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)

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

      NECESSITY, FUNCTION, 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.

      (2) "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.

      (3) "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.

      (4) "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.

      (5) "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 shall:

      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 illnesses.

      (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 with:

      (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; and

      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 procedures.

      (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 contain:

      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 history;

      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 patient's:

      (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 facility.

      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 utilization;

      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 reached;

      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 team.


      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 basis.

      (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 services.

      (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 services.

      (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 activities.

      (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 services.

      (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 regulations.

      (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.)