To: Hospital Administrators, Chief Nursing Officers, Legal Counsel, Government Affairs, Public Relations staff
Please forward to: Risk Managers, Emergency Department Staff, and Psychiatric Unit Managers
From: Chelene Whiteaker, Policy Director
Taya Briley, General Counsel
Staff Contact: Chelene Whiteaker, Policy Director, chelenew@wsha.org, 206-216-2545
Subject: Single Bed Certification: New Emergency Rule Effective April 21 for Patients with Medical Conditions
Purpose
The purpose of this bulletin is to:
- Inform hospitals of the new emergency rule filed on April 21 by the Washington State Department of Social and Health Services (DSHS) impacting single bed certification for patients with medical conditions. (CLICK HERE for the new rule.)
- Provide updated designated mental health professional protocols to hospitals. Pages 23 and 24 contain information about single bed certification. (CLICK HERE for the protocols.)
Applicability/Scope
This new emergency rule modifies criteria for a single bed certification for patients who meet detention criteria and have a medical condition(s). Not all hospitals may be able to meet this new standard. The new rule will likely impact:
- Hospitals with an emergency department
- Hospitals that are treating a patient who meets detention criteria under the involuntary treatment act for a psychiatric condition, but also has a medical condition that prevents the transfer of the patient to a certified evaluation and treatment facility
- Hospitals with a psychiatric unit
- Hospitals that can provide psychiatric services on an inpatient basis
- Psychiatric hospitals
- Residential treatment facilities
Background
On April 21, 2015, as a part of its continuing response to the Washington State Supreme Court decision, In re the Detention of DW, DSHS issued a new emergency rule modifying the regulatory requirements for single bed certification. In re the Detention of DW found the practice of boarding involuntarily detained mental health patients without providing active treatment was a violation of their civil rights. The new emergency rule was effective on April 21, 2015 and takes the place of the emergency rule in effect since December 26, 2014.
WSHA negotiated with DSHS on the language for this new emergency rule and supports the work of the department in making this version permanent as emergency rules can only be in effect for 120 days, according to RCW 34.05.350. We will send an additional bulletin when the permanent rule is set to be implemented.
Recommendation
WSHA recommends a thorough review of the new rule with your appropriate clinical teams, hospital risk managers and legal counsel. Hospitals should have an administrative process in place when a designated mental health professional asks your clinical staff about accepting a single bed certification. See WSHA’s bulletin from December 2014 for more information on the process for responding to single bed certification requests.
With respect to this new rule, it is important to understand the increased flexibility that is allowed for patients with medical comorbidities – WAC 388-865-0526(4). Detention for a patient with a medical condition(s) is now subject to a revised standard that recognizes it may not be possible to meet the needs of a seriously ill patient in a traditional mental health treatment setting. We encourage hospitals to think about a variety of scenarios that would involve this revised standard.
Effect on hospitals
The new emergency rule contains the following areas of note:
Willing and Able to Provide Treatment continues to be a requirement for a single bed certification.
The new rule continues to require that a Hospital be willing and able to Provide Treatment for all single bed certifications.
Nothing in this new rule requires a hospital to provide psychiatric treatment to patients who meet involuntary detention criteria or accept a single bed certification. However, DSHS’ position is that a designated mental health professional must have a certified evaluation and treatment bed or a single bed certification available for the patient prior to detaining the patient.
Patients with Medical Conditions
The new rule changes the requirements for patients with medical conditions in subsection (4). The language for this part of the rule is provided below. Note that there is no definition of “medical condition” or “medical co-morbidity.” Rather, the rule refers to a consumer who, “requires medical services that are not generally available at a facility certified under this chapter.” The hospital must determine whether the, “not generally available” requirement is met prior to relying on this section of the rule.
Most significantly, hospitals providing certifications for these patients are not required in all circumstances to meet all of the criteria for “timely and appropriate mental health treatment” in a case where a patient has a medical condition. This distinction was explicitly recognized in the Supreme Court’s decision in In re the Detention of DW.
Note among the criteria, the facility must document there is an option where, “An RSN [Regional Support Network] assigns a mental health professional to provide consumer appropriate mental health treatment at the facility including observation and evaluation, during the period of time the consumer is provided medical services.” Before utilizing this option, WSHA strongly advises hospitals to consult with legal counsel, risk management and insurance carriers. If the hospital and RSN choose to proceed and utilize this option, it should be done in collaboration. Both parties should have a clear understanding of roles and RSN obligations to a hospital’s policy and procedures.
WAC 246-865-0526(4) states:
“If a consumer requires medical services that are not generally available at a facility certified under this chapter, or at a state psychiatric hospital when a court has ordered a ninety- or one hundred eighty-day inpatient commitment, or at a facility that meets the requirements of subsections (2) and (3) of this section, a single bed certification may be issued to that facility for the consumer as follows:
(a) The single bed certification request must adequately describe why the consumer requires medical services that are not available at a facility certified under this chapter, or at a state psychiatric hospital when a court has ordered a ninety- or one hundred eighty-day inpatient commitment, or at a facility that meets the requirements of subsections (2) and (3) of this section;
(b) The facility that is the site of the requested single bed certification must confirm that it is willing and able to provide the medical services; and
(c) The facility has documented that one of the following has been met:
(i) With the authorization of the hospital, and consistent with any applicable hospital policies and procedures, the RSN assigns a mental health professional to provide the consumer appropriate mental health treatment at the facility, including observation and evaluation, during the period of time the consumer is provided medical services; or
(ii) The hospital provides medical services and a plan that addresses the consumer’s mental health treatment needs until the consumer is medically stable and the RSN or its designee identifies an appropriate facility for the consumer that is one of the following:
(A) The hospital providing services;
(B) A facility that is certified as an evaluation and treatment (E&T) facility; or
(C) A facility that can meet the consumer’s needs under the single bed certification criteria in this section.
(d) If a qualified medical professional determines that mental health treatment for the consumer is not clinically indicated, the requirements in (c) of this subsection do not apply. When the consumer is determined to be medically stable, the facility must ensure the requirements in (c) of this subsection are met.
For Patients without a Medical Co-Morbidity, Accepting a Single Bed Certification Means the Hospital Must Be Able to Provide Timely and Appropriate Mental Health Treatment As Defined in the New Rule
The new rule continues to define what “timely and appropriate mental health treatment” means when accepting a single bed certification for patients without medical co-morbidities. Among the requirements is having standards for administration and monitoring of medication, including psychiatric medications. WSHA understands this particular requirement may be a challenge for some facilities that have accepted single bed certifications in the past. WAC 246-865-0526(3) states:
“In order to provide timely and appropriate mental health treatment, the facility receiving the single bed certification, or the public or private agency the facility has a direct arrangement with to provide mental health treatment, must:
(a) Implement standards for administration that include written procedures to assure that a mental health professional, as defined in RCW 71.05.020 or WAC 388-865-0150, and licensed physicians are available for consultation and communication with both the consumer and the direct patient care staff;
(b) Use a plan of care/treatment. The medical or clinical record must contain documentation that:
(i) An individualized mental health treatment plan was developed, when possible, collaboratively with the consumer. If the consumer is unwilling or unable to participate in development of the plan, documentation must be made in the record. Development of this plan may include participation of a multidisciplinary team, a mental health professional, as defined in RCW 71.05.020 or WAC 388-865-0150, or collaboration with members of the consumer’s support system as identified by the consumer.
(ii) A mental health professional, as defined in RCW 71.05.020 or WAC 388-865-0150, has had contact with each involuntarily detained consumer at least daily for the purposes of:
(A) Observation and evaluation; and
(B) Assessing whether the consumer is appropriate for release from involuntary commitment to accept treatment on a voluntary basis.
(c) Have standards for administration and monitoring of medication, including psychiatric medications. Consumers have a right to make an informed decision regarding the use of antipsychotic medication consistent with RCW 71.05.215.
Single Bed Certification Applicability to Individual Patients
Consistent with the Supreme Court’s ruling in the case of In re the Detention of DW, the rule recognizes the need for the evaluation of the issuance of a single bed certification, “in each instance where such certification is sought for an individual.” [See WAC 388-865-0526(2).] WSHA believes the requirement to take the facts and circumstances of each individual patient into account will support more appropriate use of single bed certifications. The rule continues to acknowledge a distinction between an appropriate single bed certification and a patient who is boarding without appropriate resources.
Transferring of Patients on a Single Bed Certification
To assist in the transferring of patients on single bed certifications to evaluation and treatment facilities when appropriate, WAC 388-865-0526(6) states:
“A consumer who receives services under a single bed certification under this section must be transferred to an evaluation and treatment facility if on a seventy-two hour detention or fourteen-day commitment, or to a state hospital if on a ninety- or one hundred eighty-day inpatient commitment, as soon as the attending physician considers the consumer medically stable and a bed becomes available, unless the treating facility consents to continue treatment and continued treatment in the current setting is consistent with the best clinical interests of the consumer.”
Next Steps
Permanent Rule Making. WSHA expects that within the next 120 days DSHS will work through its process to make this emergency rule a permanent rule.
Background and References
WSHA bulletin on single bed certification and implications to hospitals from December 16, 2014
Washington State Supreme Court decision on In Re Detention of DW
