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PDFWAC 246-341-1146

Mental health inpatient servicesTriageAdmission, assessment, and records.

An agency certified to provide triage services must ensure the requirements in this section are met for each voluntary and involuntary admission. See WAC 246-341-1152(2) for additional requirements for an individual brought to a triage involuntary placement facility by a peace officer. See WAC 246-341-1152(3) for additional requirements for an individual involuntarily admitted to a triage involuntary placement facility based on a peace officer-initiated twelve-hour hold.
(1) Each individual must be assessed for substance use disorder and co-occurring mental health and substance abuse disorder as measured by the global appraisal on individual need-short screen (GAIN-SS) as it existed on the effective date of this section, or such subsequent date consistent with the purposes of this section. The clinical record must contain the results of the assessment.
(2) Each individual must be assessed by a mental health professional (MHP) within three hours of the individual's arrival at the facility.
(a) The assessment must include, at a minimum:
(i) A brief history of mental health or substance abuse treatment; and
(ii) An assessment of risk of harm to self, others, or grave disability.
(b) The MHP must request:
(i) The names of treatment providers and the treatment provided; and
(ii) Emergency contact information.
(c) The MHP must document all of the following in the individual's clinical record:
(i) All the information obtained in (a) and (b) of this subsection.
(ii) Sufficient information to demonstrate medical necessity. Medical necessity is defined in the state plan as "A term for describing a requested service which is reasonably calculated to prevent, diagnose, correct, cure, alleviate or prevent the worsening of conditions in the recipient that endanger life, or cause suffering or pain, or result in illness or infirmity, or threaten to cause or aggravate a handicap, or cause physical deformity or malfunction, and there is no other equally effective, more conservative or substantially less costly course of treatment available or suitable for the person requesting service. For the purpose of this chapter "course of treatment" may include mere observation, or where appropriate, no treatment at all."
(iii) Sufficient clinical information to justify a provisional diagnosis using criteria in the current and applicable Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
(3) Each individual must receive a health care screening to determine the individual's health care needs.
(a) The health care screening instrument must be provided by a licensed health care provider defined in WAC 246-337-005. A licensed health care provider must be available to staff for staff consultation twenty-four hours a day, seven days a week.
(b) The individual's clinical record must contain the results of the health care screening.
(4) A qualified staff member according to WAC 246-341-1144(4) must coordinate with the individual's current treatment provider, if applicable, to assure continuity of care during admission and upon discharge.
(5) Each individual's clinical record must:
(a) Contain a statement regarding the individual circumstances and events that led to the individual's admission to the facility;
(b) Document the admission date and time;
(c) Contain the results of the health care screening required in subsection (3) of this section;
(d) Document the date and time of a referral to a designated crisis responder (DCR), if a referral was made;
(e) Document the date and time of release, or date and time the twelve-hour hold ended; and
(f) Document any use of seclusion or restraint and include:
(i) Documentation that the use of either seclusion, or restraint, or both, occurred only due to the individual being an imminent danger to self or others; and
(ii) A description of the less restrictive measures that were tried and found to be ineffective.
(6) A triage facility that declares any intent to provide seclusion, or restraint, or both, to an individual may do so only to the extent necessary for the safety of others and in accordance with WAC 246-322-180, 246-337-110, and 246-320-271. See also WAC 246-341-1144 (3)(g).
(7) A triage facility must document the efforts and services provided to meet the individual's triage stabilization plan.
(8) A triage facility must document the date, time, and reason an individual's admission status changed from involuntary to voluntary.
[Statutory Authority: 2018 c 201 and 2018 c 291. WSR 19-09-062, § 246-341-1146, filed 4/16/19, effective 5/17/19.]
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