902 KAR 20:180.
Psychiatric hospitals; operation and services.
RELATES TO: KRS
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.
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.
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
(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.
requirements are established in 902 KAR 20:160.
3. Mean daily census
shall be as reported in the last Annual Hospital Utilization Report.
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.
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,
(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;
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
(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.
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
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
3. Results of the
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
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
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;
(vi) Social history;
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
(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.
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.
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.
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.
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
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;
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.
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
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.
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.
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
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.
(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.
(a) The hospital
shall provide psychological services to meet the needs of patients.
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.
(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
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.
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:
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.
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.
(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.
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.)