FLORIDA DEPARTMENT OF CORRECTIONS OFFICE OF HEALTH SERVICES. HEALTH SERVICES BULLETIN NO Page 1 of 15

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1 FLORIDA DEPARTMENT OF CORRECTIONS OFFICE OF HEALTH SERVICES HEALTH SERVICES BULLETIN NO Page 1 of 15 I. PURPOSE EFFECTIVE DATE: 08/27/13 The purpose of this health services bulletin is to ensure the integrity of inpatient mental health units as safe and secure therapeutic environments and to describe the levels of care that comprise the inpatient mental health care delivery system: 1. Transitional Care Units (TCU; S-Grade 4) 2. Crisis Stabilization Units (CSU; S-Grade 5) 3. Corrections Mental Health Treatment Facilities; (CMHTF; S-Grade 6) II. GENERAL GUIDELINES FOR INPATIENT MENTAL HEALTH CARE A. Mental health staff and staff from other disciplines shall collaborate to ensure the integrity of the mental health inpatient unit in maintaining a therapeutic environment that is safe and secure. B. Transfer to an Inpatient Mental Health Unit must be conducted in accordance with Procedure , Mental Health Transfers. An inmate must be medically stable prior to the initiation of a transfer to an inpatient mental health unit. C. Inpatient Mental Health services shall be provided in accordance with Chapter , F.A.C. D. Mental health service planning and documentation must be compliant with HSB , Planning and Implementation of Individualized Mental Health Services, which requires that diagnostic and treatment decisions are based on consensus of all credentialed members of the Multi-Disciplinary Services Team (MDST). E. Use of psychotropic medications on Mental Health Inpatient Units must be in accordance with HSB , Psychotropic Medication Use Standards. F. Inmates determined to be at risk for suicide or serious self injury will be placed on Self- Harm Observations Status (SHOS) in accordance with Procedure , Suicide and Self-Injury Prevention. G. The use of psychiatric restraint in inpatient mental health units must be in accordance with HSB , Psychiatric Restraint. H. When an inmate is discharged from an Inpatient Mental Health Unit, the MDST must consider and act in accordance with HSB , Health Care Clearance/Holds. I. Inmates on an inpatient unit who are within six (6) months of end of sentence (EOS), must receive mental health re-entry services in accordance with HSB , Mental Health Re-Entry Aftercare Planning Services. HSB also specifies what steps

2 HEALTH SERVICES BULLETIN NO Page 2 of 15 must be taken in the event a patient is likely to need additional inpatient care after EOS, including involuntary civil commitment. J. Discipline of Mentally Disordered Inmates in CSU, TCU and CMHTF shall be effected in accordance with Rule , Discipline and Confinement of Mentally Disordered Inmates and HSB , Mental Health Staff on Disciplinary Teams. Mental health staff is authorized to provide input to the disciplinary team before disciplinary action is taken against any inmate who has a diagnosed mental illness, intellectual disability, or who is otherwise cognitively impaired (see also Rule ). The input shall be limited to whether the patient s mental condition may have contributed to the alleged disciplinary offense and, if so, a recommendation for disposition or sanction options or alternative actions. K. At the first signs an inmate s behavior may potentially escalate to draw a Disciplinary Report (DR), mental health staff shall be summoned to intervene therapeutically, with the goal of prompting more adaptive behavior, ideally averting need for disciplinary action. In the absence of credentialed mental health staff, such as after regular work hours or on weekends, mental health nursing staff should attempt intervention with the inmate in the hopes of redirecting the inmate to conform to DC and mental health unit rules. L. Medical screening and care and nursing interventions shall be provided in accordance with HSB , Medical and Dental Care for Mentally Disordered Inmates. M. Nursing staff responsibilities in the admission process shall be accomplished in accordance with the Nursing Manual (see HSB ). Nursing staff shall inform the patient of the reason(s) for admission, provides verbal orientation to the unit, and informs the patient of the mental health unit rules. Written orientation materials may be provided if it has been determined that the inmate s risk of self-harm will not be increased by possessing them. Orientation shall be documented as part of the nursing assessment. N. Individual clinical encounters must be documented in accordance with the SOAP format specified in , Outpatient Mental Health Services. O. The patient who is transferred to a mental health inpatient unit may refuse treatment but may not refuse admission. III. LEVELS OF INPATIENT MENTAL HEALTH CARE A. Crisis Stabilization Unit (CSU; S-5) CSU level mental health care is intended for patients who are experiencing such acute and debilitating symptoms of mental impairment that they cannot be adequately evaluated and treated in a mental health infirmary or in a transitional care unit. A CSU is devoted principally toward rapid stabilization of acute symptoms and conditions. Accordingly, stays in a CSU are expected to be relatively brief, typically less than two weeks. CSU level care includes a broad range of evaluation and treatment services provided within a highly structured

3 HEALTH SERVICES BULLETIN NO Page 3 of 15 IV. residential setting. While CSU level care is less restrictive and intensive than care provided in a corrections mental health treatment facility, it is more intensive than mental health care provided in a transitional care unit. B. Transitional Care (TCU; S-4) TCU level mental health care is intended for patients with chronic or residual mental disorder symptomatology. These patients do not require crisis stabilization care or placement in a corrections mental health treatment facility, however, their mental impairment significantly compromises their ability to adapt to the demands of a general incarceration environment. TCU level care is provided in a structured residential environment and includes a broad range of services intended to increase the patient s level of adaptive functioning. Some patients may only require this level of care as a transition back to the general inmate population, while others may require this level of care indefinitely while incarcerated. C. Corrections Mental Health Treatment Facility (CMHTF; S-6) CMHTF level mental health care is intended for patients whose mental disorders are so incapacitating as to render them unable to understand the nature and consequences of their mental illness and their need for mental health care. As evidenced by their recent behavior, the consequences of their mental illness are dangerous to the well-being of themselves and/or others. Admissions to CMHTF must come via transfer from a CSU, either on an emergency basis while awaiting a court order or as a result of a court order. The emergency transfer request from a CSU is only made in light of the MDST s determination that the act of obtaining a court order poses a substantial and harmful delay in treatment that the inmate has repeatedly refused. A CMHTF is a highly structured residential setting which provides intensive mental health services and operates in accordance with the Corrections Mental Health Act ( , FS). INPATIENT MENTAL HEALTH UNIT PROGRAM REQUIREMENTS A. Each level of inpatient mental health care must offer a range of out-of-cell structured therapeutic services targeted to the individual needs of the patient. Out-of-cell structured therapeutic services are activities prescribed for the patient by MDST consensus and integrated into the ISP to target specific problems. A specific number of out-of-cell structured therapeutic service hours per week is associated with each level of inpatient care: CSU requires offering 12 hours of out-of-cell structured therapeutic services per week. Psychiatry staff must interview to assess the status and progress of new patients on at least three occasions during the patient s first week on CSU; thereafter, follow-up psychiatry staff interviews must be conducted at least every 7 days. Each encounter requires documentation by SOAP note. TCU requires offering 12 hours of out-of-cell structured therapeutic services per week. Psychiatry staff must interview to assess the status and progress of new

4 HEALTH SERVICES BULLETIN NO Page 4 of 15 TCU patients at least once every 14 days during the first 60 days of the patient s admission; thereafter, follow-up assessment by psychiatry staff is required at least every 30 days. Each encounter requires documentation by SOAP note. CMHTF requires offering 15 hours of out-of-cell structured therapeutic services per week. Psychiatry staff must interview to assess the status and progress of new patients on at least three occasions during the patient s first week on CMHTF; thereafter, follow-up assessment by psychiatry staff is required at least every 7 days. Each encounter requires documentation by SOAP note. Out-of-cell structured therapeutic services prescribed under this condition may include those sanctioned by the MDST that may be provided by disciplines other than mental health care staff, as long as such services do not displace necessary core mental health services such as individual and group therapy, case management, and medication management. For example, tutoring or special education classes, substance abuse treatment, and other services provided by non-mental health care staff, may be counted as out-of-cell structured therapeutic services if referenced in the ISP and if monitored and documented appropriately in accordance with the policies and procedures of that discipline or specialty. Activities that are not specifically referenced in and executed with fidelity to the patient s ISP cannot be counted toward required out-of-cell structured therapeutic service hours. Whereas it would be inappropriate to use dayroom or exercise hours to fulfill 10 out of 12 or 15 required out-of-cell structured therapeutic service hours, up to five or six hours of such activities may be clinically appropriate if they are conducted and supervised by a mental health staff member in accordance with the ISP, and all other required out-of-cell structured therapeutic service hours for the week are met. Regardless of the level of inpatient mental health care, two (2) hours of out-of-cell structured therapeutic services must be offered on weekends. Having met the requirements under discussion in this section, for example, two hours of dayroom activity would satisfy the weekend requisite for out-of-cell structured therapeutic services. The following list is representative of the out-of-cell structured therapeutic services that are typically offered on inpatient units: 1. Psychotropic Medication as prescribed only by the psychiatry staff or appropriately qualified and credentialed clinical associate. 2. Medication Management can range from teaching the patient the reasons for and effects of psychotropic medication, to assisting the patient in the process of medication reduction or discontinuation for health reasons. This intervention requires concurrence of the psychiatry staff or clinical associate. 3. Cognitive Restructuring is intended to enhance self-awareness, selfcontrol, problem-solving, and interpersonal communication. Cognitive restructuring is typically conducted in a group setting.

5 HEALTH SERVICES BULLETIN NO Page 5 of Stress Management teaches the patient to detect the early onset of tension and to use appropriate methods of stress management and stress reduction. 5. Anger Management teaches the patient to recognize the onset of his or her anger, to identify its roots, and to employ constructive thoughts and actions to effectively manage and resolve it. 6. Activity Therapy is for the purpose of guiding appropriate physical release, promoting group cooperation, and enhancing attention/concentration through involvement in purposeful, constructive activities. 7. Bibliotherapy and Video Therapy includes the use of books, pamphlets, and videos in conjunction with staff presentations to facilitate a desirable change in behavior and/or attitude. (Therapeutic service hours are counted according to staff time expended in the presentation plus up to ½ hour per week for successful completion of homework assignments by the patient.) 8. Adult Daily Living Skills Training is designed to promote satisfactory personal hygiene and other health practices, and habits of appropriate appearance and grooming. 9. Therapeutic Community provides for a block of time, at least once a week, during which patients have an opportunity to voice concerns as a group to mental health care staff. The process also gives mental health staff an opportunity to model communication skills in service of problem-solving and conflict-resolution. 10. Social Skills Training teaches the essentials of appropriate and respectful communication and social interactions. It addresses such topics as selfmonitoring of behavior, interpersonal boundary issues, sensitivity to cultural perspectives, and conflict resolution. 11. Preparation for Discharge to Outpatient provides guidance for handling the demands typical of the general inmate population. Overlapping to a great extent with the other structured therapeutic services listed, individual and group interventions are utilized. 12. Preparation for Discharge to Community borrows heavily from the other structured therapeutic services and coordinates with HSB to prepare the patient for adaptation to life in the community outside prison. Much emphasis is on cultivating the patient s motivation to engage with community mental health resources. B. Other interventions may be offered but must be approved by the Regional Mental Health Consultant who has researched and discussed the proposed intervention with the Mental Health Services Director or his/her designee. Approval of other interventions is contingent upon their standing with reference to evidence-based treatment and/or evidence-based practice.

6 HEALTH SERVICES BULLETIN NO Page 6 of 15 C. The provider of a structured therapeutic service must document each patient s participation on the same day the service is provided, via form DC4-664, Mental Health Attendance Record. D. Each Mental Health Case Manager shall write a weekly incidental note to document: 1. Proportion of activities attended (e.g., 3 out of 7 offered), 2. The patient's relative participation, 3. Observed progress made toward treatment goals. E. Patient participation or lack thereof in activities and services provided by non-health care staff shall be documented by those providers in accordance with policies and procedures of each specialty. F. The patient s case manager is required to review DC4-664, Mental Health Attendance Record and the medication administration record at least weekly to ensure faithful implementation of the ISP. G. A Psychiatric Clinician or Psychologist conducts daily rounds on regular business days to review patient general functioning on the unit. Documentation is via DC4-717A, Daily Mental Health Inpatient Unit Rounds Documentation Log. V. INPATIENT MENTAL HEALTH UNIT BEHAVIOR LEVEL SYSTEM Inpatient mental health services will incorporate a behavior level system consisting of performance-based behavioral incentives and consequences. The purpose of the behavioral level system is to: facilitate adaptive functioning; promote constructive goal-oriented behavior; develop coping skills that reduce the occurrence of aggressive or other disruptive behaviors that may compromise the integrity of a safe and secure treatment unit; provide opportunities to achieve increased access to property and activities based on the patient s demonstration of self-care, self-control, appropriate interpersonal interactions, compliance with mental health unit and Department rules, and cooperation with the treatment regimen. Each Level is associated with access to a set of privileges and activities which are detailed in Attachment #1 Level System Access to Care, Property, Activities, and Privileges in Mental Health Units. Following are descriptions of the behavior level system Levels and criteria for progression through the Levels. A. Level 1 Level 1 Is Automatically Assigned:

7 HEALTH SERVICES BULLETIN NO Page 7 of 15 Upon admission to a MH Unit from a lower level of care; Upon discharge from SHOS or MHOS on the inpatient unit. Upon admission to an inpatient unit from a lower level of care (for example, transfer from outpatient to CSU; TCU transfer to CSU, etc.), inmates are housed in a single cell on Level 1 status. Within 72 hours of admission, the Risk Assessment Team (RAT) reviews the inmate s record in accordance with Rule (4) and on this basis makes recommendations pertaining to movement, housing, and activities, including any restrictions deemed necessary to ensure a safe and secure therapeutic environment on the MH Unit. Within 7 days of admission, the MDST must review the inmate s behavioral performance while on Level 1 to determine if the inmate is ready to safely and appropriately handle the property and activities associated with Level 2, as detailed in Attachment #1. The patient demonstrates readiness to advance to Level 2 by (1) sustained mastery of Level 1 responsibilities concerning activities and property detailed in Attachment #1, (2) meeting MH Unit expectations pertaining to personal hygiene, count procedure, and respectful communications with staff, and (3) satisfactory compliance with DC rules and regulations in the MHU. If the MDST s initial assessment determines that the patient is to remain on Level 1 for further assessment of performance, the MDST must assess the patient s behavioral performance at least every 7 days thereafter to determine if the patient may advance to Level 2 based on the above criteria. Upon discharge from SHOS or MHOS on the inpatient unit, a patient remains at Level 1 until the MDST clears the patient for progression and assigns the Level commensurate with the patient s mental status and behavioral functioning. In such cases, the MDST will take into consideration the Level at which the patient was assigned prior to the episode prompting SHOS or MHOS admission, the extent to which treatment under those conditions has resolved the issues that precipitated the admission, and the patient s current mental status. For example, it is conceivable that a patient who was previously functioning well at Level 4 could be returned to that Level under ideal conditions after a brief assignment to Level 1 subsequent to discharge from SHOS. By the same token, it is also conceivable that the MDST may decide that a patient who required outside hospitalization for self-harm behavior during the course of an SHOS admission is to remain on Level 1 with targeted, specific property restrictions ordered for precautionary reasons by the psychiatrist or psychologist. Post-SHOS and MHOS discharge cases maintained on Level 1 must be reviewed by the MDST at least every 7 days to assess the appropriate behavior Level assignment, and documentation of its decision shall be via incidental note in the medical record. B. Level 2

8 HEALTH SERVICES BULLETIN NO Page 8 of 15 Level 2 Behavioral Performance Expectations: (1) sustained mastery of Level 2 responsibilities concerning activities and property as detailed in Attachment #1; (2) meets mental health unit expectations for personal hygiene, count procedure, and respectful communications with staff; (3) satisfactory compliance with DC rules and regulations in the mental health unit as evidenced by the absence of disciplinary actions, and (4) satisfactory participation in out-of-cell structured therapeutic services. Unless assigned Level 2 as the result of a disciplinary action, the patient who meets all Level 2 expectations for two consecutive weeks (14 calendar days) shall be eligible for advancement to Level 3. If the inmate does not meet criteria for progression and is retained at Level 2, the MDST must reassess the inmate s performance at least every two weeks thereafter. The MDST shall document its review and rationale for its decisions via incidental note in the medical record. Upon disciplinary action for infractions he or she committed on the inpatient unit, the patient is assigned to Level 2. The MDST must revise the ISP to directly address the maladaptive behavior prompting the disciplinary action, and the inmate remains at Level 2 until the conditions of the disciplinary action have been met and there has been sufficient progress toward achievement of the pertinent ISP goals. The MDST, in collaboration with the RAT, considers the patient s behavior over the duration of the disciplinary action, and proceeds as indicated in HSB Clinical and security concerns must be balanced to maintain a safe and secure therapeutic environment in this collaborative process. The clinical challenge will be to effect changes in the way the patient perceives, thinks about, and responds to events that in the past have prompted dysfunctional, maladaptive reactions. The tendency of persistent maladaptive behavior patterns to be resistant to treatment requires a high degree of collaboration between Mental Health and Security staff in bringing about more constructive responses in these cases. Within seven days after the disciplinary action is officially terminated, the MDST must determine which Level assignment is most appropriate, based on the patient s mental status, behavioral functioning, and progress toward disciplinary action-based ISP goals. If the MDST decides to maintain the patient at Level 2, as long as the patient remains at this Level the MDST must review the Level assignment on a weekly basis, documenting its rationale for maintaining or changing the Level via incidental note in the medical record. In assessing the inmate s performance, the MDST shall give considerable weight to the inmate s behavior over the prior three weekly reviews. C. Level 3

9 HEALTH SERVICES BULLETIN NO Page 9 of 15 Level 3 Behavioral Performance Expectations: (1) sustained mastery of Level 3 responsibilities concerning activities and property as detailed in Attachment #1; (2) meets unit expectations for personal hygiene, count procedure, and respectful communications with staff; (3) satisfactory compliance with DC rules and regulations in the mental health unit as evidenced by the absence of disciplinary actions, and (4) satisfactory participation in out-of-cell structured therapeutic services. Unless assigned Level 3 as the result of having been issued a DR for alleged infractions committed on the inpatient unit, the patient who meets all Level 3 expectations for two consecutive weeks (14 calendar days) shall be eligible for advancement to Level 4. If the patient does not meet criteria for progression and is retained at Level 3, the MDST must reassess the patient s performance at least every two weeks thereafter. The MDST shall document its review and rationale for its decisions via incidental note in the medical record. If assigned Level 3 as the result of a DR for alleged infractions committed on the inpatient unit, the patient remains at this Level until the disciplinary hearing results have been issued. MDST review of the patient s behavioral performance shall be conducted in accordance with HSB In the event a DR is overturned, based on its consideration of any factors relevant to maintaining the integrity of the therapeutic environment as well as specific ISP goals, the MDST may retain the patient on Level 3 or may assign the patient s former Level status. If the patient is retained at Level 3, the MDST must reassess the patient s performance at least every two weeks thereafter. The MDST shall document its review and rationale for its decisions via incidental note in the medical record. D. Level 4 Level 4 Behavioral Performance Expectations: (1) sustained mastery of Level 4 responsibilities concerning activities and property as detailed in Attachment #1; (2) meets unit expectations for count procedure, personal hygiene, and respectful communications with staff; (3) satisfactory compliance with DC rules and regulations in the mental health unit as evidenced by the absence of disciplinary actions, and (4) satisfactory participation in out-of-cell structured therapeutic services. The MDST shall review the Level 4 patient s performance at least every two weeks and document the result of its review and its rationale for any Level change via incidental note in the medical record.

10 HEALTH SERVICES BULLETIN NO Page 10 of 15 E. Level 5 Level 5 Behavioral Performance Expectations: (1) sustained mastery of Level 5 responsibilities related to activities and property as detailed in Attachment #1; (2) meets MH unit expectations for count procedure, personal hygiene, and respectful communications with staff; (3) satisfactory compliance with DC rules and regulations in the mental health unit as evidenced by the absence of disciplinary actions, and (4) satisfactory participation in out-of-cell structured therapeutic services. The MDST shall review the Level 5 patient s performance at least every two weeks and document the result of its review and its rationale for any Level change via incidental note in the medical record. F. Miscellaneous Level System Requirements and Guidelines 1. All increases and decreases in Level require the consensus of the MDST. 2. It is mandatory that the Level be lowered for a patient when the patient s behavior does not meet expectations of a given Level. The degree of Level reduction shall be according to the clinical judgment of the MDST, which shall provide rationale for its decision as an incidental note in the medical record. 3. Any behavior which disrupts the therapeutic atmosphere of the inpatient unit shall result in a reduction in Level, unless the MDST provides clear justification for its decision to act otherwise via incidental note in the medical record. Regardless, any disruptive behavior must result in counseling specific to the act, with documentation in the form of a SOAP note. 4. Placement on SHOS results in removal from the Level system, with access to property and activities in compliance with the provisions of Procedure An inmate placed on MHOS is taken off the Level system; housing and property restrictions are in accordance with Procedure and HSB , Infirmary Services. VI. INPATIENT MENTAL HEALTH UNIT ADMISSION PROCEDURES A. Placement in an inpatient mental health unit requires a diagnosed mental disorder; that is, impairment of: (1) the mental or emotional processes, (2) the ability to exercise conscious control of one s actions, and/or (3) the ability to perceive or understand reality. B. Referral to an inpatient level of mental health care is appropriate when a Multi- Disciplinary Treatment Team (MDST) has determined:

11 HEALTH SERVICES BULLETIN NO Page 11 of That a mental disorder continues to significantly compromise an inmate s ability to adjust to demands of prison life to the extent that the inmate s needs for mental health care exceed what can be provided at an outpatient level of mental health care, or 2. That the patient has failed, and is likely to continue to fail, to respond adequately to outpatient mental health infirmary level care in accordance with HSB and Procedure C. Clinical justification for the referral requires documentation that less restrictive interventions have been, and will likely continue to be, inadequate to afford the degree of protection and care necessary. Upon approval for transfer in accordance with Procedure , the mental health provider making the referral on behalf of the MDST completes whichever of the following forms is appropriate to the referral: 1. DC4-661, Summary of Outpatient Mental Health Care if the referral is to TCU level mental health care from general population, that is, the inmate is not housed on MHOS at the time of the referral; or 2. DC4-657A, Transfer Summary for Inpatient Mental Health Care if the inmate is housed on SHOS or MHOS at the time of the referral to CSU or TCU. D. The S-Grade is only changed upon the inmate s admission to an inpatient unit; it is NOT changed at the time the transfer request is made. E. Admission to a CMHTF can only be made from a CSU. F. Upon arrival at the institution for admission to inpatient level mental health care, and prior to admission to the unit, the patient may be placed in a holding cell for a period not to exceed two hours. Observations must be documented at least every 15 minutes on DC4-650, Observation Checklist. G. Patients may be admitted only by order of the attending clinician (as defined in Procedure ) to a specified level of inpatient mental health care in accordance with Procedure Admission to CSU requires assignment of mental health grade S-5. Admission to TCU requires assignment of S-4. Admission to CMHTF requires assignment of mental health grade S-6. Inpatient mental health grade assignments are made by the attending clinician on the inpatient mental health unit via form DC4-706, Profile Sheet. H. In the case of emergent transfer to CSU after regular business hours and on weekends, referrals may be made by the on-call attending clinician in consultation with senior health care staff on site. An after-hours transfer must have approval of the Central Office Duty Officer. The nurse in attendance at the CSU shall obtain verbal orders for admission within one hour by telephone from an inpatient mental

12 HEALTH SERVICES BULLETIN NO Page 12 of 15 health unit physician. A mental health unit attending clinician must countersign the verbal order within 72 hours, noting the date and time of countersignature. I. Following orientation to the Inpatient Mental Health Unit, the nursing staff shall attempt to obtain the patient s informed consent via DC4-649, Consent to Inpatient Mental Health Care. If the patient does not give written consent, the patient shall be asked to sign a refusal form (DC4-711A, Refusal of Health Care Services). If the patient refuses to sign the refusal form, a note to that effect shall be written on the form and witnessed by another staff member. J. An inpatient record shall be opened at the time of admission, and a nursing assessment shall be completed within four (4) hours of admission. K. The attending clinician must complete an admission note within twenty-four (24) hours of an admission (or the first business day following on weekends/holidays). The note shall include: 1. Chief complaint 2. Relevant mental health history 3. Mental status exam 4. Diagnoses 5. Plan/orders L. All patients admitted to inpatient level mental health care shall receive a psychiatric evaluation, documented via DC4-655, Psychiatric Evaluation. The evaluation is to be typed or neatly printed (cursive handwriting is not permitted). However, a psychiatric evaluation does not need to be completed for inpatient-to-inpatient unit transfers unless the inmate is being admitted to a higher level of care. The psychiatric evaluation is due within three (3) regular business days of admission to an inpatient unit. M. No admission note is necessary if the psychiatric evaluation is completed within twenty-four (24) hours of admission and the attending clinician is the psychiatrist who completed the evaluation. N. Within three (3) regular business days of admission, the assigned case manager shall meet with the patient to explain the mental health unit behavioral level system. This must be documented as an incidental note in the chart. O. A risk assessment team comprised of mental health staff, security staff, and classification staff must conduct a risk assessment in accordance with Rule , Rule (8), and Rule F.A.C. in order to ensure staff and inmate safety. P. The attending clinician shall update the S-grade corresponding with level of care on the DC4-706 within three (3) days of admission. Clerical or other support staff shall update the OBIS HS06 screen accordingly.

13 HEALTH SERVICES BULLETIN NO Page 13 of 15 Q. A physical examination shall be completed within three (3) regular business days of admission. VII. INPATIENT MENTAL HEALTH UNIT DISCHARGES AND TRANSFERS Request for transfer to another inpatient mental health unit or a different level of inpatient mental health care, or the decision to discharge from inpatient status, must be by consensus of the MDST. Clinical rationale for the transfer or discharge must be clearly documented. Transfers from one inpatient mental health unit to another, regardless of level of care involved, require completion of a DC4-657A at the time of transfer. When a patient is discharged from an inpatient unit to general population, a DC4-657, Discharge Summary for Inpatient Mental Health Care must be completed and has to include an outpatient aftercare plan. The discharge or transfer summary is placed in the health record at the time of discharge or transfer, the infirmary record is packaged separately, clearly marked, and forwarded with the health record. Criteria for Transfer or Discharge from a CSU Transfer to CMHTF The patient requires a treatment regimen that is not available in the CSU, as indicated by any one of the following: Management of acute symptoms has required use of four-point restraints on at least three occasions in any two-week period. On three occasions in any two-week period, management of the patient s acute symptoms has required psychotropic medication emergency treatment orders (ETOs) because the patient has refused or remained non-compliant with the prescribed regimen of psychotropic medication. The patient s acute symptoms have been unresponsive to CSU level treatment and, as a result, the patient s behavior poses imminent danger to the safety and well-being of the patient and/or others. Transfer to TCU Patient s symptomatology matches the general characteristics of TCU patients as outlined in section III. B Levels of Inpatient Mental Health Care in this HSB. Discharge to Outpatient At least seven (7) days must have elapsed since the end of the last episode of psychiatric seclusion, restraints, or self-harm observation status.

14 HEALTH SERVICES BULLETIN NO Page 14 of 15 The attending clinician, representing the MDST consensus, will consult with the institutional psychological services director to determine if discharge to the lower level of care is clinically appropriate. The attending clinician will document the consultation as an incidental note in the inpatient record. Patients in the CSU will not be discharged to a confinement or close management setting before they have been stepped down to a TCU. Criteria for Transfer or Discharge from a TCU Discharge from TCU to Outpatient Patient mental status and level of functioning will enable satisfactory adjustment within the general inmate population. A patient transferred from CMHTF has to be treated at TCU level of care for at least 30 days prior to being discharged to the general inmate population. An aftercare plan has been completed. At least seven (7) days have lapsed since the end of the last episode of psychiatric seclusion, restraints or self-harm observation status. Discharge from TCU to Special Housing The MDST has documented its clinical justification that, with outpatient level mental health care, the patient s mental status and level of functioning will enable satisfactory adjustment to the special housing to which the inmate will be assigned; An aftercare plan has been completed; At least seven (7) days have lapsed since the end of the last episode of psychiatric seclusion, restraints, or self-harm observation status.

15 HEALTH SERVICES BULLETIN NO Page 15 of 15 Discharge from CMHTF A patient discharged from CMHTF shall be referred to a TCU; transport from CMHTF to a TCU shall be direct. Assistant Secretary for Health Services Date Attachments: #1 Level System Access to Care, Property, Activities, and Privileges in Mental Health Units This Bulletin Supersedes: HSOI No dated 1/18/89 HSB dated 4/15/91 HSB dated 4/15/91 HSB dated 4/15/91 HSB dated 12/5/88, 4/19/89, 4/15/91, 4/7/99, and 2/8/13.