Attachment+A+-+Policy+and+Procedure.docx

Attachment A

REVISION SUMMARY FROM PREVIOUS TO CURRENT VERSION

Category added/changed/fixed: None

Items added/changed/fixed:

Added under PURPOSE and POPULATION:

· 7. The Crisis Drop-in and Stabilization Unit shall attend quarterly community coordinators meetings identified by the state to participate in discussion about community trends vendors shall report program updates and data reporting to the members.

· 8. (additional text): All admissions and discharges for the Stabilization Unit shall be the responsibility of the Human Service Center staff.

Added under DEFINITIONS (stabilization unit specific):

· Medication Monitoring: The process of observing the client’s self-administration of medications, documenting compliance, and reporting any concerns to a licensed practitioner.

Under Crisis Drop-in and stabilization unit differentiations (under stabilization) added:

· The Stabilization Unit staff will orient individuals served to the unit and service program once HSC and nursing staff has determined admission is appropriate. This will include, but is not limited to:

· Patient Rights and Responsibilities

· Privacy and Confidentiality Practices

· Civil Rights and Grievance Procedures

· Informed Consent for Services

· Service Description

· Fees Associated with Services

· Cell Phones and Electronic Devices

· On-site visitation rules/off-site visitation passes

· Provide resident and guest check-in

· Tobacco use rules

· Added the bolded text as an example of intensity into this statement: Emergency department will be accessed when safety concerns are imminent requiring more intense observation such as 1:1 status or a secure unit.

Under Medication Monitoring Procedure (Drop in Medication practice) – bolded words/language changes from “reconciled” to “verified” as follows:

· 1. Individuals who are receiving drop-in services at the location of the stabilization unit will not have medications verified by nursing.

Under Medication Monitoring Procedure (Medication review at the stabilization unit) – edits and bolded words/language changes from “reconciled” to “verified” as follows:

· 1. At admission to the stabilization unit, RNs will assess and identify discrepancies to patient’s medications for individuals admitted to the stabilization unit (i.e., medication verification does not occur for drop-in individuals who are not admitted for services).

Under Medication Monitoring Procedure (Post Admission Medication Practice and Documentation) added and clarified process for self-administration of medications:

· - 9. Self-administration process:

· Obtain client Self-Administration Record, client medications from locked area, and any needed supplies for client to self-administer (i.e. medication cup, water, pill cutter, glucometer, pen needle, syringe, alcohol wipes, etc.) and place all items where visible to both client and observer

· Ask client to state name and date of birth and verify against self- administration record

· Review self-administration record with client to determine which medications are due at that time and observe as they select the medication bottles/packages/vial/injections for self-administration

· With each medication, observe as client reads out medication name, dosage, and instructions and compare with information on the self-administration record as client also compares the information

· Observe as client prepares each medication as needed for ordered route (i.e. put in medication cup, drawn up for injection, prepare dose on medication pen, etc.)

· Should there be a discrepancy observed between what is ordered and what is prepared address discrepancy with client prior to moving on to next medication

· Once all medications that are due are prepared by client according to instructions, observe as client self-administers the medications

· Observed self-administered medications could include oral medications, injected medications (i.e. insulin), inhaled medications (i.e. inhalers, nebulizers), topical medications (i.e. ointments, lotions, transdermal patches), dropper medications (eye/ear), nasal spray

· Once medications are self-administered, both the client and the staff observing sign/initial the self-administration record Added under Discharge criteria and procedure - Discharges from a stabilization unit occur when:

· 5. All discharges for the Stabilization Unit shall be the responsibility of the Human Service Center staff.

Under Individual Policies while in the Facility – Supports to Optimize Service Delivery added/edited:

· 2. Crisis Drop-in and Stabilization Unit and Human Service Center shall identify Treatment Team members for individuals served.

· 6. Assistance with transportation arrangements or coordination of appointments. Transportation must include, but is not limited to:

· Transportation as directed by the Human Service Center, in order to attend programming, community support groups, and practical supports. Community integration and incorporating community supports (peer support or support groups).

· Medical appointments or non-emergent transport to receive care or support.

· When arrangements are made by Human Service Center staff for an admission, those staff will coordinate with and direct Crisis Drop-in and Stabilization Unit staff to transport the individual served to the unit for admission.

· If the individual served needs to go to other locations to get their essential belongings for their stay, the Crisis Drop-in and Stabilization Unit staff will accommodate to ensure basic needs are met. This includes, but is not limited to:

· Pharmacy

· Individual served home

· Homeless Shelter

· Hospital

· Jail

· 10. Assistance with identifying and organizing therapeutic, skills-building, social and recreational activities that provide positive structure for the individuals served.

· 14. J. A private room for Human Service Center staff to provide therapeutic interventions with appropriate office furniture.

· 14. K. Initiate crisis intervention protocols and therapeutic response techniques when situations arise.

· 16. C. The Crisis and Stabilization Unit will follow the Human Service Center’s individualized plan of care for individuals served. The Crisis Drop-in and Stabilization Unit will not create their own Care/Treatment Plan.

· 17. State will not reimburse for hours not worked. All overtime needs to be preapproved by the State of North Dakota.

Added under the Smoke/Tobacco/E-cigarettes Free Policy section:

· Crisis Drop-In and Stabilization Unit Staff include a screening for tobacco and tobacco use disorders of individuals served as part of the initial and ongoing assessment. Also will integrate education specific to tobacco use disorder into clinical programming. Such education may be included in other individual served education programming, such as substance education, HIV, and other education.

Removed Attachments for interpreter services secondary to identification that those contracts are not available for use through our vendor agencies.

Added additional references.

Navigational changes: None

Functional changes: Ensure vendors are using their own interpreting contracts.

Majority of additions were moved from the contracts with vendors to this policy and are not new requirements. Moving forward the contracts will reference alignment requirements with this policy rather than having some of these procedural components in the contract.

Documentation Reference Status: None

Table of Contents

One of the services which may be provided as needed through the stabilization unit is social detoxification. For the purposes of the Human Service Centers and associated stabilization Units it shall be referred to as social withdrawal management. Social withdrawal management is utilized when individuals served are experiencing mild impairment or withdrawal symptoms that do not meet criteria for medically monitored detoxification. Psychosocial and rehabilitative treatment and monitoring are the primary interventions.

MISSION To provide drop-in, screening, and assessment for access to effective intervention and/or stabilization for all people, while ensuring safety and timely connection to resources, and for the purpose of the improvement of people’s lives.

CORE VALUES

1) Person-centered care: The unique characteristics, preferences, and goals of each individual will be respected and at the center of all service planning and provision.

2) Recovery-oriented: Recovery from Mental Health and Substance Use Disorders is a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential (SAMHSA, 2011).

3) Trauma-informed: A trauma-informed system is one in which all parties involved recognize and respond to the impact of traumatic stress on those who have contact with the system including individuals, caregivers, and service providers (SAMHSA, 2014).

4) Integrated: It is recognized that quality care is integrative. Assessment and service planning include awareness of mental health, substance abuse, and physical health concerns. Necessary services are provided in a seamless and integrated manner.

5) Transparent: Team members will strive always to be open and honest in business practices and clinical work. Individuals served are partners in service plans developed and services provided.

6) Accountability: It is critical to demonstrate that quality and effective services are being provided to all served. Input will be sought from individuals regarding their experience with services and adjustments will be made as necessary to meet identified needs.

7) Evidence-based practice: Team members shall provide high quality evidence-based practices across all areas of service provision.

8) Data-driven: Data regarding key outcome and access areas is collected and reviewed in real-time to inform practice decisions to individually improve/individualize care for each individual as well as inform agency level successes and quality improvement targets.

CONFIDENTIALITY

1. Crisis Drop-in and Stabilization Units owned and operated by contracted vendors of the state have entered into Business Associate Agreements in addition to the contract. Contracted Crisis Drop-in and Stabilization Units are required to comply with the Business Associate Agreement in regard to safeguarding the privacy and security of Protected Health Information (PHI), the use and disclosure of PHI, and reporting breaches and violations involving PHI.

2. The Business Associate Agreement permits HSCs and contracted Crisis Drop-in and Stabilization Units to disclose PHI to one another without an authorization.

3. 42 C.F.R. Part 2, the federal law governing the Confidentiality of Substance Use Disorder Patient Records, does not permit HSCs and contracted Crisis Drop-in and Stabilization Units to disclose substance use disorder patient records to one another without an authorization. The authorization must comply with 42 C.F.R. Part 2’s authorization requirements.

4. HSCs are required to provide individuals adequate notice of the uses and disclosures of PHI and substance use disorder patient records, the individual's rights, and the HSC’s legal duties with respect to PHI and substance use disorder patient records. Such notice must be provided no later than the date of the first service delivery or at the time of admission. In an emergency treatment situation, the notice must be provided as soon as reasonably practicable after the emergency treatment situation. In the case that a patient does not have capacity upon admission to understand their health/medical status, the notice must be provided as soon thereafter as the patient attains such capacity.

PURPOSE AND POPULATION

1. The purpose of the Crisis Drop-in and Stabilization Unit is to provide community-based services to individuals with behavioral health concerns in a monitored supportive environment. The focus is to provide support to individuals in or at risk for crisis or worsening behavioral health symptoms.

2. The treatment setting provides a protective environment that includes stabilization, support, risk assessment and crisis-psychotherapy, wellness, and connection to ongoing services provided 24 hours a day, 7 days a week, 365 days a year. These facilities are intended to be short-term, intensive and recovery oriented.

3. The Crisis Drop-in and Stabilization Unit must have the capacity to manage and screen high acuity individuals, such as:

a. Individuals who are verbally and physically agitated (posturing, but not to include violent, physical harm, or assault)

b. Individuals with co-occurring substance use and behavioral health disorders

c. Individuals who are referred by law enforcement

d. Individuals on an alternative treatment order

e. Individuals who present under the influence of a substance (e.g., drug/alcohol)

f. Individuals who may be experiencing suicidal thoughts, homicidal thoughts, and/or symptoms of psychosis

4. The target population for the Crisis Drop-in and Stabilization Unit is individuals ages 18+, who present with behavioral health symptoms or the imminent risk of acute or crisis behavioral health symptoms.

5. The length of stay and treatment at the Crisis Drop-in and Stabilization Unit is flexible. Typically, individuals stay 2 to 5 days, but length is dependent on each individuals’ response to services.

6. The Crisis Drop-in and Stabilization Unit provides outreach and communication to establish working partnerships with local hospitals and emergency departments, law enforcement, shelters, and other community partners.

7. A representative from the Crisis Drop-in and Stabilization Unit shall attend quarterly community coordinators meetings identified by the state to participate in discussion about community trends vendors shall report program updates and data reporting to the members.

8. Human Service Crisis team members provide community-based assessments which may result in recommendation for Crisis Drop-in and Stabilization Unit services. All admissions and discharges for the Stabilization Unit shall be the responsibility of the Human Service Center staff. In the event where a crisis services community-based assessment has safety concerns, but not to the level where law enforcement accompaniment is necessary, Crisis Drop-in and Stabilization Unit staff may be requested to respond with the mobile crisis staff when facility staffing allows.

DEFINITIONS

Stabilization Unit Specific:

1. Stabilization Unit: The facility location where crisis residential, low intensity residential, and social withdrawal management services occur.

2. Crisis Residential: residential treatment is required to support safety needs of individual.

3. Withdrawal management: Aligns with clinically managed residential withdrawal management ASAM level 3.2WM. Clinically managed residential withdrawal management means an organized service that may be delivered by appropriately trained staff who provide 24-hour supervision, observation, and support for individuals who are intoxicated or experiencing withdrawal. This level is characterized by its emphasis on peer and social support rather than medical and nursing care. This level provides care for individuals whose intoxication/ or withdrawal signs and symptoms are sufficiently severe to require 24-hour structure and support; however, the full resources of a medically managed residential treatment program are not necessary. There are clinical protocols in place to identify individuals who are beyond the capacity of the facility and to transfer them to higher acuity of care as needed.

4. Low Intensity Residential: Clinically-managed low-intensity residential treatment means a program that provides clinically managed low-intensity residential treatment for substance use disorder and other addictive disorders. Treatment services facilitate the application of recovery, relapse prevention, and coping skills and strategies. They promote prosocial skills, skills of daily living, personal responsibility, and reintegration of the individual into network systems of work, education, and family life.

5. Crisis Drop-in The drop-in matches subacute services to individual’s individualized needs while determining if stabilization unit admission is indicated or if referral to another level of care should be made.

a. Individuals may present to the drop-in unsure of the services provided or if they match their current needs. Individuals may ask clarifying questions to determine if they wish to stay for screening and triage. The individual may voluntarily depart prior to any triage or services being provided if preliminary description and informed consent of process and services don’t align with the individual’s perception of what they need at that moment in time.

b. If the individual has endorsed willingness to learn more and explore if stabilization Unit admission or Department of Health and Human Services (DHHS) supports would be beneficial for them. The individual collaborates with DHHS team members who screen and triage for immediate and longitudinal behavioral health needs.

6. Medical clearance - Medical clearance refers to the medical evaluation of patients in the emergency department (ED) (or similar setting) whose symptoms appear to be psychiatric in origin. The objective is to determine whether serious underlying medical illness exists, which would render admission to a psychiatric clinically managed facility unsafe or inappropriate.

7. Medication Monitoring: The process of observing the client’s self-administration of medications, documenting compliance, and reporting any concerns to a licensed practitioner.

8. Nursing pre-admission review – A registered nurse who works at, or is consulting with the crisis stabilization unit, works directly with the HSC teams and crisis services to utilize their nursing discretion to ensure necessary medical interventions fall within the scope provided under the facility specific level of care treatment licenses. Registered nurses review Crisis Drop in and Stabilization Unit medical parameters for appropriateness of placement and advocate for when individuals may need to seek external medical clearance either via HSC physician/prescriber, Primary Care Provider (PCP), or Urgent care/Emergency Room referral. Nursing may also indicate when medical interventions necessary for ongoing treatment being recommended from the Emergency Room or medical evaluation indicate complex medical needs exceeding the care that the facility is licensed to provide and advocate for alternate disposition and treatment planning.

9. Hypoglycemia - Hypoglycemia refers to abnormally low blood glucose levels in circulating plasma. It is defined as a glucose value less than 70 mg/dl (3.9 mmol/L). “Serious hypoglycemia” refers to values <54 mg/dl (3.0 mmol/L). Ferri's Clinical Advisor 2022, 831-833.e1

10. Opioid Treatment Services (OTS) - An umbrella term that encompasses a variety of pharmacologic and non-pharmacologic treatment modalities. This term broadens understanding of opioid treatment to include all medications used to treat opioid disorders and psychosocial services that are offered concurrently with these pharmacotherapies. Pharmacological agents include opioid agonist medications such as methadone and buprenorphine and opioid antagonist medications such as naltrexone. (American Society of Addiction Medicine, 2013).

11. Clinical Opiate Withdrawal Scale (COWS) - The Clinical Opiate Withdrawal Scale (COWS) is an 11-item scale that can be used in inpatient and outpatient settings to reproducibly rate common signs and symptoms of opiate withdrawal and monitor these symptoms over time. The summed score for the complete scale can help determine the stage or severity of opiate withdrawal and assess the level of physical dependence on opioids. The symptoms of opioid withdrawal have been likened to a severe influenza infection (e.g., nausea, vomiting, sweating, joint aches, agitation, tremor), and patients should not exceed the lowest score in most categories without exhibiting some observable sign or symptom of withdrawal. COWS scoring: Score: 5- 12 = mild; 13-24 = moderate; 25-36 = moderately severe; more than 36 = severe withdrawal.

12. Medication for opioid use disorders (MOUD) - medications for opioid use disorder (MOUD) are evidenced based treatment options for opioid use disorders including methadone, buprenorphine, naltrexone.

Nurse Practices Act Administrative Code 43-12.1-02:

1. "Registered nurse" means an individual who holds a current license to practice in this state as a registered nurse and who practices nursing independently and interdependently through the application of the nursing process.

2. "Nurse" means an individual who is currently licensed as an advanced practice registered nurse, specialty practice registered nurse, registered nurse, or licensed practical nurse.

3. "Nursing" means the performance of acts utilizing specialized knowledge, skills, and abilities for people in a variety of settings. The term includes the following acts, which may not be deemed to include acts of medical diagnosis or treatment or the practice of medicine as defined in chapter 43-17:

a. The maintenance of health and prevention of illness.

b. Assessing and diagnosing human responses to actual or potential health problems.

c. Providing supportive and restorative care and nursing treatment, medication administration, health counseling and teaching, case finding and referral of individuals who are ill, injured, or experiencing changes in the normal health processes.

d. Administration, teaching, supervision, delegation, and evaluation of health and nursing practices.

e. Collaboration with other health care professionals in the implementation of the total health care regimen and execution of the health care regimen prescribed by a health care practitioner licensed under the laws of this state.

4. "Unlicensed assistive person" means an assistant to the nurse, who regardless of title is authorized to perform nursing interventions delegated and supervised by a nurse.

Nurse Aide Training, Competency Evaluation, and Registry Administrative Code 33-43-01:

1. "Competence" means the application and integration of knowledge, skills, ability, and judgment necessary to meet standards.

2. "Delegation" means the authorization for performance of selected nursing interventions from a licensed nurse to a certified nurse aide, home health aide, nurse aide, or medication assistant I or II.

3. "Medication administration" means the delivery of medication, by an individual delegated to and supervised by a licensed nurse, to an individual whose use of that medication must be monitored and evaluated applying specialized knowledge, skills, and abilities possessed by a licensed nurse.

4. "Medication assistant" means an individual who is registered on the nurse aide registry as a certified nurse aide or nurse aide who has successfully completed the requirements of a department-approved medication assistant program for a specific employment setting. Upon successful completion of a medication assistant program, the certified nurse aide or nurse aide is eligible to be registered on the department's nurse aide registry as a medication assistant I or a medication assistant II.

a. Medication assistant I (MA I) is a certified nurse aide or nurse aide who has completed all the requirements for a department-approved medication assistant I program. A medication assistant I is limited to employment in a setting in which a licensed nurse is not regularly scheduled.

b. Medication assistant II (MA II) is a certified nurse aide who has completed all the requirements for a department-approved medication assistant II program. A medication assistant II may be employed both in a setting in which a licensed nurse is regularly scheduled and a setting in which a licensed nurse is not regularly scheduled.

5. "Qualified instructor for a certified nurse aide training program" means a registered nurse with a minimum of two years of nursing experience, at least one year of which must be in the provision of long-term care facility services. Instructors must have completed a course in teaching adults or have experience in teaching adults or supervising nurse aides. In a nursing facility-based program, the director of nursing is prohibited from performing the actual training. However, a director of nursing who meets the qualified instructor requirements may provide the general supervision for the program. Other health-related professionals who have a minimum of one-year experience in their field may supplement the instructor.

6. "Qualified instructor for a nurse aide training program" is a registered nurse.

7. "Regularly scheduled presence of a licensed nurse" means that a licensed nurse is present a minimum of eight hours in a twenty-four-hour period of time in a setting where nursing care is continuously delivered.

8. "Routine, regularly scheduled medication" means the components of an identified medication regimen for an individuals or groups of individuals with stable conditions which are administered on a routine basis and do not require determination of need, drug calculation, or dosage conversion.

9. "Stable" means a situation in which the patient's or individual's clinical and behavioral status and nursing care needs are determined by the registered nurse or licensed practitioner to be predictable, nonfluctuating, and consistent or in which the fluctuations are expected, and the interventions are planned.

10. "Supervision" means maintaining accountability to determine whether or not nursing care is adequate and delivered appropriately. Supervision includes the assessment and evaluation of the patient or individual's condition and responses to the nursing plan of care and evaluation of the competence of the person providing the nursing or nursing-related care.

a. "Direct supervision" means that the responsible licensed nurse or licensed practitioner is physically present in the patient or individual area and is available to assess, evaluate, and respond immediately.

b. "Indirect supervision" means that the responsible licensed nurse or licensed practitioner is available through periodic inspection and evaluation or by telecommunication, or both, for direction, consultation, and collaboration.

CLINICALLY MANAGED RESIDENTIAL WITHDRAWAL MANAGEMENT (Social Detoxification) ASAM level 3.2-D WM Administrative Code 75-09.1-08-01:

1. "CIWA-Ar" means the revised clinical institute withdrawal assessment for alcohol scale published in the archives of general psychiatry 48:442-447, May 1991, which is a ten-item scale for clinical quantification of the severity of alcohol withdrawal syndrome.

2. Withdrawal management means process of attenuation of the physiological and psychological features of withdrawal, and interrupting the momentum of habitual compulsive use in individuals with addiction.

3. Clinically managed residential withdrawal management - means an organized service that may be delivered by appropriately trained staff who provide 24-hour supervision, observation, and support for individuals who are intoxicated or experiencing withdrawal. This level is characterized by its emphasis on peer and social support rather than medical and nursing care. This level provides care for individuals whose intoxication/ or withdrawal signs and symptoms are sufficiently severe to require 24-hour structure and support; however, the full resources of a medically managed residential treatment program are not necessary.

CRISIS DROP-IN AND STABILIZATION UNIT DIFFERENTIATIONS

Drop-in:

1. Up to 24 hours, Individuals may drop-in anytime.

2. Individuals will have access to crisis intervention, risk assessment, and referrals to resources and support.

3. Individuals will be welcomed, personal items will be secured locker/bin, and they will be provided orientation to the drop-in facility services and accommodations.

4. Drop-in staff will complete drop in information form with the individual.

5. The Drop-in staff will assess for smoking cessation or nicotine replacement needs of the individual.

6. The Drop-in staff will contact mobile crisis staff to do a screening and triage which includes a risk assessment.

7. All attempts will be made to have an assessment by mobile crisis staff within 20 minutes of arrival, continuing as needed throughout the next 23 hours. During assessment, mobile crisis staff will complete a screening and assign any safety observation procedures and precautions necessary for the individual. The levels are defined as:

a. 15-minute checks will be initiated when there is urgent risk to self, others, or property.

b. 30-minute checks are set as routine for all individuals while at the Unit.

c. 60-minute checks may be initiated based on clinician assessed stability.

d. Emergency department will be accessed when safety concerns are imminent requiring more intense observation or a secure unit.

8. Patients should not be kept at the drop-in side of the stabilization unit with BAC levels higher than 250 mg/dL. The blood alcohol cutoff requirement is set to ensure safety of individuals served. The crisis stabilization units are clinically managed, not medically managed. Individuals who have a lower tolerance to alcohol should be assessed for alcohol poisoning. Individuals who have a higher tolerance to alcohol may not appear functionally impaired, but that may be an indicator to expect withdrawal severity that would exceed the parameters for which the crisis units are licensed for.

9. Individuals arriving with or without prior assessment by the mobile crisis staff:

a. Will be allowed to remain in the waiting area as long there is not concern for safety and security. Personal safety of everyone is of the utmost importance. Violence or destruction of property will not be tolerated. Individuals demonstrating violent behavior will not be received for admission.

i. Immediate threat to others and property- Drop-in staff will contact law enforcement for safety assistance and mobile crisis staff for assessment.

ii. Non-immediate threat to others and property- Drop-in staff will contact mobile crisis staff for assistance and assessment. Drop-in staff will follow the monitoring requirements as set out by the mobile crisis staff for safety and monitor for any medical concerns. Any concerns or questions will be directed to the mobile crisis staff or nursing staff for further clarification and interventions. Drop-in staff will document information on the Drop-in Information Form based on the monitoring instructions and record therapeutic and medical interventions along with any incidents or concerns. Incident reports will be completed for situations that involve near misses, injury, ambulance, or police intervention.

10. Cell phones will be allowed in the Drop-in areas. Other electronics may be allowed with prior approval based on necessity and space.

Stabilization Unit:

1. An adult who is experiencing a behavioral health crisis that does not require

a. inpatient hospitalization, but needs a supervised, structured environment for acute symptom management and/or continued stabilization for these listed below.

b. More than 24 hours, but not to exceed 3-5 days unless ongoing level of care is required and meets medical necessity.

2. The Stabilization Unit staff will obtain their name and the reason the individual is arriving for service.

3. The Stabilization Unit and HSC staff will obtain informed consent for treatment.

4. The Stabilization Unit staff will orient individuals served to the unit and service program once HSC and nursing staff has determined admission is appropriate. This will include, but is not limited to:

a. Patient Rights and Responsibilities

b. Privacy and Confidentiality Practices

c. Civil Rights and Grievance Procedures

d. Informed Consent for Services

e. Service Description

f. Fees Associated with Services

g. Cell Phones and Electronic Devices

h. On-site visitation rules/off-site visitation passes

i. Provide resident and guest check-in

j. Tobacco use rules

5. Safety observation procedures and precautions that were identified by the admitting practitioner/crisis worker will be maintained as the person transitions from the drop-in side or upon direct admission from the community. The levels are defined as:

a. 15-minute checks will be initiated when there is urgent risk to self, others, or property.

b. 30-minute checks are set as routine for all individuals while at the Unit.

c. 60-minute checks may be initiated based on clinician assessed stability.

d. Emergency department will be accessed when safety concerns are imminent requiring more intense observation such as 1:1 status or a secure unit.

STABILIZATION UNIT ADMISSION STATUS

1) Admissions to the stabilization Unit should have subacute presentations. Acute and severe medical needs should be addressed by emergency medical services, emergency rooms, hospitals, or medically managed withdrawal units.

2) Subacute services that are deemed stable enough to be treated in an organized residential nonmedical setting may fall within the following levels of care:

a) Withdrawal Management when licensed for this level of care (e.g., social withdrawal management) – if for purpose of providing stable, supportive environment for those withdrawing because of substance use and not necessitating medical management.

i) Refer to section “Social Withdrawal Management” of this document for full admission criteria.

ii) The individual’s detoxification needs are not of a severity that requires medical monitoring or inpatient hospital level of care.

iii) Admission criteria is met as outlined in NDAC 75-09.1-08-04, including but not limited to “Before an individual may be admitted to a social detoxification program, the individual must meet the diagnostic criteria for a substance-induced disorder of the current DSM and current clearance by a physician or a CIWA-Ar score of less than or equal to seven…”

b) Low Intensity Residential – short term residential placement for those with substance abuse or dual disorders.

c) Crisis Residential – residential treatment is required to support safety needs of individual. Individual has a primary behavioral health need that is the cause of significant psychological, personal care, vocational, educational, and/or social impairment.

i) The impairment results in a clear, current risk to the individual’s ability to live in his/her customary setting for an individual who, without the clinical interventions and individualized treatment within that setting, would then meet the criteria for a higher level of care, e.g., inpatient, and/or an emerging/impending risk to the safety or property of the individual or of others

3) No admissions to the crisis residential unit of any status should occur for an individual until the BAC level is < 250 mg/dL.

MEDICAL HEALTH REVIEW TO DETERMINE APPROPRIATE PLACEMENT TO STABILIZATION UNIT SUBACUTE LEVEL OF CARE PROCESS

Review of General Medical Placement Parameters

1. A registered nurse must participate in the admission process to the Stabilization Unit unless all the following conditions are met:

a. The individual does not have any medical conditions for which they are supposed to be taking medications and does not have any currently prescribed medications, and

b. The individual has no request to use any over the counter or herbal medication during their stay, and

c. No current substance intoxication, and

d. There are no concerns regarding the individual’s ability to perform activities of daily living independently, and

e. The vital signs obtained by certified staff fall within the parameters allowed for CSC placement noted below, and

i. Systolic blood pressure (top number) within 90-160 mmHg

ii. Diastolic blood pressure (bottom number) less than 120 mmHg.

iii. Heart rate within 50-120 beats per minute.

iv. Respiratory rate between 10-26 breaths per minute.

f. The individual does not have any physical or mental health symptoms necessitating emergency medical evaluation (see next section), and

g. There is no indication from records available that the information provided is not accurate (e.g., current medical charting indicates presence of active diagnoses and medication treatment recommendations).

h. The above criteria (a-g) may be waived if the patient is well known to the stabilization Unit and there is a standing care plan created and mutually agreed upon by the HSC team, affiliated stabilization unit, and a medical representative (APRN, PA, MD/DO) indicating the need for intermittent supportive placement, and when deemed to be clinically necessary by the treatment team.

i. If any of the above criteria (a-g) are not met, then a registered nurse must be involved in the admission process. If the individual is not on any medications and does not wish to start any medications, the nurse may consult with the team and help determine whether a physician/prescriber should assess the individual after admission. If during the individual’s stay it is determined that medications (prescribed or over the counter) are requested or should be taken, then a nurse should be consulted at that time to ensure medication management policies and procedures are adhered to.

2. Unless the above criteria were all met, licensed team members screening and triaging individuals for admission to the stabilization unit shall collaborate with a registered nurse (RN) prior to admission to determine if the individual served can safely be treated with crisis residential or social withdrawal management (social detoxification) from a medical perspective.

3. Routine admission for crisis residential (as opposed to withdrawal management admission) does not require emergency room clearance prior to admission but must have a nursing assessment. Nursing judgement will determine if medical clearance through the human service center physician, advanced practice prescriber, on-call contracted psychiatry services or emergency room evaluation is necessary.

4. The facility shall provide availability of 24-hour nursing support to meet the needs of the individual served whenever possible, as this is deemed the most appropriate level of nursing support to align with level of care needs.

5. If 24-hour nursing support (and associated supervision of NAs, MA I’s, or MA II’s) is available:

a. Social withdrawal management (social detoxification) services may be provided.

b. Use of pro re nata (PRN) medications within registered nurse delegation to a MA and within the MA scope of practice (per administrative rule and limitations of this facility setting) may occur. PRN medications able to be delegated to an MA are limited to medications that do not require assessment prior or evaluation of response to dose provided. Thus, PRN medications for withdrawal management cannot be delegated to a medication assistant.

c. The decision to administer PRN medications cannot be delegated in situations where an assessment of the individual is required prior to administration.

d. Some situations allow the administering of PRN medications without directly involving the licensed nurse prior to each administration.

i. The decision regarding whether an onsite assessment is required is at the discretion of the licensed nurse.

ii. Written parameters specific to an individual individual's care must be written by the licensed nurse for use by the medication assistant when an onsite assessment is not required prior to administration of a medication. The written parameters:

1. Supplement the physician's PRN order; and

2. Provide the medication assistant with guidelines that are specific regarding the (PRN) medication.

e. Individuals who present to the stabilization unit with standing PRN medication orders may request those to be given if a registered nurse approves every dose that an individual self-requests and administers. If the RN is uncomfortable with the PRN dosing, then they must reach out to HSC physicians/prescribers during the day for clarification or community urgent care or emergency room partners for questions after hours, nights and weekends.

6. If registered nurse staffing patterns are not sufficient to provide 24-hour nursing support and supervision to MAs:

a. No PRN medications may be utilized that require any assessment before or after dosing, as a registered nurse must assess for the appropriateness of use of the PRN as that cannot be delegated to a MA. The exception to this is lifesaving PRN medications. Lifesaving medications such as albuterol inhalers for asthma attacks, epinephrine for allergies, naloxone for opioid overdose, etc. will never be denied. If a PRN medication is deemed lifesaving it should be listed as such on the MAR to avoid any delay with administration.

b. If a physician/prescriber wishes to order a PRN medication when 24-hour nursing is not available, the written order must detail all the following:

i. A specific order for each patient (i.e., no standing orders applicable for every patient. However, the center may have standing order selections that meet the following criteria for physician/prescribers to quickly make selections from).

ii. A specific order for every as needed medication with guidelines of when the medication can be provided to the individual.

iii. PRNs in this context can only be given when the patient requests it for the assigned and specific indication.

iv. The order specifically identifies what indications the patient could ask for as needed medication dosing (e.g., sleep, anxiety etc.)

v. The order must state that no assessment will be needed for this PRN prior to providing the PRN or after receiving the PRN. Thus, no orders can state “hold/monitor for sedation” as these orders imply after-dosing assessment which can only be done by a nurse.

vi. PRN orders should be ordered with consideration of when an assessment would typically be warranted with any PRN even if they are over the counter medications. Thus, typically PRN dosing should start at a low frequency and only increase to higher frequency after discussion with the prescriber that there is indication to do so. For example, although acetaminophen (Tylenol) can be given four times daily. In this scenario whatever is ordered is without any assessment prior or after the individual takes the mediation, so PRN dosing for pain should be at once or twice daily depending on context as frequent or maximum PRN dosing should require further assessment of the pain, side effects to the medication, and discussion of efficacy.

vii. All PRN dosing orders should take into consideration drug-drug interactions with other over the counter or prescription medications, maximum dosing of combining standing orders with additional PRN doses, and risk for additive effects for sedation, seizure threshold, toxicity, or other side effects.

c. Depending on the level of RN staffing shortage, withdrawal management services may need to be suspended. Any reduction in RN availability (in person or remote) less than 24/7 must be discussed with the associated human service center (HSC) regional director, clinical director, and medical director to determine if staffing patterns are sufficient to provide any level of withdrawal management (e.g., maintenance of those already admitted versus new admissions and duration of admission for withdrawal management HOLD status).

7. Staffing patterns must support 24-hour availability of vital signs including blood pressure, pulse, and temperature performed by trained staff (i.e., CNA, NA, LPN, RN). Peripheral devices may be utilized, and performed by trained staff (i.e., team members who have been specifically trained how to use the devices, CNA, NA, LPN, RN).

8. Any time an RN is not available for consultation (e.g., after hours, weekends, holidays, or any other time when an RN is not available), or at nursing discretion after review/consultation, admissions to lay status must be medically cleared through the local urgent care or emergency room, unless all the above conditions articulated in # 1 above are met.

9. During business hours the stabilization unit registered nurse may consult with various medical professionals depending on if the individual is open to services with the psychiatry team at the HSC, how quickly an HSC psychiatry consultation can be obtained, and/or how acute the issue is that needs attention/consultation. For individuals who receive services from a physician or advanced practice prescriber through the HSC, the registered nurse may reach out to their office for collaboration and medical support. For individuals who are not established patients with a physician or advanced practice prescriber with an HSC, medical questions, consultation, and medication refill requests should go through the individual’s usual prescriber or local emergency room providers in emergency situations. Any time when RN support is not immediately available by phone or in-person for consultation, other stabilization unit staff can send the individual to the nearest emergency services facility or contact their local hospital or emergency services representative to collaborate on how to safely treat the individual seeking care.

Medical criteria necessitating referral for emergency medical evaluation at admission and during all levels of care provided at the crisis stabilization center

1.