Overview of 27-65 C.R.S.� �Care and Treatment of the Mentally Ill Act

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What is 27-65?

• Refers to Title 27, Article 65 C.R.S.
• Statutes specific to “Institutions” (27) and the Care & TX of Persons with Mental Illness (65)
• Replaces Article 9 (Commitment & General Provisions) from 1975
• Covers all people experiencing MI, not just those in imminent danger and/or gravely disabled

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Why 27-65

• Civil commitment= severe infringement of public rights/freedoms
• Such restriction of liberties requires due process of law
• 27-65 sets out procedural safeguards
• Preservation of rights
• Secures care & treatment suited to needs of the person
• Foster highest LOF and encourage voluntary tx in LRE
• Dignity & Respect

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3

How does DBH assist in monitoring 27-65?

• Monitor compliance and provide interpretation of statutes
• CDHS/DBH Procedural Manual (2004R)
• Implementation of the Care and Treatment of the Mentally Ill Act (27-65 C.R.S.)
• CDHS/DBH Rules Manual
• The Minimum Standards for the Care and Treatment of Person with Mental Illness (2CCR 502-1)
• Noting: these are resources for DBH to enforce consistent standards with facilities that DBH does not contract with as well.

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GENERAL PROVISIONS

Rules Manual, 19.100

Types of Designated Facilities

• Licensed general or psychiatric hospitals
• Community Mental Health Centers (CMHCs) or Clinics
• Residential Child Care Facilities (RCCFs)
• Acute Treatment Units (ATU’s)
• By special designation
• No nursing facilities or assisted living facilities unless operated by one of the above
• No jails or other types of facilities unless by special designation

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Types of Designations

• 72-Hour Evaluation and Treatment
• 72-Hour facilities cannot keep an involuntary patient longer than 72 hours, excluding week-ends and holidays, depending on the facility’s license.
• Short-Term Treatment
• Can be either inpatient or outpatient
• Short-term facilities cannot keep an involuntary patient for longer than 180 days (extended short-term certification)
• Long-Term Treatment
• Can be either inpatient or outpatient
• CMHCs must be designated as Long-Term Treatment facilities.

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Placement Facilities

• Designated facilities may enter into a written contract with another facility to provide mental health services on their behalf
• A placement facility may be a general or psychiatric hospital, community clinic and emergency clinic, convalescent center, nursing care facility, intermediate health care facility or residential facility, licensed residential child care facility or community mental health center or clinic
• Direct care supervision must be provided by a professional person

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72-Hour Holds

• “Any person who appears to have a mental illness and, as a result of such mental illness, appears to be an imminent danger to self or others.”

AND/OR

• “Any person who appears to have a mental illness and as a result of mental illness appears to be gravely disabled.”

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Reminder

• No designated facility has to accept a 72-hour hold unless ordered by a court

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• Emergency Department physicians may complete an evaluation and release the person

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Those who can place a 72-hour hold:

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• LCSWs, LPCs, LMFTs, peace officers, professional persons, RNs and LACs with additional knowledge, judgment & skill in mental health may place a person under an emergency 72-hour hold (CRS 27-65-105)

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Persons Who May determine the conclusion of a 72-Hour Mental Health Evaluation & Certify for Treatment

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• “Professional Persons”, a person licensed to practice medicine or a psychologist licensed to practice in Colorado.

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Actions Following 72-Hour Evaluation

• Person is certified for treatment

OR

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• Person signs in for voluntary treatment OR

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• Person is released after evaluation by the professional person

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ENFORCEMENT AND WAIVERS

Rules Manual 19.200

Compliance Monitoring

• Designated facilities shall be monitored for compliance annually
• Placement facilities may be monitored at the discretion of the Department of Human Services (CDHS) / Division of Behavioral Health (DBH)
• CDHS/DBH will investigate all complaints related to the 27-65 Statute and Rules

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Waivers

• Waiver of the specific rule requirements may be waived by DBH if the waiver would not adversely affect the health, safety and welfare of the patient

AND

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• Either it would improve patient care or application of the particular rule would create a demonstrated financial hardship on the facility

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ORGANIZATIONAL PROVISIONS

Rules Manual, 19.300

Rights and Advocacy

• The facility must post the list of Patient Rights found in the Rules
• The facility must give all persons detained under 27-65 a written copy of the rights listed in the Rules
• If the person is unable to read the rights, they shall be read the rights in a language they understand
• Children who are voluntarily receiving services under CRS 27-65-103 have additional rights of which they must be advised (“Advisement of Minor Patient Rights”)

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Rights Restrictions

• Some Patient Rights may be limited or denied for good cause by the professional person providing treatment

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• Only the following rights may be restricted:
• To receive and send sealed correspondence
• To have access to letter writing materials
• To use the telephone
• To have visitors (except the client’s attorney, religious representative or physician)
• To wear his/her own clothing

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Rights Restrictions�(continued)

• The reason for denying the right must be documented in the clinical record and evaluated on an ongoing basis

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• Restrictions must be ordered and documented every 7 calendar days by a professional person

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Rights Restrictions and Secure Treatment Facilities

• Rights restrictions for Secure Treatment Facilities have some specific differences
• Secure Treatment Facility = Colorado Mental Health Institute at Pueblo (CMHIP) HSFI
• For review of specific rules for this setting and population, please review Rule 19.312

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Rights of Minors

• Minor refers to a person under 18 years of age.
• These provisions do not apply to any minor admitted as a result of a judicial proceeding that authorizes the placement of the child pursuant to the Children’s Code, C.R.S. Title 19

22

Rights of Minors

• In addition to the rights listed for adults, minors 15 years of age or older, with/without the consent of a parent/legal guardian, have the right to:
• Consent to receive mental health services
• Consent to voluntary hospitalization
• Object to hospitalization

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Rights of Minors

• If a minor 15 years of age or older objects to a hospitalization, they have the right to have that objection reviewed by the courts under the provisions of Section 27-65-103 C.R.S.
• Minors under the age of 15 have the right to object to hospitalization and to have a guardian ad litem appointed pursuant to Section 27-65-103
• A written notice of the “rights of minor children” plus an “objection form” must be given to the minor upon admission to a designated facility.

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Rights of Minors

• Inpatient: If a minor is a resident of a designated facility in excess of 14 calendar days, appropriate educational programs shall be made available.
• Educational programs may be provided by either the local school district or by the designated facility-if the program is approved by the CDE.

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Advocacy

• Facilities must have a designated patient representative

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• Persons must be given the name and telephone number of the patient representative
• This process shall be included in written policy and procedure or documented in the clinical record

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Advocacy (continued)

• The facility must post the name, location, phone number and responsibilities of the patient rep and include where to get a copy of the complaint process

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• Facility must have policies for handling complaints that include forwarding unresolved complaints to DBH

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Employment of Patients

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• Vocational programs do not have to pay minimum wage unless they are of economic benefit to the facility

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• Work assignments, consent form and hourly wages must be documented in clinical record

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Quality Improvement

• JCAHO or CMS accredited facilities will follow those guidelines

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• Otherwise QI Program includes seven parameters for review, identified in Rule 19.330.B

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Data Requirements

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Data is reported to DBH on an annual basis:

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• 72 hour mental health holds
• Short and long-term certifications
• Voluntary persons
• Involuntary persons
• Persons under Imposition of Legal Disability

Staff Training Requirements

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• Facilities must develop a curriculum and schedule for training/competency

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• Facilities must develop policies and testing to assure competency

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• All staff participating in care and treatment must be trained and competent on the provisions of these rules and the statute

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• Staff who administer involuntary meds must be annually trained and competent on those rules

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Staff Training Requirements (continued)

• All direct care staff must be trained in the recognition and response to common side effects of psychiatric meds and trained to respond to emergency medication reactions

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• Staff in non-JCAHO or CMS facilities who administer restraint/seclusion techniques must have annual training in lower level behavioral interventions and the seclusion/restraint rules

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• Staff must be trained on needs identified via QI Program

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Staff Training Requirements (continued)

• Staff involved in the administration of the program shall be trained and competent on alternative or representative medical decision making. These advance directives include but are not limited to, medical durable powers of attorney, proxy decision making and guardianships.

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• Appropriate placement facilities staff must be trained and competent on the provisions in these rules and the statute

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Confidentiality

• HIPAA guidelines must be followed

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• Limits information to family or friends unless the patient signs a release of information, and/or has designated someone as “Personal Representative”.
• Access remains for authorized representatives of CDHS

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Confidentiality

• HIPAA guidelines must be followed

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• Limits information to family or friends unless the patient signs a release of information, and/or has designated someone as “Personal Representative”.
• Access remains for authorized representatives of CDHS

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Confidentiality (continued)

• Observed criminal behavior committed on the premises of a designated or placement facility or any criminal offense committed against any person while performing or receiving services is not considered privileged or confidential

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• Information that concerns child abuse/neglect or therapist abuse shall be reported to appropriate authorities

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TREATMENT PROVISIONS

Rules Manual, 19.400

Medical/Dental Care

• Each patient must have access to emergency medical care and written plan for providing emergency care that includes physical exams within 24 hours of admission and availability of a physician or emergency medical facility at all times

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• Must be able to access emergency treatment within 1 hour upon determination of emergency

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���� Medical/Dental Care

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• CMHCs – Only follow for certified individuals �
• Hospitals and Other designated facilities – Follow for all individuals

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Medical/Dental Care (continued)

• Patients to be referred to appropriate specialists for further treatment/evaluation and the information will be documented in the record

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• Must be ongoing appraisals of the general health of each patient and documentation in clinical

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• No facility obligation to pay for such services – only to secure the services for each patient

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Psychiatric Medications

• Informed consent required

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• Facility policy required regarding informed consent and documentation of such in record

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• Must follow advance directives to extent possible

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• Psychiatric meds may be administered by any professional authorized by law – not just MD

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Psychiatric Medications (continued)

• Facility must have policies on:
• Administration of meds, errors and adverse reactions
• Discontinuance of meds
• Disposal of meds
• Acceptance of verbal, fax or electronically transmitted med orders

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Psychiatric Medications (continued)

• Individual clinical records must contain following information:
• Name and dosage of med
• Reason for medication
• Time, date and dosage when administered
• Name and credentials of person administering med
• Name of prescribing professional
• Notation if emergency or court-ordered

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Involuntary Psychiatric Medications

• Rules DO NOT APPLY to refusal of non-psychiatric medications or medical emergencies

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• Persons must be on a hold or certification to be given emergency psychiatric meds

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Involuntary Psychiatric Medications (continued)

• Emergency is defined as:
• Imminent danger of hurting self or others (can rely on symptoms if predicted dangerousness in past)
• A recent overt act such as credible threat of bodily harm, assault or self-destructive behavior
• Substance abuse emergencies are not included in this definition

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Involuntary Psychiatric Medications (continued)

• Under the Colorado Department of Public Health and Environment statute (CRS 26-20-104), “chemical restraints shall only be given on the order of a physician”
• This is a change in statute, Jan. 2009

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Involuntary Psychiatric Medications (continued)

• If the emergency has abated because of meds but the MD believes it necessary to continue the meds to keep the emergency in abeyance beyond 72 hours, then :
• A written request must be submitted for a court hearing within the first 72 hours
• There must be documentation concurring consultation with another MD with their opinion regarding the emergency – if not obtained within 72 hours the medication must be stopped unless the medication must be titrated

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Involuntary Psychiatric Medications (continued)

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• Cannot give emergency meds beyond 10 days without a continuation order from the court

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• Patient must be notified of right to contact attorney and this must be noted in record

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Involuntary Psychiatric Medications (continued)

• Specific facts outlining behaviors supporting the use of emergency meds must be detailed in clinical record

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• Behaviors must be documented every 24 hours until a court order is obtained or the emergency is resolved or the patient accepts medications voluntarily

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Involuntary Psychiatric Medications (continued)

• Patient must be offered emergency meds on a voluntary basis each time they are given – if patient consents and the MD determines they will likely continue to accept the meds, this must be documented in the record and emergency medication procedure to be ended.

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• If the patient refuses again and an emergency situation arises, emergency med procedures may be re-instituted (no time frame)

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Non-Emergency Involuntary Medications

• If a person is certified and would benefit from, but will not consent to psychiatric meds, the facility may petition the court for involuntary meds if the following conditions are met:

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• Patient is incompetent to participate in the decision
• Medication is necessary to prevent significant deterioration in mental condition or to prevent patient from causing harm to self or others

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Non-Emergency Involuntary Medications (continued)

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• Less intrusive appropriate treatment is not available
• Person’s need for psychiatric medication is sufficiently compelling to override patient’s interest in refusing treatment
• Petition must specify recommended medications
• Cannot administer until court order is received

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Seclusion/ Restraint

• JCAHO and CMS approved facilities to follow those standards

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• Staff shall ensure no person will harm or harass a person who is secluded or restrained

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• Only certified persons, or persons on a 72-hour hold, can be restrained against their objection.

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• Voluntary persons must sign an informed consent for using special procedures

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Seclusion

• Use only for preventing imminent injury to self/others or eliminate prolonged, serious disruption to treatment environment

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• Any time a person is alone in a room and not allowed to leave, that is seclusion

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• An unlocked designated facility may place a person in seclusion to prevent departure if person is dangerous to self/others (meets standards for 72-hour holds)

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Seclusion (continued)

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• Must be based on current clinical assessment

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• Use only when other less restrictive methods fail

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• Can only be ordered by a professional person

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Restraint

• Cannot restrain single limb unless court ordered

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• Type of restraint must be appropriate to type of behavior, physical condition of person, age and effect restraint may have on the person

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Restraint (continued)

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• Applied only if alternative interventions have failed or would be unsafe or ineffective

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• Only ordered by professional person

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• Does not apply to transportation between one facility to another.
• (C.R.S. 26-20-101 et seq)

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Informed Consent for Therapy or Treatments Using Special Procedures

• Written consent must be obtained for ECT and/or behavior modifications using physically painful, aversive or noxious stimuli

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• Guardians cannot consent to ECT

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• ECT cannot be administered to anyone under age 16

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Informed Consent for Therapy or Treatments Using Special Procedures (continued)

• ECT requires use of the DBH consent form

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• Can be administered under a court order if consent is not obtained

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• Can be administered under emergency conditions if the life of the person is in imminent danger because of the person’s condition

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Continuity of Care and �Transfer of Care

• Facilities written policies to include:
• Access to all necessary care and services within the facility
• Coordination with previous care providers
• Coordination with family members, guardians and other appropriate persons reflecting patient’s culture and ethnicity
• At least one face-face or telephone conference.

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Continuity of Care and �Transfer of Care (continued)

• Facilitation of access to proper medical care
• Transfer to another facility when adequate arrangements are made
• 24 hour notice of transfer to certified persons unless it is an emergency
• Notification of transfer to 2 persons as indicated by patient

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Transportation

• Assessment for dangerousness and potential for escape is required

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• Can be transported (no restraints) by ambulance, care van, private vehicle if clinically appropriate and safe
• If dangerous to self/others or escape risk, may request transportation Sheriff

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Outpatient Certification

• Must be certified inpatient first

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• Must continue to meet requirements for certification

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• Must have a recent physical exam

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Outpatient Certification (continued)

• Arrangements must be made for access to:
• Case management
• Medical management
• Essential food, clothing, shelter
• Medical care and emergency dental care

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Outpatient Certification (continued)

• Service plan must reflect those arrangements and reflect outpatient certification status
• Service plan must also include requirements of Rule19.482.2 (Admission and Assessment data)

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• If patient fails to comply with service plan, patient may be taken into custody and assessed for current clinical needs

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Outpatient Certification (continued)

• Cannot force medication on person unless it is an emergency or court-ordered

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• If patient is not detained following assessment, facility must assist patient in returning to a reasonable location

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Treatment Records

• Electronic records are permitted, however a mechanism needs to be in place to capture required signatures

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• Entries must be signed, dated with degree and title

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• Must be kept in secure location

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Treatment Records (continued)

• Facilities must have policy that keeps records for:

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• Outpatient – 7 years after discharge or 7 years beyond reaching age 18 after discharge

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• Inpatient – 10 years after discharge or 10 years beyond reaching age 18 after discharge

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Treatment Records (continued)

• Records must include:

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• Written assessment information
• Individualized, integrated comprehensive service plan (except for persons being evaluated under CRS 16-8-103.7, NGRI)
• Treatment progress documentation
• Discharge planning information
• Discharge summary

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Contact Information

• For information on statute, rules, DBH monitoring, additional copies of this training or a copy of the training CD, etc., please contact
• Lori Banks, 303-866-7424, or lori.banks@state.co.us
• Your facility’s DBH liaison

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��The Hold and Treat�Process�

Process for 72-hour evaluation

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Person presents as

dangerous to self/others

or gravely disabled due to

mental illness.

Evaluator reports to court results of screening; respondent accepts voluntary treatment.

Evaluator reports to court results of screening; respondent refuses or fails to accept screening. Evaluator recommends to court that respondent be detained for involuntary evaluation.

Respondent detained for 72 hour evaluation in a designated facility by a professional person (transport arranged if to another facility).

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Respondent released if not in need of treatment.

Court-ordered 72 hour

evaluation: “M-3” process: anyone with knowledge of situation can petition for court-ordered eval via County Attorney. Court designates evaluation facility or professional person, who screens respondent.

OR: 72 hour hold: Persons qualified to place a person on hold completes the M-1. Rights (M-2) read to respondent.

(It is acceptable for the professional person to evaluate w/o detaining, if clinically appropriate)

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Respondent accepts voluntary treatment

Respondent refuses voluntary treatment, continues to meet M-1 criteria, is placed on Short-term Certification

At the conclusion of 72 hour eval:

Respondent given voluntary treatment advisement (M 2.1)

OR

Voluntary treatment

Process for Short-Term Certification (3 months/90 days)

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Respondent refuses voluntary treatment, continues to meet M-1 criteria, & is placed on Short-term Certification

Must meet one of the following conditions:

1.Respondent advised of availability of voluntary treatment but has refused.

2.Respondent accepted voluntary treatment but reasonable grounds exist to believe person wouldn’t remain in treatment

Professional person provides a report to court of jurisdiction of facts supporting Certification for Short term treatment (M-8)

Application for court-appointed attorney completed.

Notice of Certification & Cert. For Short-Term Treatment completed

These three documents are provided to the court simultaneously, w/in 48 hours. The original (M-8) must verify respondent’s receipt of (M-8).

While this process identifies the legal steps taken through the 27-10 process, there needs to be evidence that the respondent is kept informed of each step in this process, as much as is reasonable.

Copies of Certification & supporting letter provided to: respondent, his/her designee, respondent record,

Footnote on M-8 provides advisement to respondent of right to a hearing, by calling or writing to court of jurisdiction

Client Rights read to respondent

When respondent has received sufficient benefit from treatment, s/he may be released, at which time the certification is terminated. Form M-10 is completed & distributed per distribution list on Form.

Process for Extended Short-Term Certification (3 months/90 days)

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Respondent fails to consent for voluntary treatment, continues to meet M-1 criteria, & continues on Short-Term Certification.

Must continue to meet one of the following conditions:

1.Respondent advised of availability of voluntary treatment but has refused.

2.Respondent accepted voluntary treatment but reasonable grounds exist to believe person wouldn’t remain in treatment

AND

The Professional Person in charge of treatment believes that a period longer that 3 months is necessary.

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Prior to the end of the Short-Term Certification, the Professional Person must provide a report to court of jurisdiction of facts supporting Certification for Extended Short-term treatment

Extended Certification for Short- Term Treatment (M-11) completed.

Copies of Extended Certification & supporting letter provided to: respondent, his/her designee, respondent record,

Footnote on M-11 provides advisement to respondent of right to a hearing, by calling or writing to court of jurisdiction.

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These two documents are provided to the court simultaneously, w/in 48 hours. The original (M-11) must verify respondent’s receipt of (M-11).

In Denver County, the Involuntary Medication process is frequently timed to coincide with the Certification process. If the court hearing includes Involuntary Medications, the treating psychiatrist is required to testify.

Process for Long-Term Certification (6 months/180 days)

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Respondent fails to consent voluntary treatment, continues to meet M-1 criteria, & has received five (5) consecutive months treatment under provisions of STC & Extended STC.

Must continue to meet one of the following conditions:

1.Respondent advised of availability of, but has not accepted, voluntary treatment.

2.Respondent accepted voluntary treatment but reasonable grounds exist to believe person wouldn’t remain in treatment.

AND

The Professional Person in charge of treatment believes that a period longer that 6 months is necessary.

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Professional Person in charge of treatment to file petition for Long Term Care & Treatment (M-12) IMMEDIATELY upon conclusion of month 5.

Petition must be accompanied by report stating sufficient facts to establish reasonable grounds meeting original 27-10 criteria.

Petition must include a request for a hearing (M-15) before the court

Copy of petition must be given to the respondent and his/her attorney simultaneously with the filing with the court, & petition must show that copies were provided..

Form M-15 contains notice to the respondent that s/he may request a jury trial. Attorney must file written request with the court.

Court Action: A hearing or jury trial will be scheduled by the court. Testimony and cross examination completed by Respondent’s attorney, and by County Attorney for the Petitioner (e.g., the Professional Person, representing the treatment facility). Upon conclusion of the hearing, the judge will either: 1. Issue an order for 6 month Long Term Care and Treatment; 2. Terminated the Certification, or 3., Enter any other appropriate order.

Other “appropriate treatment orders” may include Impositions of Legal Disability for life issues that are compromised because of mental illness, like housing & financial affairs.

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Extension of Order Long-Term Certification (6 months/180 days)

Respondent fails to consent voluntary treatment, continues to meet M-1 criteria, & has received five (5) consecutive months treatment under provisions of STC & Extended STC.

Must continue to meet one of the following conditions:

1.Respondent advised of availability of, but has not accepted, voluntary treatment.

2.Respondent accepted voluntary treatment but reasonable grounds exist to believe person wouldn’t remain in treatment.

AND

The Professional Person in charge of treatment believes that a period longer that 6 months is necessary.

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Professional Person in charge of treatment to file petition for Extension of Long Term Care & Treatment (M-14) IMMEDIATELY upon conclusion of month 5.

Petition must be accompanied by report stating sufficient facts to establish reasonable grounds meeting original 27-10 criteria.

Petition must include a request for a hearing (M-15) before the court

Copy of petition must be given to the respondent and his/her attorney simultaneously with the filing with the court, & petition must show that copies were provided. Copies also provided to respondent’s designees..

Form M-15 contains notice to the respondent that s/he may request a jury trial. Attorney must file written request with the court.

Court Action: a. At least 20 calendar days before the order expires, the court will give written notice to the respondent & attorney that an extension hearing may be held before the court or a jury. If no hearing is requested, the court may proceed ex parte on behalf of the Respondent & issue an order for Extension. If a hearing is requested, the same process from the previous slide is followed. Upon conclusion of the hearing, the judge will either: 1. Issue an order for 6 month Long Term-Care and Treatment; 2. Terminate the Certification, or 3., Enter any other appropriate order.

Other “appropriate treatment orders” may include Impositions of Legal Disability for life issues that are compromised because of mental illness, like housing & financial affairs.

“ex parte” means a judicial proceeding on behalf of one party

Process for Transferring Certification to Outpatient Treatment

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Respondent fails to consent voluntary treatment, continues to meet M-1 criteria, & has received inpatient treatment under provisions of STC, Extended STC, or LTC.

Professional person determines respondent to be moved.

Respondent must be given 24 hour notice or must waive that right. Copy of Transfer of Cert (M-9) provided to Respondent & his/her attorney

Professional person determines that with appropriate treatment, respondent is able to live in a community

Sending treatment team coordinates transfer with receiving treatment team including Transfer of Certification.

Court receives Transfer of Certification (M-9)

Receiving cmhc has agreed to accept the outpatient certification.

If respondent is moving to a different cmhc, the sending cmhc & receiving cmhc have created a “continuity of care” agreement.

In accepting a Transferred Certification, the cmhc shall abide by the following RULES:

1. Have documentation of recent physical exam;

2. Have arrangements to assure case management

medication management;

essential food, clothing, shelter; and

Medical and emergency dental care.

3. Develop service plan reflecting these requirements

4. In addition, the cmhc shall meet the record content found in Rule 19.482.1 et seq.:

* 6-month assessment of continued need for cert

* identification of specific criteria for termination of cert

* Monthly review of service plan with assessment of progress toward termination of cert.

5. Should the designated facility determine the Respondent continues to meet M-1criteria, it is responsible for petitioning the court for further extensions.

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Process for Transferring Certification to another facility

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If respondent moving to nursing home or assisted living, a Placement Facility Agreement must be in place between the receiving cmhc and the living setting.

Facility is designated by DBH to provide appropriate treatment (e.g.: designated for STC vs. LTC)

OR

Respondent fails to consent voluntary treatment, continues to meet M-1 criteria, & has received inpatient treatment under provisions of STC, Extended STC, or LTC.

Professional person determines that respondent needs to receive treatment in another facility

Sending treatment team coordinates transfer with receiving treatment team including Transfer of Certification.

Respondent must be given 24 hour notice or must waive that right. Copy of Transfer of Cert (M-9) provided to Respondent & his/her attorney

Court receives Transfer of Certification (M-9)

In accepting a Transferred Certification, the cmhc shall abide by the following RULES:

1. CMHC responsible for assuring placement facility is appropriate for respondent’s treatment.

2. Facility placement agreement of file w/ DBH

3. Responsible for training staff at placement facility

4. Assure direct care supervision is provided by professional persons.

5. Have documentation of recent physical exam;

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6. Have arrangements to assure case management

medication management;

essential food, clothing, shelter; and

Medical and emergency dental care.

7. Develop service plan reflecting these requirements

8. The CMHC shall meet the record content found in Rule 19.482.1, and in particular, the following:

* 6-month assessment of continued need for cert

* identification of specific criteria for termination of cert

* Monthly review of service plan with assessment of progress toward termination of cert.

9. Should the designated facility determine the Respondent continues to meet M-1criteria, it is responsible for petitioning the court for further extensions.

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Imposition of Legal Disability

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Respondent continues to meet M-1 criteria, & remains on Long-Term Cert., or additional “insane” criteria.

(Statement in statute that respondent cannot be “subject to 72 hour hold or STC)

Petition must be accompanied by report stating sufficient facts to establish reasonable grounds meeting original 27-10 criteria. AND identify specific legal rights deprived or disability to be imposed.

ILD Petition (From M-23) MAY accompany a petition for Long Term Cert.

Court Action: Court or jury must find that person has MI AND meets M-1 criteria AND the loss of a right is both necessary & desirable

Court Action: Court shall appoint an attorney to represent respondent, paid by court if respondent is indigent.

Upon respondent’s or attorney’s request, court to appoint one or more professional persons to assist respondent in preparation of case

Upon demand, made at least 5 days prior to hearing, respondent has right to request jury of six (6)

Burden is upon person (or facility) seeking the imposition, or seeking to remove same, by clear & convincing evidence.

Pending hearing the Court MAY issue a temporary order imposing disability or deprivation of right.

Impositions are reviewed every 6 months by the Court of jurisdiction.

Emergency Involuntary Medications�(Pg. 23 Procedures, 19.420-19.423, 27-10-111)

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• Imminent danger self/others

• Overt act or credible threats of harm

• Assaultive or self-destructive

E-meds needed >er 72hrs?

Does the MD believe the Ψ emergency abated because of meds & of opinion that Ψ med necessary to keep emergency in abeyance beyond 72 hours?

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Within 72 hrs, the facility:

1. Sends written request for Court hearing.

2. Documents consult from a 2^nd MD who examines person, reviews med record & documents assessment as to whether/not Ψ emergency condition continues to exist.

3. Documents notification of person’s right to contact atty/court.

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STOP

Discontinue E-meds

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Emergency resolved?

Every 24 hrs until final court order issued (NTE 10 days), there is documentation of 1) substantiating behaviors needing cont. of E-meds &

2) new MD orders for E-meds.

Each time meds administered, voluntary meds must be offered and documented if accepted.

Meds accepted?

Is the person on a 72Hr. Hold, Short-Term or Long-Term Certification?

​

Emergency Condition exists?

STOP

E-Meds NA

​

There must be documentation that the person was offered Voluntary Meds- Did the Person Accept meds?

The MD can order administration of psych meds w/out person’s consent for up to 24 hours if there is documentation of the specific behaviors & nature of the emergency condition AND the attempt at voluntary meds.

YES

NO

NO

YES

YES

NO

NO

YES

YES

NO

YES

NO

If Court Order has not been obtained within 10 days, then the facility must discontinue E-meds.

Court-Ordered Meds �(Non-Emergency Involuntary Medications Pg. 23 Procedures, 19.420-19.423)

81

When a person is in a non-emergency situations and on a short-term or long-term certification and would benefit from psychiatric medications but is refusing, the facility may petition the Court for administration of involuntary Ψ meds.

The petition must document the following:

1. The person is incompetent to

effectively participate in tx decision ;

2. Psychotropic medication is

necessary to prevent significant &

likely long--term deterioration in

person's mental condition or to

prevent likelihood of causing

serious harm self/others;

3. Less intrusive appropriate

tx alternatives are not available;

4. The need for psychotropic

medication overrides legitimate

interest of the person in refusing tx;

5. Specify the medication recommending.

Documentation of notification to person of right to contact attorney/court.

​

No psychiatric medications shall be administered without the person’s consent until a court order authorizing involuntary use is received – unless the person meets criteria for Emergency Involuntary meds.

Court-Ordered meds cannot exceed the expiration date of the order for Long-Term Certification (6 months).

Charting for all medications must include: 1) med name & dose; 2) reason for ordering; 3) time/date/dosage when administered; 4) name & credentials of person administering; 5) name of prescriber; and 6) if Emergency or Court Ordered.