Attachment 3 - Design Guide MH 2021.pdf

Design Guide for Inpatient Mental Health & Residential

Rehabilitation Treatment Program Facilities

JANUARY 2021

PG 18-12: INPATIENT MENTAL HEALTH (IPMH) & MENTAL HEALTH RESIDENTIAL

REHABILITATION TREATMENT PROGRAM (MH RRTP) DESIGN GUIDE

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TABLE OF CONTENTS

1.0 GENERAL

1.1 Foreword

1.2 Acknowledgments 1-6

1.3 Introduction 1-13

1.4 Policies / Standards / Codes 1-14

1.4.1 VA Policies/Standards 1-14

1.4.2 Industry Codes/Standards 1-15

1.4.3 HIPAA 1-15

1.5 Abbreviations 1-17

2.0 GENERAL PLANNING AND DESIGN NARRATIVE 2-1

2.1 Operational Summary 2-4

2.2 Defining VHA Inpatient Mental Health (IPMH) and Residential Rehabilitation Treatment Program (MH RRTP) Facilities 2-5

2.3 VA IPMH Description 2-5

2.4 VA MH RRTP Description 2-7

2.5 VA IPMH/MH RRTP Comparison 2-8

2.6 Design Consideration for Specific Populations 2-10

2.7 The Inter-Disciplinary Team 2-12

2.8 Guiding Principles for Planning and Design 2-13

2.9 Outcomes 2-20

3.0 PLANNING AND DESIGN

3.1 Inpatient Mental Health Units (IPMH) 3-3

3.1.1 Patient Safety and the Environment of Care 3-3

3.1.2 Security Level Zone Plans and Definitions 3-3

3.1.3 IPMH Mental Health Environment of Care

Checklist (MHEOCC) 3-5

3.1.4. Site Visit Examples of Mental Health Units 3-6

3.1.5 IPMH Unit Diagrams and Descriptions 3-14

3.1.5.1 Relationship Diagrams 3-15

3.1.5.2 Unit Size 3-22

3.1.5.3 Room Occupancy 3-23

3.1.5.4 Inpatient Entrance 3-24

3.1.5.5 Patient Room 3-27

3.1.5.6 Patient Toilet/Shower

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3-30 3-31

3.1.5.7 Seclusion Room

3.1.5.8 Nurse Station

3.1.5.9 Interior Common Areas and Corridors 3-33

3.1.5.10 Outdoor Spaces 3-36

3.2 Mental Health Residential Rehabilitation Treatment Program (MH RRTP) 3-38

3.2.1 Resident Safety and the Environment of Care 3-38

3.2.2 MH RRTP Safety and Security 3-38

3.2.3 Site Visit Examples of Residential Treatment Units 3-39

3.2.4 MH RRTP Unit Diagrams and Descriptions 3-44

3.2.4.1 Relationship Diagrams 3-45

3.2.4.2 Unit Size 3-48

3.2.4.3 Room Occupancy 3-48

3.2.4.4 Entrance/Reception 3-49

3.2.4.5 Resident Room 3-50

3.2.4.6 Resident Toilet/Shower 3-51

3.2.4.7 Staff Station Design 3-52

3.2.4.8 Interior Common Areas and Corridors 3-53

3.2.4.9 Outdoor Spaces 3-54

3.3 Renovation Summary 3-55

4.0 TECHNICAL CONSIDERATIONS 4-1

4.1 Site Design 4-4

4.1.1 Introduction 4-4

4.1.2 Site Planning 4-5

4.1.3 Topography 4-5

4.1.4 Proximity to Adjoining Facilities 4-6

4.1.5 Shared Site Features 4-6

4.1.6 Landscape Design 4-7

4.1.7 Exterior Spaces 4-7

4.2 Architecture 4-9

4.2.1 Introduction

4.2.2 Architectural Scale

4.2.3 Covered Entry 4-10

4.2.4 Windows and Glazing 4-10

4.3 Interior Design 4-11

4.3.1 Introduction 4-11

4.3.2 Sustainability 4-12

4.3.3 Elements of Interior Design 4-12

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4.3.3.1 Positive Engagement 4-12

4.3.3.2 Biophilic Design 4-13

4.3.3.3 Way-finding 4-14

4.3.3.4 Acoustics 4-14

4.3.3.5 Lighting 4-15

4.3.3.6 Finishes (Flooring and Base) 4-17

4.3.3.7 Finishes (Walls) 4-21

4.3.3.8 Ceilings 4-23

4.3.3.9 Wall Mounted Items 4-24

4.3.3.10 Interior Wall Partitions 4-26

4.3.3.11 Interior Doors 4-27

4.3.3.12 Interior Windows and Glazing 4-31

4.3.3.13 Furnishings 4-31

4.4 Structural Systems 4-35

4.4.1 Seismic Design 4-35

4.4.2 Physical Security 4-35

4.5 Heating, Ventilation and Air Conditioning Systems 4-35

4.5.1 Life Cycle Analysis 4-35

4.5.2 Energy Conservation 4-35

4.5.3 Load Calculations 4-35

4.5.4 Exterior Design Conditions 4-36

4.5.5 Indoor Design Conditions 4-36

4.5.6 Supply Air Requirements 4-36

4.5.7 Outdoor Air Requirements 4-36

4.5.8 Exhaust and Return Air Requirements 4-36

4.5.9 Noise Criteria 4-36

4.5.10 Design Features 4-36

4.5.11 Temperature Control Criteria 4-37

4.5.12 Humidity Criteria 4-37

4.5.13 Equipment Locations 4-37

4.6 Plumbing 4-37

4.6.1 Domestic Water 4-37

4.6.2 Plumbing fixtures 4-38

4.6.3 Sanitary, Vent and Storm systems 4-38

4.6.4 Medical gas systems 4-38

4.6.5 Seismic Requirements 4-38

4.7 Lighting and Power Systems 4-38

4.7.1 Lighting 4-38

iv

4.7.2 Power 4-39

4.8 Telecommunications, and Special Telecommunications, Monitoring and Signal Systems 4-39

4.8.1 General 4-39

4.8.2 Telecommunications network outlets 4-39

4.8.3 Tele-mental health video conferencing 4-40

4.8.4 Nurse call 4-40

4.8.5 Television 4-40

4.8.6 Security 4-40

4.8.6.1 Duress alarm 4-41

4.8.6.2 PACS (physical access control system) 4-41

4.8.6.3 Video assessment and surveillance 4-41

4.8.7 Public address system (PAS) 4-41

4.9 Fire Protection and Life Safety 4-41

4.9.1 General 4-41

4.9.2 Automatic sprinkler 4-42

4.9.3 Fire alarm 4-42

5.0 ROOM TEMPLATES

5.1 General

5.1.1 General Notes

5.1.2 Abbreviations

5.1.3 Legend 5-6

5.2 IPMH Room Templates 5-9

FA2 Patient Care Unit Staff - Patient Area 5-9

5.2.1 Sally Port 5-9

5.2.2 Intake room / Interview room 5-15

5.2.3 Group Room 5-23

5.2.4 Patient Laundry Room 5-30

FA3 Patient Care Unit Patient Area 5-36

5.2.5 One-Bed Universal Patient Room

With Patient Universal Toilet / Shower 5-36

5.2.6 Two-Bed Universal Patient Room

With Patient Universal Toilet / Shower 5-47

5.2.7 Seclusion Room/Anteroom, Toilet/Shower 5-58

FA4 Patient Care Unit Patient Common Area 5-68

5.2.8 Dayroom 5-68

5.2.9 Dining Room 5-76

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5.2.10 Patient Lounge 5-84

FA6 Patient Care Unit Clinical Staff Area 5-91

5.2.11 Nurse Station 5-91

5.2.12 Nurse Workroom

5.2.13 Medication Room

5.2.14 Team Room 5-115

5.2.15 Combined Nurse Station (Small) 5-123

5.2.16 Combined Nurse Station (Large) 5-124

5.3 MH RRTP 5-125

FA2 Common Resident Service Area 5-125

5.3.1 Community Room with Kitchen 5-125

5.3.2 Recreation Therapy Room 5-135

5.3.3 Large Group Therapy Room / Classroom 5-144

FA4 Resident Care Unit Resident Area 5-152

5.3.4 Resident Lounge 5-152

5.3.5 Veteran Special Population Resident Lounge 5-162

5.3.6 One-Bed Universal Resident Bedroom

With Resident Universal Toilet / Shower 5-168

5.3.7 Two-Bed Universal Resident Bedroom

With Resident Universal Toilet / Shower 5-180 FA5 Resident Care Unit Support Area 5-192

5.3.8 Staff Station 5-192

5.3.9 Staff Workroom 5-198

5.3.10 Medication Room

5.3.11 Team Room 5-216

5.3.12 Combined Staff Station (Small) 5-224

5.3.13 Combined Staff Station (Large) 5-225

6.0 APPENDIX 6-1

6.1 Addressing Acute Medical Care Needs 6-4

6.2 Site Visit Summary 6-5

6.3 Staff Opinion Survey Summary 6-136

6.4 IPMH & MH RRTP Facility Workshop Summary 6-152

6.5 Emerging Evidence 6-159

6.6 Literature Reviews 6-173

6.7 Endnotes 6-180

6.8 Bibliography 6-182

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1.0 GENERAL

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REHABILITATION TREATMENT PROGRAM (MH RRTP) DESIGN GUIDE

1.0 GENERAL 1-1

1.1 Foreword 1-3

1.2 Acknowledgments 1-6

1.3 Introduction 1-13

1.4 Policies / Standards / Codes 1-14

1.4.1 VA Policies/Standards 1-14

1.4.2 Industry Codes/Standards 1-15

1.4.3 HIPAA 1-15

1.5 Abbreviations 1-17

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1.0 GENERAL

1.1 Foreword

VA Program Offices, project teams, designers and constructors, are obligated to our Nation’s Veterans and taxpayers to make the most effective and efficient use of resources, by providing a continuum of safe, secure, high quality, high performance, and high value environments of care and service for Veterans. The VA Office of Construction and Facilities Management (CFM) supports the Department’s mission through development and application of standards as a basis for disciplined planning, design, and construction of VA facilities.

VA Standards are the culmination of a partnership among the Department of Veterans Affairs (VA), the Veterans Health Administration, Program Officials, Clinicians, Industry, Academic and Research Organizations, Expert Consultants, and the Office of Construction and Facilities Management. Design Guides are developed through integration of VA-specific requirements, Federal law and regulation, benchmarking of industry best practice, evidence-based research and design, and value-based analysis of leading edge innovation. The result is the establishment of best value standards for optimum functionality, safety, operability, performance, and quality throughout the VA environment of care and service.

Design Guides (PG-18-12) are a critical component of the VA Technical Information Library (TIL) (www.cfm.va.gov/TIL) which provides standards for all VA planning, design, and construction projects. Design Guides focus on selected healthcare departments and services and include an overview narrative of VA-specific planning and design principles and concepts, room templates, equipment lists, and basic technical/engineering requirements. They communicate the basis of design and are required to be utilized by project teams working on new construction and renovations of existing facilities. Design Guides will maximize the effectiveness and efficiency of the planning and design process and ensure a high level of design, while controlling construction, operating, and maintenance costs.

The material contained in Design Guides constitutes a standard for VA Planning, Design and Construction. For all VA projects, it is required that project teams comply with the following in all phases of project development:

1. All applicable VA Standards published in the VA Technical Information Library (TIL) shall be applied as a basis, foundation, and framework in planning, design, and construction. Any substantial variance from Standards shall be considered only as required to accommodate specific site, functional, and operational conditions.

Upon consideration of variance CFM shall be consulted, and each Administration will function as Authority Having Jurisdiction for decision. Each substantial variance shall have a basis rationale and be documented in the project record.

2. Clinicians, providers, primary users, and other stakeholders shall be involved in all phases of project development to best adapt Standards for specific functional, operational, and site conditions, and to provide optimum service environments for Veterans. This also includes installations and modifications of systems or www.cfm.va.gov/TIL

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Stakeholder involvement shall be documented in the project record.

Design Guides are not project specific. It is impossible to foresee all rapidly evolving requirements of healthcare facilities and each site or project will have unique requirements or conditions. Site specific issues must be addressed within the context of these standards and applied to each individual project. Use of this Guide does not preclude the need for, nor absolve planners, designers, and constructors of their responsibility to provide complete, functional, safe, and secure designs suited to the unique requirements of each project, within budget, and on schedule.

Materials, equipment and systems are shown in an illustrative, performance-based format and are not intended to depict, suggest, or otherwise constitute endorsement of any specific product or manufacturer. Manufacturers should be consulted for actual dimensions, configurations, and utility requirements.

All participants in the project development process must embrace VA Planning, Design and Construction Standards as fundamental in providing optimum environments for Veterans’ care and services, in fulfilling VA’s mission.

Donald L. Myers, AIA, NCARB Director, Facilities Standards Service US Department of Veterans Affairs Office of Construction and Facilities Management

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REHABILITATION TREATMENT PROGRAM (MH RRTP) DESIGN GUIDE

1.2 Acknowledgments

Credit is due to the following individuals whose leadership, knowledge, skills and ability made this document possible:

DEPARTMENT OF VETERANS AFFAIRS - Veterans Health Administration (VHA)

OFFICE OF MENTAL HEALTH AND SUICIDE PREVENTION (10NC5)

Marsden McGuire, MD, Director, Continuum of Care and General Mental MBA Health, Office of Mental Health and Suicide

Prevention (OMHSP)

Andrew Pomerantz, MD Senior Consultant, Office of Mental Health and Suicide Prevention (OMHSP)

Cliff Smith, PhD., ABPP Deputy Director, Office of Mental Health and Suicide Prevention (OMHSP)

Peter Mills, PhD, MS Psychologist, NCPS Field Office

Jay Cohen, PhD., LP Chief of Staff, Office of Mental Health and Suicide Prevention (OMHSP)

Timothy Smith, PhD National Director, Inpatient and Outpatient Psychosocial Rehabilitation and Recovery Services, Office of Mental Health and Suicide Prevention

(OMHSP)

Kendra Weaver, PsyD Senior Consultant, Office of Mental Health and Suicide Prevention (OMHSP)

Matthew Miller, Phd, Director, Suicide Prevention Program, Office of MPH Mental Health and Suicide Prevention (OMHSP)

Michele Karel, PhD National Mental Health Director, Geriatrics Mental Health, Office of Mental Health and Suicide Prevention (OMHSP)

Kim Coleman Prier, Deputy Director, MH RRTP, Office of Mental Health LCSW and Suicide Prevention (OMHSP)

Jamie R. Ploppert National Director, MH RRTP, Office of Mental Health and Suicide Prevention (OMHSP)

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REHABILITATION TREATMENT PROGRAM (MH RRTP) DESIGN GUIDE

OFFICE OF CONSTRUCTION AND FACILITIES MANAGEMENT (CFM)

Kayvan Madani Nejad, PhD., AIA

Gary Fischer, AIA

Fei (Linda) Chan, Assoc. AIA

NCARB

Dave Tash, PE

Orest Burdiak

Jacob Brown

Elizabeth Yo, RA

David Treece, AIA

Senior Healthcare Architect, Project Manager

Senior Healthcare Architect

Senior Healthcare Planner

Senior Mechanical Engineer

Principal Interior Designer

Senior Medical Equipment Specialist

Architect, Planner

Senior Healthcare Architect/Planner

OFFICE OF MENTAL HEALTH AND SUICIDE PREVENTION (10NC5)

Camilla Doctor, LCSW Program Specialist, MH RRTP, Office of Mental Health and Suicide Prevention (OMHSP)

Elizabeth Czekanski, Clinical Nurse Advisor, Mental Health, Office of DNP, MS, RN-BC, NE- Nursing Service

BC

John Bradley, MD Director, Mental Health Services, VA Boston Healthcare System

Matt Moore, PhD Quality Improvement and Implementation Consultant, Office of Mental Health and Suicide Prevention (OMHSP)

Peggy Henderson, Psy.D Director, Consumer and Liaison Services Psychosocial Rehabilitation and Recovery Services Office of Mental Health, VA Central Office

Tykia Andree, LCSW Program Coordinator, PRRTP, Community Based Care, VA Medical Center, Pittsburgh, PA

Sharon De Peralta, PhD, Section Chief, Acute & Intensive Mental Health MBA, RN, CPHQ Programs, San Diego, CA

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REHABILITATION TREATMENT PROGRAM (MH RRTP) DESIGN GUIDE

VA MEDICAL CENTERS

MCLEAN HOSPITAL

Michele Gougeon, MSS, MSc

NORTHAMPTON VA

MEDICAL CENTER

Dana Weaver

WORCESTER RECOVERY

CENTER

Jeffrey L. Geller, MD, MPH

DARTMOUTH- HITCHCOCK

MEDICAL CENTER

Terri Kotrady, RN-BC

WHITE RIVER JUNCTION

VA MEDICAL CENTER

Robert Scott, MD PhD

CENTRAL VERMONT

MEDICAL CENTER

Justin Knapp, MD

VERMONT PSYCHIATRIC

HOSPITAL

Heidi Gee

Executive Vice President and Chief Operating Officer

Chief of Mental Health at VA Central Western Massachusetts Healthcare System

Medical Director

Clinical Nurse Supervisor

Chief of the Department of Mental Health & Behavioral Sciences

Medical Director

Hospital Operations Chief

OFFICE OF CONSTRUCTION AND FACILITIES MANAGEMENT (CFM)

Rand Hakim, AIA NCARB Planner

Mark Mueda, AIA, LEED AP Senior Healthcare Planner

Lam Vu, PE, CEM Senior Electrical Engineer

Frederick Lau, PE Structural Engineer

Kyle Terry, PMP, CFM Cost Estimator, Cost Estimating Service, OFP, CFM

Senior Fire Protection Engineer, VHA Center for Peter A Larrimer, PE Engineering and Occupational Safety and Health

Forrest F. Frakes, PG, CET, (CEOSH), Pittsburgh, PA Senior Telecommunications Specialist, VA Office of

PC Information & Technology

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REHABILITATION TREATMENT PROGRAM (MH RRTP) DESIGN GUIDE

VA MEDICAL CENTERS

MEDSTAR HARBOR

HOSPITAL

Jemima Kanham, MD, FAPA

SUN BEHAVIORAL

HOUSTON

Laura Brown

MENNINGER CLINIC

John Gomolka

MICHAEL E. DEBAKEY VA

MEDICAL CENTER

Kaki M. York

LOUISVILLE VA MEDICAL

CENTER

Dr. Jaclyn Engelsher, DNP

SUN BEHAVIORAL

KENTUCKY

Ann Mitchell

LEXINGTON VA MEDICAL

CENTER

Dr. Autum McCane, PhD

EASTERN STATE

HOSPITAL

Andrew Cooley, MD

ESSEX COUNTY HOSPITAL

CENTER

Frank J. DelGaudio, SASHE

CARRIER CLINIC

Donald Parker

LYONS VA MEDICAL

CENTER

Manjula Chilakapati

MEDSTAR HARBOR

HOSPITAL

Jemima Kanham, MD, FAPA

Psychiatrist

Chief Executive Officer

Director of Facilities and Property Manager

Department Executive

Chief Nurse for Mental Health & Behavior Sciences Service

Director of Clinical Services

Chief Mental Health Service

Chief Medical Officer

Hospital Director

President, Carrier Clinic

Deputy Associate Chief of Staff

Psychiatrist

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REHABILITATION TREATMENT PROGRAM (MH RRTP) DESIGN GUIDE

VA MEDICAL CENTERS

UCLA RESNICK

NEUROPSYCHIATRIC

HOSPITAL

Miranda Daniel, LCSW, ACM

WEST LOS ANGELES VA

MEDICAL CENTER

Richard Martin, MSN, RN, BC

WILLOW ROCK CENTER

Jessica Eschman, LCSW

JOHN GEORGE

PSYCHIATRIC HOSPITAL

Sheetal Riaz

VA MEDICAL CENTER PALO

ALTO

William Faustman, PhD

MENLO PARK VA MEDICAL

CENTER

Frank N. Quiles, CFM

ST. JOSEPH’S BEHAVIORAL

HEALTH CENTER

Paul Rains, RN, MSN

SAN JOSE BEHAVIORAL

HEALTH

Sean Peterson

JAY MAHLER RECOVERY

CENTER

Jim Christopher, MBA, LMFT

SEATTLE CHILDREN’S

Anne Moore, MSN, BSN, RN-BC

VA PUGET SOUND HEALTH

CARE SYSTEM – SEATTLE

DIVISION

Ellen Li, MD

Utilization Management Director

Interim, Inpatient, Behavioral Health Manager

Program Director, Willow Rock CSU

Interim Engineering Manager

Utilization Management Director

Chief, Office of Facility Planning and Development

President/System Behavioral Health Lead

Chief Executive Officer

Interim Clinical Director

Director Psychiatry & Behavioral Medicine

VAPSHCS Psychiatrist

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VA MEDICAL CENTERS

VA PUGET SOUND

HEALTH CARE SYSTEM –

AMERICAN LAKE DIVISION

Michelle Loewy, Ph.D

Phycologist

SITE VISIT PARTICIPANTS

Ben P. Lee, AIA, ACHA, PP, CID,LEED AP, NCARB

NK Architects

CONSULTANTS - VDCI

Alden S. Bradstock, III, PE President

Mitchell Norris, MSW Medical Equipment Planner

Marta Cavero, PE Vice President Electrical Engineering

Nick Heinz, PE Senior Vice President

Michael Bokulic Mechanical Engineer

Bridgette Moore, MSEd Business Development Manager

Tillman Johnson, AIA,NCARB

Architect

CONSULTANTS - SMITHGROUP

Cindy Beckham Principal, Healthcare Studio Leader

Stephen Parker, AIA, NCARB, LEED AP BD+C

Architect + Planner

Liz Vandermark Architect, Research Director

Lou Pasada, ACHE, Lean Six Sigma Certified

Principal, Senior Healthcare Planner

Matthew Reiskin Architect, Project Manager

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REHABILITATION TREATMENT PROGRAM (MH RRTP) DESIGN GUIDE

CONSULTANTS - HDR

Director of Federal Healthcare Ron Villasante, RA, CAP, MRCP, March Planning, Senior Professional

Associate

CONSULTANTS - FORMERLY WITH SMITHGROUP

Shary Adams, AIA, ACHA, EDAC, LEED Principal, Senior Medical Planner

AP BD+C

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REHABILITATION TREATMENT PROGRAM (MH RRTP) DESIGN GUIDE

1.3 Introduction

When the original version of the Mental Health Design Guide was produced in 2010, it was very much a creature of its time. The various levels of mental health care in VA, such as inpatient, residential and outpatient, were all included in one volume. The promise of the recovery model of care (which holds that all persons with mental health challenges can lead a self-directed life and thereby achieve their full potential) and the struggle to advance safe and home-like environments of care were still early in their implementation. Since then we have learned a great deal about the safety issues through experience and optimal environments by comparing best practices from across the nation and beyond. The current volume focuses on inpatient and residential levels of care (outpatient care is covered in a separate recently published volume) and is designed to give as updated and complete a picture of the principles, and their application, that allow Veterans seeking mental health care the best chance of recovery.

Although it is not often considered during an episode of care, the Veteran’s experience directly impacts their willingness to seek these services if needed in the future – especially when (as is sometimes the case for inpatient facilities), the admission was made on an involuntary basis.

As Dr. Bradley Karlin eloquently stated in the Introduction to the 2010 Guide, “Facility design impacts the beliefs, expectations, and perceptions patients have about themselves, the staff who care for them, the services they receive, and the larger health care system in which those services are provided. Moreover, facility design can also have a significant impact on the beliefs, attitudes, and behaviors of staff and on how staff identify and interact with patients and the environment.” This is true now more than ever and explains why such a pain-staking effort is made to collect perspectives across multiple disciplines, occupations and roles to inform these recommendations for optimal facility design. The importance of making site visits to existing and planned facilities, inside and outside VA, to arriving at an understanding of the full range of others’ experiences and wisdom, cannot be overestimated.

In this edition, the Inpatient section provides information to minimize opportunities for Veterans to harm themselves such as ligature risks and a lack of clear lines of sight. Both the Inpatient and Residential sections emphasize the notion of patient engagement where spaces are created to allow Veterans the opportunity to interact with staff and each other in a way that promotes recovery. An important example is the nurses’ station which is comprised of an “on-stage” area that purposely avoids unnecessary separation or barriers between Veterans and staff, and a conceptually and functionally different “off-stage” area where staff work to complete tasks that do not include Veteran participation or that require privacy. Both Inpatient and Residential levels fully enshrine the notion of home-like surroundings compatible with safety, including use of muted colors, open space, light and access to the outdoors and fresh air.

Looking back in another ten, or perhaps even five, years, the authors of the next Design Guide will notice what we missed or underemphasized here and will undoubtedly correct those shortcomings. However, our hope is that, with this volume, VA will continue to lead the way for inspiring today’s leaders and providers to promote the optimal environment of mental health care - one that they would want for themselves or their loved ones should the need arise..

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1.4 VA Policies / Standards and Industry Policies / Standards

The standards set forth herein are not intended to be project-specific, nor are they crafted as a regulatory code. The Design Guide addresses space and equipment planning, based on the functional, technical, and systems to support the operational requirements associated with the various inpatient mental health services. The narrative and graphic material developed in this document are based on the site visits of both recently built, renovated and older facilities, staff interviews, collaborative work sessions and meetings, and research of relevant publications and standards.

1.4.1 VA Policies/Standards (add hyperlinks to the documents online)

1. VHA Handbook 1160.01 - Uniform Mental Health Services in VA Medical Centers and Clinics (amended Nov. 16, 2015)

2. VHA Directive 1160.03(1) – Programs for Veterans with Posttraumatic Stress Disorder (PTSD) (Nov. 16, 2017)

3. VHA Handbook 1160.04 – VHA Programs for Veterans with Substance Use Disorders (Mar. 7, 2012)

4. VHA Handbook 1160.06 – Inpatient Mental Health Services (Sept. 16, 2013)

5. VHA Handbook 1160.05 – Local Implementation of Evidence-Based Psychotherapies for Mental and Behavioral Health Conditions (revised Dec. 8, 2015)

6. VHA Handbook 1162.02 – Mental Health Residential Rehabilitation Treatment Program (MH RRTP) (Jul.15, 2019)

7. VHA Handbook 1162.09 – Health Care for Homeless Veterans (HCHV) Program (May 2, 2014)

8. VHA Handbook 1163 – Psychosocial Rehabilitation and Recovery Services (Aug.

13, 2019)

9. VHA Directive 1167 – Mental Health Environment of Care Checklist for Mental Health Units Treating Suicidal Patients (May 12, 2017)

10. VHA Directive 1172.05 – Recreation Therapy Service (Feb. 1, 2017)

11. VHA Directive 1140.11 – Uniform Geriatrics and Extended Care Services in VA Medical Centers and Clinics (Oct. 11, 2016)

12. VHA Directive 1330.01(2) – Health Care Services for Women Veterans (amended Jul. 24, 2018)

13. VA Design, Construction Standards and Tools:

a. Master Construction Specifications PG-18-1

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b. Design Guides (PG-18-12)

c. Design Manuals (PG-18-10)

d. Equipment Guide List (PG-18-5)

e. Room Finishes, Door, and Hardware Schedule (PG-18-14)

f. Space Planning Criteria for VA Facilities (PG-18-9)

g. MH RRTP Annual Safety and Security Assessment (ASSA) Tool FY19 or current

h. VA Environmental Program Service Mental Health Guide 2014

1.4.2 Industry Codes/ Standards

1. Facility Guidelines Institute: 2018 Edition

a. Guidelines for Design and Construction of Hospitals

b. Guidelines for Design and Construction of Outpatient Facilities

c. Guidelines for Design and Construction of Residential Health, Care, and Support Facilities

2. National Fire Protection Association (NFPA) 101 Life Safety Code

3. NFPA National Fire Codes

4. Occupational, Safety and Health Administration (OSHA) Standards

5. Architectural Barriers Act Accessibility Standard (ABAAS) for Federal Facilities, including the Barrier Free Design Standard.

6. Healthcare Insurance Portability and Accountability Act of 1996 (HIPAA) protects individual’s rights to audible as well as visual privacy.

7. Behavioral Health Design Guide Edition 7.3 Feb 2018 (Formerly: Design Guide for the Built Environment of Behavioral Health Facilities) Includes REVISED Patient Safety Risk Assessment Tool to align with The Joint Commission’s November 2017 Recommendations

8. Patient Safety Standards, Materials and Systems Guidelines recommended by the New York State Office of Mental Health, current edition.

1.4.3 HIPAA

The Healthcare Insurance Portability and Accountability Act of 1996 (HIPAA) protects individuals rights to audible as well as visual privacy. This is especially the case with respect to protection of each individual’s medical records, private information and communications. The law protects all conversations between patients and admission interviewers, caregivers, nurses, physicians and families. ARRA passed by U.S. government in 2009 enacts special provisions and legal enforcement tools for patient privacy, protection and security. Office of Civil Rights (OCR) monitors HIPAA security rule compliance based on ARRA provisions. Current penalties that can be implied by OCR for non-compliance with HIPAA are divided in four categories: (i)

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REHABILITATION TREATMENT PROGRAM (MH RRTP) DESIGN GUIDE

without knowledge; (ii) based on reasonable cause; (iii) willful neglect and (iv) willful neglect, not corrected. Penalties differ per violation versus maximum penalty according to these four categories and vary between $100 and up to $1,500,000.

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1.5 Abbreviations

Abbreviations

A/E Architectural / Engineering Firm

A/I ACQ/INS

A/V Audio Visual

AAMA American Architectural Manufacturers Association

ACT Acoustical Ceiling Tile

ADA Americans with Disabilities Act

AFF Above Finished Floor

AHJ Authority Having Jurisdiction

AIA American Institute of Architects

ANSI American National Standards Institute

ASHRAE American Society of Heating, Refrigerating & Air Conditioning Engineers

C Degree Celsius

CC Contractor Furnished, Contractor Installed

CCTV Closed Circuit Television

CMS Centers for Medicare and Medicaid Services

CFM Office of Construction & Facilities Management

DG Design Guide

EES Essential Electrical System

F Degrees Fahrenheit

FC Foot-candle

FD Floor Drain

FMS Facilities Management Service

GFI/GFCI Ground Fault Circuit Interrupter

HAC Housekeeping Aides Closet

HIPAA Health Insurance Portability and Accountability Act of 1996

HVAC Heating, Ventilating and Air Conditioning

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Abbreviations

HR Hour

IPMH Inpatient Mental Health

ISIT Interdisciplinary Safety Inspection Team

JSN Joint Schedule Number

LED Light Emitting Diode

LEED Leadership in Energy and Environmental Design

LB Pound/Pounds

MH Mental Health

MH RRTP Mental Health Residential Rehabilitation Treatment Program

MHEOCC Mental Health Environment of Care Checklist

MHS Mental Health Services

MID Motion Intrusion Detection

NEC National Electrical Code

NFPA National Fire Protection Association

NSF Net Square Foot, Net Square Feet

NSM Net Square Meters

OIT Office of Information & Technology

OSHA Occupational Safety and Health Administration

PG Program Guide

PSDM Physical Security Design Manual

PTSD Posttraumatic Stress Disorder

RCP Reflected Ceiling Plan

SER Sentinel Event Reduction

SF Square Foot, Square Feet

SMI Serious Mental Illness

SS Stainless Steel

STC Sound Transmission Class

SUD Substance Use Disorders

TBI Traumatic Brain Injury

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Abbreviations

TIL Technical Information Library provided by the VA online @ http://www.cfm.va.gov/TIL/

TV Television

VA Department of Veterans Affairs

VACO Veterans Affairs Central Office

VAMC Veterans Affairs Medical Center

VC VA Furnished, Contractor Installed

VHA Veterans Health Administration

VOC Volatile Organic Compound

VV VA Furnished, VA Installed http://www.cfm.va.gov/TIL/

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2.0 GENERAL

PLANNING AND DESIGN

NARRATIVE

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2.0 GENERAL PLANNING AND DESIGN NARRATIVE 2-4

2.1 Operational Summary 2-4

2.2 Defining VHA Inpatient Mental Health (IPMH) and Residential Rehabilitation Treatment Program (MH RRTP) Facilities 2-5

2.3 VA IPMH Description 2-5

2.4 VA MH RRTP Description 2-7

2.5 VA IPMH/MH RRTP Comparison 2-8

2.6 Design Consideration for Specific Populations 2-10

2.7 The Inter-Disciplinary Team 2-12

2.8 Guiding Principles for Planning and Design 2-13

2.9 Outcomes 2-20

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2.0 GENERAL PLANNING AND DESIGN NARRATIVE

2.1 Operational Summary

The Veterans Health Administration (VHA) is an integrated health care system that provides comprehensive mental health care among other health care services for Veterans. The continuum of VHA mental health care covers a range of mental health conditions, delivered in settings that include outpatient, intensive outpatient, residential and inpatient care, as well as community-based settings.

The information in this Design Guide provides guidance to create Inpatient Mental Health (IPMH) and Mental Health Residential Rehabilitation Treatment (MH RRTP) care facilities for Veterans with a focus on recovery care in a safe environment.

As stated in the VHA Handbook 1160 on therapeutic communities, “Recovery” is identified as, “the single most important goal for the mental health service system…”

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2.2 Defining VHA Inpatient Mental Health (IPMH) and Residential Rehabilitation Treatment Program (MH RRTP

The multiple levels of VHA Mental Health services and associated facilities supporting treatment transition and preparation for discharge are shown in Table 2.1 below. The information in this Design Guide applies to VHA Inpatient Mental Health (IPMH, Level 6) and Residential Rehabilitation Treatment Program (MH RRTP, Level 5) facilities only. Section 2.1.1 will focus on identifying the relative differences between the Level 5 and Level 6 Veteran Mental Health populations that drive facility design solutions unique to each population. While both population and facility types vary, staff and Veteran engagement in a safe environment is foundational to the planning and design concepts for both IPMH and MH RRTP facilities.

Table 2.1 LEVELS OF CARE FOR VA MENTAL HEALTH summarizes the levels of care provided by VHA Mental Health services.

2.3 VA IPMH Description

The VA IPMH patient (Level of Care 6, see Table 2.1) requires inpatient acute mental health treatment, under direct medical supervision and care from clinical staff with provisions for high levels of observation and safety measures. This Veteran population is at risk of harming themselves or others and/or requires observation and monitoring in a protected environment.

VA IPMH Units are ‘locked facilities’. Patients cannot leave the facility without being discharged by staff to a less secure environment.

A VA IPMH unit provides stabilization care for Veterans with acute mental health issues, while providing a broad range of clinical interventions to treat the patient according to recovery principles and prepare them for discharge to home or the next level of care. IPMH requires the greatest level of safety and security for patients and staff, due to the nature of the mental health of these patients. In the patient care continuum, the IPMH patient is most acutely ill and vulnerable to self-injury and injury to others. For this reason, the facility design must support a heightened level of safety integration with minimal compromising or detraction from the healing and therapeutic environment. Figure 2.1 provides an example of a Patient Bedroom environment for IPMH that addresses provisions for heightened patient safety.

A critical component of design on the IPMH unit is the Nurse Station, which must facilitate both positive engagement with patients as well as safety for staff. This station includes two

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sections: an “on-stage” and an “off-stage” area. The on-stage Nurse Station area is openly visible and approachable for patients, to encourage patient/staff interaction and engagement, and is designed to maximize visibility of the unit by staff at the Nurse Station and to promote milieu management. A glass partition can be used to achieve safety from patients climbing over counters but should not fully enclose the station to the ceiling. The second area, the ‘Closed Station’ is the off-stage area, referring to the rooms behind the Nurse Station which includes the Team Room, Nurse Work and Medication Room. These areas are all accessible from the ‘on-stage’ Nurse Station and should have windows for visibility to the unit when possible. It is preferable that each room have a secondary egress into one of the adjacent rooms to allow the staff an area for safety and security. Please refer to Chapter 3 for design specifications.

All materials and accessories in IPMH facilities must meet VA Dir 1167, Mental Health Environment of Care Checklist (MHEOCC) requirements. Please refer to Chapter 3.1.3 and

3.1.5 of this Design Guide for additional MHEOCC references.

Note: Many photos included in the Design Guide are from facilities outside the Veterans Health Administration. These photos may include details that do not meet Mental Health Environment of Care Checklist (MHEOCC) requirements. These photos are for reference only.

Figure 2.1 This example of an IPMH patient room incorporates soft colors, finishes and accessories that create a therapeutic space. Note: All IPMH areas must meet Mental Health Environment of Care (MHEOCC) requirements. Carl T. Hayden VAMC, Phoenix, AZ (SmithGroup)

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2.4 VA MH RRTP Description

In contrast to the IPMH, the goal of the MH RRTP is to empower the Veteran to regain a lifestyle of self-care, independence and personal responsibility. Facilities for MH RRTP residents shall have one secure, key-less entry point allowing resident independence of access. For this reason, special design considerations should be given to concealment and access of hazardous items into the facility.

MH RRTP facilities have greater freedom in finish materials and room accessory selection to create a home-like atmosphere with finishes, colors and spatial relationships. (see Figure 2.2) The settings reflect a residential rather than institutional nature. The IPMH Environment of Care Checklist (MHEOCC) requirements do not apply to MH RRTP. For safety and security standards related to the MH RRTP refer to the VA Mental Health Residential Rehabilitation Treatment Program Directive 1162.02.

Figure 2.2 This resident bedroom is an example of a residential and home-like atmosphere at a MH RRTP facility. The Next Door: Nashville, TN (Earl Swenson)

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2.5 IPMH/MH RRTP COMPARISON

Diagram 2.1 shows a summary comparison of service and design elements in IPMH and MH RRTP facilities. The Veteran is referred to as ‘Patient’ in the IPMH setting and ‘Resident’ in the MH RRTP setting. The average length of stay is longer in a MH RRTP facility than that of an IPMH facility, and supports freedom of access and a need to make the facility feel home-like.

In an IPMH facility, patient amenities and services are provided in a secure area on the patient unit, while in a MH RRTP facility amenities are accessible, open and potentially off the unit.

The percentage of private beds to provide in an IPMH facility is greater than in a MH RRTP.

Consistent with the goal of the MH RRTP to assist the Veteran transition back to the community, fewer numbers of private patient rooms enhances socialization and the recovery process.

Greater numbers of private rooms in IPMH units allow patients to access private space to reduce stress.

For both IPMH and MH RRTP settings, the unit is defined as the area where the Veterans safely and securely reside and are treated on a 24-hour per day, 7-day per week continuous basis. It includes bedrooms and other associated common amenity areas.

For IPMH units, amenity areas include Day Rooms, Dining Rooms and areas for relaxation.

In addition, access to secure and safe outdoor areas should be provided with porches and/or courtyards.

For the purpose of this design document, ‘secure’ is defined as an area that controls access and prevents the introduction of hazardous items to the unit.

For MH RRTP units, resident common areas include exercise, recreation therapy and group therapy rooms. Outdoor areas in the MH RRTP facilities should be provided, but are not included in the facility program, because they are not required to be enclosed and securable.

IPMH and MH RRTP facilities may contain a single unit or multiple units. Refer to PG 18-9 to determine the number of units and rooms per facility and the patient/Veteran room sizes.

Additional definition of each space type is described in Section 3.0 of this Design Guide.

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Diagram 2.1 High level comparison of VHA IPMH and MH RRTP facilities.

* Homelike is defined by each facility. The intention is to limit the institutional atmosphere for both staff and Veterans.

** To be determined by facility *** Semi-private rooms shall not exceed two (2) beds per room with Toilet/Shower facilities provided in each Veteran room.

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2.6 DESIGN CONSIDERATION FOR SPECIFIC POPULATIONS

Special physical design features are required to accommodate the levels of care for specific populations in the IPMH environment. VHA Handbook 1160.01 provides guidance on the needs and requirements for all specific Veteran mental health populations. Specific populations that may require special operational and/or facility accommodations include but are not limited to Homeless Veterans, Women Veterans, Veterans with Spinal Cord Injury (SCI), older Veterans with specialized care needs, Veterans with substance use disorders and Veterans with medical care needs.

Homeless Veterans

Separate storage for personal belongings that cannot be brought into the patient room is defined by PG 18-9. Consideration of storage on or off the unit for larger quantities of personal items shall be given consistent with local policy.

Women Veterans

VA mental health facilities must address requirements for Women Veterans as defined in the VHA Directive 1330.01. All inpatient facilities must provide separate and secured patient self-locking sleeping accommodations. Should mixed gender units be provided, the design must include safe, separate and secure sleeping and Toilet/Shower facilities for this patient population. Bedrooms and/or units designated for the Women Veteran population shall be located in close proximity to staff for added oversight and should include a Lounge and Day Room.

Veterans with Spinal Cord Injury (SCI)

Veterans with SCI may be treated in an IPMH facility if the patient is medically stable and does not require specialized equipment which the unit or IPMH staff cannot support. To accommodate IPMH care to medically stabilized Veterans with SCI, the facility design must provide at least one patient room per unit with a detachable hand-held shower with a minimum 6’ long flexible hose. The shower hose shall be stored in a locked staff area until put in place for the patient to use. During use, the patient requires direct staff supervision. During project design, consult with National Center for Patient Safety (NCPS), as well as, Office of Nursing Service (ONS) and Office of Mental Health & Suicide Prevention (OMHSP) regarding specific situations and considerations.

Specialized Care Needs Common Among Older Veterans

Some older Veterans require specialized geropsychiatric care, given medical, sensory, functional, and/or neurocognitive conditions. These physical conditions require enhanced observation and support as patients with these conditions are at higher risk for falls, disorientation, and stress in a new environment. Some younger Veterans with medical or neurocognitive disorders require similar accommodations.

Special attention shall be given to designing for fall prevention and mitigation, provision of sensible way-finding and a familiar atmosphere for patients with cognitive or memory impairment. Signage design with familiar themes, patient individualization and colors to clearly identify patient rooms can reduce Veteran confusion and improve way-finding. Ligature-free

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handrails and soft furniture with soft edges and minimal points of impact can reduce harm should patient falls occur. Ample and diffuse daylight reduces glare for improved visualization of interior spaces, and acoustic treatments to attenuate noise, which reduces stress. A home-like atmosphere creates a more familiar and approachable environment, which can reduce Veteran stress and disorientation.

A design concept based on a ‘Pod’ of patient rooms may facilitate safe care, observation, and storage of mobility/sensory aids for these Veterans. For further guidance about the use of medical/functional aids on IPMH units, please refer to the MHEOCC. Note that Veterans with dementia or other neurocognitive disorders who do not require the safety of an IPMH environment of care may be better served in a Community Living Center, including for short-stay dementia or mental health recovery care.

Reference VHA Directive 1140.11, Uniform Geriatrics and Extended Care Services in VA Medical Centers and Clinics and VHA Office of Geriatrics and Extended Care and Office of Mental Health and Suicide Prevention (2019) for guidance for developing or enhancing short-stay behavioral care in VHA Community Living Centers.

Veterans with Substance Use Disorders

For patients admitted to IPMH and diagnosed with a substance use disorder, specific design strategies need to be implemented. The design of patient rooms and common spaces shall mitigate the concealment of items hazardous to their recovery. These areas shall have clear lines of sight for quick visual assessment by staff during rounds. To prevent the passage of hazardous items, operable windows shall not be provided. Outdoor spaces shall be designed separate from publicly accessible areas to deter hazardous item passage into the facility.

Veterans with Medical Care Needs

Some Veterans requiring admission to a locked, acute IPMH unit may require treatment for chronic and relatively stable medical conditions (e.g., hypertension, diabetes, need for mobility aids), with appropriate clinical observation of medical equipment as warranted.

When it is determined that overall safety and care are not compromised by the Veteran remaining in an IPMH unit, appropriate accommodations must be provided in the mental health setting for the medical treatment. In general, special medical facility accommodations like patient headwalls/medical gases, patient lifts and isolation rooms (positive/negative pressure) will not be provided on an IPMH Unit. Local facility policy will determine what special and/ or reasonable accommodations for patients with co-morbidity can be made through staff consultation with NCPS, ONS, and OMHSP.

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2.7 THE INTERDISCIPLINARY TEAM

The IPMH Interdisciplinary Team is comprised of healthcare professionals who collaborate as partners to provide a comprehensive and holistic treatment approach to the delivery of Mental Health care. These professionals and para-professionals, who require appropriate space when performing their duties on the unit, may include, but are not limited to:

The Interdisciplinary Team offers therapeutic programming in a variety of settings. These settings support treatment, safety and recovery for each individual Veteran as well as the Veteran patient population as a whole. Therapy and recreation rooms are designed to support patient interaction with individual members of the Interdisciplinary Team. Day Rooms, Dining Rooms and Patient Lounges are designed to serve as alternative interaction spaces for Veterans and Interdisciplinary Team members. Open milieu and distributed seating areas on the patient units provide locations for unscheduled interactions to take place.

Interdisciplinary Team collaboration is supported with team rooms and quiet areas for private team collaboration. The team room is adjacent to and accessible from the Nurse Station in an “off-stage” setting, which allows for uninterrupted discussions. The nurse workroom can also serve as a space for “off-stage” Interdisciplinary Team interaction.

Figure 2.3 This rendering is an example of a team room that provides a space for Interdisciplinary Team collaboration.

Practitioners

• Registered Nurses

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2.8 Guiding Principles for Planning and Design

“Mental health recovery is a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of the person’s choice while striving to achieve his or her full potential.” 1

Based on this recovery-oriented foundation, there are ten components of recovery as listed below.

Facility designs must support the work of the Interdisciplinary Team to provide recovery-oriented care by creating spaces that enable personal control of the environment (lighting, access to nature), promote self-directed peer support (porches, open milieu seating), encourage individualization (room personalization) and convey respect and hope (non-institutional atmosphere). The narratives, diagrams and room templates in this Design Guide define the spaces and space relationships required to achieve a recovery-centered design.

The Guiding Principles for Planning and Design apply to both IPMH and MH RRTP facilities unless noted otherwise.

Figure 2.4 Example of design features, in a MH RRTP non-anti-ligature area, that promote a home-like atmosphere. These design features include natural daylighting, a fireplace, furniture selections and the use a wood on the feature wall. VA IPMH areas must comply with the MHEOCC requirements. Navos Center (Mithun)

All information to follow is based on the Guiding Principles for Planning and Design. The Principles are guided by VHA Directives and the details of their application were discussed during workshop sessions with a cross-disciplinary team that includes architects, engineers, planners, psychiatrists, psychologists, nurses, other clinicians, patient advocates and Veterans.

Ten Fundamental Components of Recovery 2

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Principle #1: Mental Health Environments Are Recovery-Oriented

VA Mental Health is patient and family-centered, rehabilitation/recovery oriented, evidence-based and focused on community reintegration.2

Figure 2.5 Principle #1 Example: Open environments and distributed seating encourage interaction.

Menninger Clinic, Houston, TX, (Kirksey)

Examples of design techniques that enhance social interaction and support therapeutic rehabilitation and recovery include:

• Encourage and enhance Veteran and family interaction by providing family visitation rooms with associated visitor lockers to help ensure Veteran, staff, and visitor safety

• Provide secure milieu management areas to safely encourage unimpeded interaction and engagement between staff and Veterans

• Establish clear lines of sight for staff to all areas, so staff can both observe and encourage interaction (see Figure 2.5)

• Provide a mix of individual/group therapy and psycho-education classroom spaces (sizes, configurations and amenities) to allow for varying levels of socialization and interaction

• Provide smaller Veteran room groupings and co-locate specific Veteran (patient or resident) populations together

• Create access to outdoors, natural light and views of nature

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Principle #2: Mental Health Environments are Therapeutically Enriching

A therapeutically enriching environment that is home-like, familiar and visually and physically accessible to nature promotes healing, autonomy, respect and privacy. 3

Figure 2.6 Principle #2 Example: Outdoor spaces support a therapeutic environment and personal enrichment. This example shows a labyrinth, lawn and a covered seating area to provide patients with a variety of activity spaces. Vermont Psychiatric Care Hospital, Berlin, VT (Architecture +)

Examples of design techniques that enhance therapeutic enrichment include:

• Creating spaces that foster a sense of community between the Veterans and staff by creat-ing non-programmed/flexible…