. The arrangements

the hospital has made to assure that the patient being transferred for

emergency services to a nonpsychiatric facility will continue to receive

further evaluation or treatment of the psychiatric problem, as needed;

      b. The policy for

referring a patient needing continued psychiatric care after emergency services

back to the referring facility; and

      c. The policy for

notifying a patient's family of an emergency and of arrangements that have been

made for referring or transferring the patient to another facility for

emergency service.

      (c) Physician

services shall be available twenty-four (24) hours a day on at least an on-call


      (d) There shall be

sufficient physician staff coverage for all psychiatric and medical services of

the hospital, in keeping with their size and scope of activity.

      (e) The attending

physician shall state the final diagnosis, complete the discharge summary, and

sign the records within fifteen (15) days following the patient's discharge.

      (2) Nursing


      (a) The hospital

shall have a nursing department organized to meet the nursing care needs of the

patients and maintain established standards of nursing practice.

      (b) The psychiatric

nursing service shall be under the direction of a registered nurse who:

      1. Has a master's

degree in psychiatric or mental health nursing, or its equivalent, from a

school of nursing accredited by the National League for Nursing; or

      2. Has a

baccalaureate degree in nursing with two (2) years' experience in nursing

administration or supervision and experience in psychiatric nursing.

      (c) There shall be a

registered nurse on duty twenty-four (24) hours a day.

      (d) There shall be

an adequate number of registered nurses, licensed practical nurses, and other

nursing personnel to provide the nursing care necessary under each patient's

active treatment program.

      (e) There shall be

continuing in-service and staff development programs to prepare nursing

personnel for active participation in interdisciplinary meetings affecting the

planning or implementation of nursing care plans for patients.

      (3) Psychological


      (a) The hospital

shall provide psychological services to meet the needs of patients.

      (b) Psychological

services shall be provided under the direction of a licensed psychologist.

      (c) There shall be

an adequate number of psychologists, consultants, and supporting personnel to

assist in essential diagnostic formulations, and to participate in program

development and evaluation of program effectiveness, in training activities and

in therapeutic interventions.

      (4) Therapeutic


      (a) The hospital

shall provide a therapeutic activities program that shall be appropriate to the

needs and interests of the patients and directed toward restoring and

maintaining optimal levels of physical and psychosocial functioning.

      (b) The number of

qualified therapists, support personnel, and consultants shall be adequate to

provide comprehensive therapeutic activities, such as occupational,

recreational, and physical therapy, consistent with each patient's active

treatment program.

      (5) Pharmaceutical

services. The hospital shall comply with requirements of 902 KAR 20:016,

Section 4(5) and the following requirements:

      (a) Medication shall

be administered by a registered nurse, a physician, a dentist, a physician's

assistant, or an advanced practice registered nurse, except in the case of a

licensed practical nurse under the supervision of a registered nurse.

      (b) Medication shall

be given only by written order signed by a physician, dentist, advanced

practice registered nurse, therapeutically-certified optometrist, or physician

assistant. A telephone order for medication shall be given to only a licensed

practical or registered nurse, or a pharmacist. The order shall be signed by

the ordering physician, dentist, advanced registered nurse practitioner,

therapeutically-certified optometrist, or physician assistant within

seventy-two (72) hours from the time the order is given. A telephone order may

be given to a licensed physical, occupational, speech, or respiratory therapist

in accordance with the therapist's scope of practice and the hospital's protocol.

      (6) Laboratory

services. A hospital shall comply with 902 KAR 20:016, Section 4(4) concerning

the provision of laboratory and pathology services.

      (7) Social services.

      (a) A hospital shall

provide social services to meet the need of the patients.

      (b) There shall be a

director of social services who has a master's degree from an accredited school

of social work.

      (c) There shall be

an adequate number of social workers, consultants, and other assistants or case

aides to perform the following functions:

      1. Secure

information about a patient's development and current life situation in order

to provide psychosocial data for diagnosis and treatment planning and for direct

therapeutic services to a patient, patient group, or family;

      2. Identify or

develop community resources including family or foster care programs;

      3. Participate in

interdisciplinary conferences and meetings concerning diagnostic formulation,

treatment planning and progress reviews; and

      4. Participate in

discharge planning, arrange for follow-up care, and develop a mechanism for

exchange of appropriate information with a source outside the hospital.

      (8) Dietary

services. A hospital shall comply with 902 KAR 20:016, Section 4(3), pertaining

to the provision of dietary services, and requirements contained in this subsection.

      (a) Dietary service

personnel who have personal contact with the patients shall be made aware that

emotional factors may cause patients to change their food habits and shall

inform appropriate members of the professional staff of any change.

      (b) Meals shall be

provided in central dining areas for ambulatory patients.

      (9) Radiology


      (a) If radiology

services are provided within the facility, the hospital shall comply with 902

KAR 20:016, Section 4(6) concerning the provision of radiology services.

      (b) If radiology

services are not provided within the facility, the hospital shall have an

arrangement with an outside source. The arrangement shall be outlined in a

written plan. The outside radiology service shall have a current license or

registration pursuant to KRS 211.842 to 211.852 and relevant administrative


      (10) Other services.

If surgery, anesthesia, physical therapy or outpatient services are provided

within the facility, the hospital shall comply with the applicable sections of

902 KAR 20:016.

      (11) Chemical

dependency treatment services. A psychiatric hospital providing chemical

dependency treatment services shall meet the requirements of 902 KAR 20:160,

Sections 3 and 4, and shall designate the location and number of beds to be

used for this purpose. (10 Ky.R. 260; eff. 8-3-83; Am. 16 Ky.R. 1024; eff.

1-12-90; 23 Ky.R. 2305; 3049; eff. 2-19-97; 24 Ky.R. 1962; 2401; 25 Ky.R. 333;

eff. 8-17-98; 27 Ky.R. 1929; 2472; eff. 3-6-2001; TAm eff. 3-11-2011.)