FLORIDA STATE HOSPITAL OPERATING PROCEDURE NO. 155-28 STATE OF FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES CHATTAHOOCHEE, February 28, 2018 Mental Health/Substance Abuse CLINICAL PATHWAYS Purpose: The intent of this procedure is to treat residents as effectively and efficiently as possible, and to provide efficient and effective means of making informed decisions when transitioning residents to future living environments. 1. Scope: This procedure applies to all persons residing in residential units at Florida State Hospital. 2. References: a. Florida Statute Chapter 394, Florida Mental Health Act (Baker Act) b. Florida Statute, Chapter 916, Mentally Deficient and Mentally Ill Defendants. c. Florida Rules of Criminal Procedure 3.212, Commitment of a Defendant Found Incompetent to Proceed d. Florida Rules of Criminal Procedure 3.218, Commitment of a Defendant Found Not Guilty By Reason of Insanity e. Children and Families Operating Procedure 155-12 Forensic Transfers to Civil Mental Health Treatment Facilities f. Children and Families Operating Procedure 155-22 Leave of Absence and Discharge of Residents Committed to a State Mental Health Treatment Facility Pursuant to Chapter 916, F.S. g. Children and Families Operating Procedure 155-35, Violence Risk Assessment Procedure in State Mental Health Treatment Facilities 3. Definitions: h. Florida State Hospital Transfer Manual i. Florida State Hospital Discharge Manual a. Barriers to Discharge meetings. A meeting wherein a resident s barriers to discharge are to be reviewed and updated monthly for residents who have been at the facility less than 24 months, and Bi-monthly for residents who have been hospitalized more than 24 month. Additionally, Forensic and Civil Unit based management may also schedule meetings to review and address a resident s barriers to discharge. This Operating Procedure supersedes: Operating Procedure 155-28 dated January 19, 2017 OFFICE OF PRIMARY RESPONSIBILITY: Psychology DISTRIBUTION: See Training Requirements Matrix
b. Civil Transfer. The process as outlined by Children and Families Operating Procedure 155-12 and the Florida State Hospital Transfer Manual to facilitate forensic to civil transfers for residents who no longer require a secure forensic setting as determined by criteria within that procedure. c. Community Case Manager or Forensic Specialist. An employee of a community mental health provider agency who provides contracted services for their agency to our residents. d. Conditional Release Plan. A recovery team s written proposal for a resident s conditional discharge to an approved placement, to be submitted to the Committing Court. This plan provides specifics of the resident's proposed placement, case management information and a list of various restrictions and responsibilities placed upon the resident while he resides in the community on Conditional Release status. e. Department of Children and Families Circuit Adult Mental-Health and Drug Abuse Program Office/Managing Entities. Each circuit of Department of Children and Families has an Adult Mental- Health and Drug Abuse Program Office in conjunction with Managing Entities who monitor services and provides linkages. f. Discharge. Court approved release of a resident to a community placement or to the custody of a designated person. Court approval is not needed for a resident committed under civil statute. g. District Forensic Coordinator/Specialist. An employee in the Program Office who provides monitoring and linkage services. This person is designated as the single point of accountability to deal with the State s forensic issues. h. HCR-20 Assessing Risk for Violence Version 3 (HCR 20 v3). An instrument used to help in the assessment of the probability of violence risk. The HCR-20 Assessing Risk for Violence Version 3 is completed for persons committed as Not Guilty by Reason of Insanity and Incompetent to Proceed at specified critical decision points: consideration for freedom of movement that would result in community access; proposed transfer from the hospital Forensic Service to a Civil hospital placement; and discharge from Florida State Hospital to the community. i. Violence Risk Factors. Resident characteristics reviewed to include historical, clinical and contextual factors that are associated with a probability of violence. j. Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS). The LOCUS was created by the American Association of Community Psychiatrists. The LOCUS is a system for evaluating the current status of a resident and his/her needs based on six evaluation parameters to include: risk of harm, functional status, medical, addictive and psychiatric co-morbidity, recovery environment, treatment and recovery history, and engagement. 4. General: a. Clinical Pathways facilitates effective assessment, treatment, and discharge planning for Florida State Hospital residents. Each pathway is intended to direct early assessment and help the recovery team decide on the most appropriate clinical pathway for the resident. Each pathway includes treatment best suited for helping the resident proceed towards a least restrictive environment. b. Discharge Planning is the responsibility of the recovery team. A discharge planning decision is made in a recovery team s staff conference. Following discussion, the recovery team s Human Services Counselor/Discharge Planner/Community Case Manager locates an appropriate discharge community living environment. 2
c. Discharges to the community for residents committed as Not Guilty by Reason of Insanity or Incompetent to Proceed must always be pre-approved in writing by Court Order. Court approval is not required for a resident committed under a civil statute. d. The recovery team considers relevant data from multiple sources, including assessment of barriers and risk, as part of making clinical decisions and determining each resident's clinical pathway. e. A recovery team s determination of the resident s Clinical Pathway will be made at the staffing for each resident within 90 days of admission, and documented in the clinical record. Once a Clinical Pathway decision is made, the recovery team will develop a recovery plan specific to the pathway. The ongoing appropriateness of the selected pathway will be monitored at every scheduled recovery team review with updates made to the recovery plan when indicated. 5. Clinical Pathway / Disposition Decisions: The recovery team will consider the resident's history, progress in treatment, clinical presentation, and adequacy of aftercare resources. The recovery team should have a clear profile/ understanding of the resident s violence risk factors, as well as recommended level of care. The recovery team s evaluation of the resident should reflect the resident's current presentation and level of functioning. a. Barriers to discharge will be reviewed and updated monthly for residents who have been at the facility less than 24 months, and Bi-monthly for residents who have been hospitalized more than 24 month. Additionally, b. The HCR-20 Assessing Risk for Violence Version 3 (HCR 20 v3) is completed for persons committed as Not Guilty by Reason of Insanity and Incompetent to Proceed at specified critical decision points: (1) consideration for freedom of movement that would result in community access; (2) proposed transfer from the hospital Forensic Service to a Civil hospital placement; (3) discharge from Florida State Hospital to the community; and decision. (4) proposed non-restorability opinion to the court which may result in judicial placement Current literature shows that in order to accomplish a successful discharge for a resident who is Not Guilty by Reason of Insanity, the results of the HCR 20 v3 should reflect a Low to Moderate risk for future violence in a community setting. c. If a resident committed under F.S. 916.15 has a history of murder charges or a history of a sex crime, the need for psychological/personality testing should be determined prior to the recovery team seeking placement and approval of a Conditional Release Plan. (1) If testing is indicative of treatment needs prior to discharge, the staffing is held no later than at the time the Conditional Release Plan is routed to the circuit for approval. (2) If testing indicates treatment needs prior to discharge, these should be addressed prior to discharge. Following treatment interventions, the resident should be re-tested no sooner than 6 months from the time of the last measure if using the same instrument. A staffing is then held no later than at the time the Conditional Release Plan is routed to the circuit for approval. 3
d. If a resident committed under F.S. 916.15 has a history of high profile offenses (i.e., murder or sex offenses), the case will be presented to Civil or Forensic Review Board as applicable and the appropriate Assistant Hospital Administrator will submit the write up as notification to the Program Office. e. The pathway decision guides the Human Services Counselor search for an appropriate placement. 6. Clinical Pathways: a. Expeditious Dispositions Pathway: (1) The resident at the time of admission presents clear indications that statutory commitment criteria are not met. These residents consist of two distinct populations. Either they do not meet criteria for admission (present as a high functioning person who does not meet criteria, who is not mentally ill (i.e., is malingering) or whose mental illness is in remission) or Florida State Hospital is not suited to meet their presenting needs (e.g., Intellectual Disability or certain medically complex cases). follows: (2) Staff responsibilities once an Expeditious Dispositions Pathway is chosen are as (a) If the resident is not mentally ill (i.e., is malingering), the psychology staff completes necessary testing and/or obtains needed behavioral observations to support the conclusion and completes a competency evaluation with appropriate recommendations in the report for the Court s consideration; (b) If the resident s mental illness is in remission by the time s/he is admitted, the psychology staff reviews the resident s adjustment from the time of admission and completes a competency evaluation or as quickly as feasible transfers a resident committed as Not Guilty by Reason of Insanity to a more appropriate treatment setting than the admission unit; (c) If the recovery team opines the resident s presenting concern is an Intellectual Disability in the absence of a serious and persistent mental illness, the psychology staff completes a competency evaluation with recommendations to the Court for the resident to be evaluated to determine if s/he meets criteria for commitment to the Agency for Persons with Disabilities or if the resident is Not Guilty by Reason of Insanity, transfers the resident to the most appropriate treatment setting from the admissions unit; or (d) If the recovery team opines that the resident does not meet criteria (i.e., was admitted for medical reasons or appears to have been admitted due to behavior related to a personality disorder in absence of a serious and persistent mental illness) and a court order is required for discharge, the report shall not be mailed to the Court until approved by an administrative review board. (e) Additionally, the recovery team: 1. Ensures the resident participates in the process to the extent possible. 2. The Human Services Counselor will notify the Senior Human Services Counselor Supervisor, the Office of Recovery Planning/Social Services Standards Specialist and the Hospital Attorney via e-mail of the recovery team s decision. 3. The Senior Human Services Counselor Supervisor, and the Office of Recovery Planning/Social Services Standards Specialist will contact 4
b. Forensic Clinical Pathway: the appropriate Adult Mental-Health and Drug Abuse Program circuit office for residents in Civil and Forensic Services. The Human Services Counselor/Discharge Planner in the unit will contact the Forensic Specialists or Community Case Manager depending on the resident s service area. 4. The Hospital Attorney will contact the committing court by means of the competency evaluation or clinical summary as applicable. 5. If indicated, the appropriate Assistant Hospital Administrator will contact the Program Office. (1) The resident presents as one who will likely be restored to competency early (i.e., at or before the 125 days from the admission date). (2) The resident presents as one who will likely become competent with coaching or court education services (i.e., is likely to be restored to competence at 126 days to 150 days). (3) The resident remains ITP by 150 days but displays adequate mental and behavioral stability needed to discharge the resident to the community on a Conditional Release Plan to continue competency restoration efforts in a community program offering court education training. (4) The resident remains ITP by 150 days but cannot be discharged on a Conditional Release Plan and requires a transfer to Civil Services to follow the Civil Clinical Pathway. (5) The resident is Not Guilty by Reason of Insanity and can be discharged from Forensic Services on a Conditional Release Plan. (6) The resident is Not Guilty by Reason of Insanity and shows adequate behavioral stability but cannot be discharged from Forensic Services on a Conditional Release Plan and requires transfer to Civil Services. (7) Barriers to discharge are to be reviewed and updated monthly for residents who have been at the facility less than 24 months, and Bi-monthly for residents who have been hospitalized more than 24 month. Recovery teams must have a solid rationale (i.e., one which outlines the resident s behavioral issues) to warrant continued service provision in Forensic Services. Recovery teams having difficulties discharging residents due to community resistance, financial reasons, or other barriers the team s Social Services Staff is unable to resolve should contact the Office of Recovery Planning/Social Services Standards Specialist for a resolution. If discharge remains problematic after the Office Recovery Planning/Social Services Standards Specialist has been involved, the appropriate Assistant Hospital Administrator will be contacted for further assistance. (8) Forensic recovery teams may choose to discharge residents from the Forensic Clinical Pathway to a Low Structure or High Structure Community Clinical Pathway placement but the level of structure is to be determined by the resident s historical, clinical and risk factors noted in the HCR 20 v3 results, and the level of care recommended via completion of the LOCUS to include recovery team input and consensus. c. Civil Clinical Pathway: (1) The resident meets criteria for continued hospitalization under Chapter 916, F.S. as Not Guilty by Reason of Insanity or Incompetent to Proceed. The resident needs treatment, structure 5
and supervision within a 24/7 staffing pattern, but does not appear to require treatment in a secure Forensic residential placement. Severity and chronicity of the criminal history should be considered by the recovery team. Alternatively, the resident meets criteria for voluntary or involuntary hospitalization under Chapter 394, F.S. (2) At the time of the decision: (a) The resident no longer meets the requirements for placement in a secure forensic setting and is eligible for placement pursuant to inter and intra-hospital procedures on transfers to civil mental health treatment facilities or has been in/voluntarily admitted to the Civil Services. (b) Civil mental health treatment facilities include: 1. Florida State Hospital; 2. North East Florida State Hospital; and 3. Correct Care Solutions/South Florida State Hospital (c) Recovery teams may choose to transfer a resident to another Civil facility which may be closer to a resident s catchment area or otherwise better meet his/her treatment needs. (d) Admission Coordinator will send the relevant discharge or transfer information to the designated contact person at the target facility. (3) Staff responsibilities once a Civil Clinical Pathway is chosen are as follows: (a) Ensure the resident participates in the process. (b) Civil recovery teams may choose to discharge residents from the Civil Clinical Pathway to a Low Structure or High Structure Community Clinical Pathway placement, but the level of structure is to be determined by the resident s historical, clinical and risk factors noted in the HCR 20 v3 results and level of care recommendations based on the completion of the LOCUS to include recovery team input and consensus. d. Low Structure Community Clinical Pathway: (1) Residents in this clinical pathway generally have a history of some success in the community (they have few hospitalizations, possibly some work history, and limited involvement in the criminal justice system). Residents might have significant educational achievement or a significant support system. The resident does not meet commitment criteria but does need a level of some structure and supervision. (2) At the time of the discharge decision, the resident does not meet commitment criteria of dangerousness to him/herself or others due to mental illness or is manifestly capable of surviving alone, or in an alternative less restrictive setting. The resident does not pose a risk to him/herself through neglect. The resident does need a level of some structure and supervision based on recommendations from the completion of the LOCUS to include recovery team input and consensus. Further, without that level of care, the resident is at some risk for decompensation. (3) Low structure pathways include, but are not limited to: (a) Traditional case management; 6
(b) Assisted Living Facilities (ALF); (c) Adult Foster Care; (d) Family placements; (e) Placements with friends; (f) Nursing Home. (4) Staff responsibilities once a Low Structure Community Clinical Pathway is chosen are as follows: (a) Ensure the resident participates in the process. (b) Human Services Counselors/Discharge Planners will contact the appropriate Community Case Manager/Forensic Specialist to review resources and placement options and provide information to the recovery team. (c) Once the resident has been screened and accepted for a low structure community placement, the psychology staff member prepares a clinical summary, competency evaluation, or special clinical summary based on whether or not the resident was committed as Not Guilty by Reason of Insanity or Incompetent to Proceed. The Human Services Counselor/Discharge Planner will prepare the draft Conditional Release Plan and submit to recovery team for review and recommendations. The Human Services Counselor /Discharge Planner will forward for further review by Forensic Coordinators/Managing Entities. Following supervisory and Review Board approval as appropriate, the clinical summary or competency evaluation, and conditional release plan if applicable, will be mailed to the committing court prior to the resident s discharge. The appropriate Assistant Hospital Administrator will discuss high profile cases with the Program Office as indicated. 1. For residents committed under Chapter 394, F.S. with a history of high profile charges a special clinical summary will be presented to Civil Review Board and forwarded to the Program Office as notification prior to the resident s discharge. Special clinical summaries will include a current mental status, HCR-20 v3 results, LOCUS findings and will be filed in the resident s chart once approved. 2. A resident committed under Chapter 394, F.S. with a history of charges requires a notification letter to the State Attorney (Form 28). 3. A resident committed under Chapter 394, F.S. as a Mosher requires a Mosher notification letter being sent to the State Attorney prior to discharge. 4. A resident committed under Chapter 394, F.S. who is a Registered Sex Offender requires FSH to follow CFOP 155-48 prior to their discharge. Assigned Social Services staff members will make the required notifications to local and receiving Sheriff s Departments. 5. Residents committed under Chapter 394, F.S. may have no prior history of charges, but have current pending charges. The Dorm Chart/Master Record(s) of these residents will be flagged via green card stock that an outside county needs to be contacted prior to the time of the resident s discharge. A Psychology staff member will 7
complete the contact, documenting the name of the person spoken to, the number called, the reason for the call, the contents of the conversation, and any required additional follow up information on a Form 582 Report of Contact. In these aforementioned cases, the county jail is the discharge environment and the recovery team should work quickly to discharge the resident. 6. Hospital Legal reviews commitment orders for clarification of notification requirements. (5) Treatment will emphasize community re-integration (e.g. visits with significant others, trips to possible placement sites [applies to Civil Service only], assuring resources to meet daily living needs are in place). e. High Structure Community Clinical Pathway: (1) Residents in this clinical pathway generally have a documented history of placement failures in the community. These placement failures may be indicated by: (a) repeated hospitalizations, (b) repeated use of community crisis stabilization units, (c) multiple living placements, (d) multiple encounters with the criminal justice system, (e) repeated use of detoxification units, (f) little or no work history, (g) largely impaired social relationships, and (h) other indications. (2) To succeed in the community a resident requires significant structure and supervision. Severity and chronicity of the resident s criminal history should be considered by the recovery team. (3) At the time of the discharge decision: (a) A resident does not meet commitment criteria of being dangerous to him/herself or to others due to mental illness. A resident committed as Incompetent to Proceed does not meet commitment criteria of being manifestly incapable of surviving alone, or in an alternative, less restrictive setting, and could continue to receive competency training in the community. (b) The resident does not pose a risk through neglect, but does need a generally high level of structure and supervision based on recommendations from the completion of the LOCUS and HCR-20 v3 with input from the recovery team and consensus. The needed level of structure and supervision should be tailored to the resident's needs and risk factors. Without the needed level of care, the resident is at risk for decompensation and possible re-offense or re-entry into the criminal justice system or the inpatient mental health system. 8
(4) The living environment can be sought in State funded beds such as Daysprings, Apalachee Center, and Passageways when all efforts to discharge residents in their own circuit have been attempted. (5) Some catchment areas only have an Assisted Living Facility or low structure pathway resource available to residents within the circuit service area, yet the resident requires a high structure community placement due to historical, clinical or risk factors. In these cases, the proper discharge living environment should be sought in another circuit service area following approval from the Program Offices of both circuits. Examples of high structure pathway resources include, but are not limited to: (a) Forensic halfway houses that have special programs for integrating clients back into the community (e.g.; Apalachee, Passageways); (b) Community mental health provider agency residential programs; (c) Intensive case management; (d) Forensic case management; (e) Florida Assertive Community Treatment (FACT) Teams; (f) Other special case management. (6) Human Services Counselors/Discharge Planners will utilize Florida Health Finder website and contact Community Case Management/Managing Entity to identify high structure pathway resources. (7) Staff responsibilities once a High Structure Community Clinical Pathway is chosen are as follows: (a) Ensure the resident participates in the process. (b) The Human Services Counselor/Discharge Planner will contact the appropriate Case Manager/Forensic Specialist/Managing Entity to review resources and living environment options and provide information to the recovery team. Requests for additional information from the Forensic Coordinators will be made by the unit Human Services Counselor. The Office of Recovery Planning/Social Services Standards Specialist will work closely with recovery team members to include case management in obtaining living environment options and pursuing discharge/transfer. (c) If options are approved by the recovery team, the Human Services Counselor/Discharge Planner will review the options and recommendations with the Senior Human Services Counselor Supervisor. (d) For residents committed as Not Guilty by Reason of Insanity or Incompetent to Proceed, the psychology staff member will prepare a clinical summary or competency evaluation. Following supervisory and Review Board approval as appropriate, the clinical summary or competency evaluation, and conditional release if applicable, will be mailed to the committing court prior to the resident s discharge. The appropriate Assistant Hospital Administrator will discuss high profile cases with the Program Office as needed. The proposed conditional release plan will be submitted to the court at the same time or upon approval from Program Office (for high profile cases). 9
(e) In the Forensic and Civil Services, the proposed plan is developed by the Human Services Counselor/Discharge Planner in conjunction with the resident, the recovery team, the Senior Human Services Counselor Supervisor, the Office of Recovery Planning/Social Services Standards Specialist, the Adult Mental-Health and Drug Abuse Program Circuit Forensic Coordinators, Managing Entities and Forensic Specialists. The Human Services Counselor/Discharge Planner coordinates recommendations and approvals of Conditional Release Plans with the Forensic Coordinators. Proposed Conditional Release Plans must be approved by the Forensic or Civil Review Board, depending on a resident s area of service, prior to submission to the Court. (8) Treatment will emphasize community re-integration (e.g., visits with significant others, trips to possible placement sites or virtual tours, assuring resources to meet daily living needs are in place). 7. Training Requirements: A check in the box below indicates which employees within the department are required to read this operating procedure and when they will receive training at Florida State Hospital. Employees within identified departments will also be required to review the policy each time it is updated. Department All Employees Clerical Dental Dieticians, Laboratory, Special Therapy, X-Ray Techs Direct Care Emergency Operations Environmental Services (Aramark) Financial Services Food Services Health Information Services Human Resources Information Systems Legal Materials Management Nursing X Operations & Facilities (Aramark) Pharmacy Physician/ARNP (Prescriber) Professional Development Psychology Quality Improvement Recovery Planning/Social Services Rehab Services Resident Advocacy/Risk Mgt. Supervisors/Managers Volunteer Services Other: Worksite Education New Employee Orientation Discipline Specific Training X X X X Annual Update 10
Signed Original on file in Quality Improvement Program BOB QUAM Chief Hospital Administrator SUMMARY OF REVISED, ADDED OR DELTED MATERIAL Changed Barrier Reviews to Barriers to Discharge meetings; changed Barrier Review Worksheet; Changed timing on review of Barriers to Discharge by Recovery Team; Removed Office of Social Services; Added Senior Human Services Counselor Supervisor, Admission Coordinator, Office of Recovery Planning/Social Services Standards Specialist; Changed 180 days to 150 days; Combined Recovery Planning/Social Services under Department for training requirements; Changed title of Hospital Administrator to Chief Hospital Administrator to include name of individual. 11