You asked about standards for nursing homes that have behavioral health units or specialized programs for adults with mental illness other than dementia.

SUMMARY

The Public Health Code establishes admission, staffing, and patient treatment requirements that nursing homes must follow to obtain Department of Public Health (DPH) authorization to admit patients whose primary diagnosis is a mental illness. DPH has granted 80% of Connecticut's 246 licensed nursing facilities this authorization.

Some of these homes provide specialized services for people with mental illness. The Department of Mental Health and Addiction Services (DMHAS) informally identifies 10 homes that have a “secured behavioral health unit.” State law does not define this term or establish standards for these units' operation.

Illinois, Michigan, and Ohio nursing home regulations establish extra requirements for nursing homes that admit patients with mental illness. In 2000 the Illinois legislature enacted a law requiring the state Public Health Department to adopt regulations governing assessment, care and discharge planning, and treatment services for people with serious mental illness in nursing homes (210 ILCS 45/3-202.2). Those regulations also identify other services and activities homes must provide and the personnel they must employ.

Michigan regulations provide for special certification of entire nursing homes or distinct parts of homes that admit only patients with mental illness. The regulations set physician and nursing services and staff training requirements, among other topics.

Ohio regulations require each nurse aide to receive annually at least 12 hours of in-service education. Aides that work in “specialty units,” such as mental health care units, must receive sufficient additional hours of annual training to meet unit residents' needs. The training must address the residents' special needs (Ohio Admin. Code, ch. 3701-17-07.1)

CONNECTICUT (Public Health Code §19-13-D13)

The Public Health Code establishes basic admission, staffing, and patient treatment requirements that nursing homes must follow to obtain DPH authorization to admit patients whose primary diagnosis is a mental illness. DPH treats this authorization as a “mild mental health rider” to the homes' basic license.

Before a patient may be admitted to an authorized home, a physician who has completed a psychiatric residency must determine in writing (1) the person's condition, (2) that he or she is not a danger to self or others, and (3) that nursing home care is appropriate. If a patient's condition changes in way that may cause the patient to injure him or her self, others, or property, the patient must be transferred immediately to a more suitable institution.

A skilled nursing home of any size or an intermediate care nursing home with 60 or more beds must have a registered nurse (RN) or nurse with special psychiatric care training on-site at all times. Smaller intermediate care facilities can employ such a nurse on a consultant basis for at least eight hours a week.

DMHAS identifies the following homes as having a “secured behavioral health unit”:

ILLINOIS (77 IL Admin. Code §§ 300.4000 to 4090)

Applicability

These regulations apply to all nursing homes that care for residents with a “serious mental illness.” These homes must meet all other state nursing home regulations. Homes with 20 or fewer such residents can ask the Public Health Department to waive certain personnel rules.

The regulations define a serious mental illness as one that:

1. constitutes a major disorder (e.g., schizophrenia, major recurrent depression, and bipolar, delusional, or schizo-affective disorders);

2. substantially limits at least two functions (self-maintenance, social functioning, community living activities, or work-related skills); and

3. is expected to last at least one year and result in substantial limitation in major life activities.

The regulations exclude alcohol and substance abuse, Alzheimer's disease, and other forms of dementia resulting from organic or physical disorders from their definition of serious mental illnesses.

An individual with serious mental illness will typically, the regulations state, have experienced two or more hospitalizations and receive or have been deemed eligible for Supplemental Security Income or Social Security Disability Income.

Personnel Requirements

The regulations (unless waived, see above) require each facility to have a psychiatric medical director, a separate psychiatric rehabilitation services director and coordinator, and psychiatric aides (or certified nurse assistants with special psychiatric training). They specify licensure or registration, training, and experience requirements for each position.

Each resident with serious mental illness must be under the care of a psychiatrist who must see the resident at least every 90 days.

Assessments and Reassessments

The regulations require a home to establish an interdisciplinary team to assess a person with serious mental illness within 14 days after admission. The team must include the individual; his or her guardian; the psychiatric rehabilitation services coordinator; and the individual's primary service providers, including a nurse, psychiatrist, social worker, and activity professional, and any other appropriate professionals.

The assessment must include a (1) psychiatric evaluation, (2) psychosocial assessment, (3) skills assessment, (4) assessment of the individual's interests and expectations concerning his or her psychiatric rehabilitation, (5) oral health screening, (6) discharge plan, and (7) any other assessments the team recommends or that the individual's physician or psychiatrist orders.

The team must conduct a complete reassessment at least every year.

Treatment Plan

The home must develop a treatment plan for each person with serious mental illness within seven days after the assessment is completed. The plan must cover the resident's needs, the priority with which they should be addressed, specific goals and objectives for each goal, and services to implement the objectives.

Psychiatric Rehabilitation Services

A home must provide:

1. 24 hours of continuous supervision, support, and therapeutic interventions;

2. psychotropic medication administration, monitoring, and self-administration;

3. case management services and discharge preparation and training;

4. psychiatric rehabilitation services addressing major domains of functioning and skill development;

5. crisis services; and

6. personal care assistance.

The psychiatric rehabilitation program must provide an array of individual and group therapeutic activities, including training in areas such as self-maintenance, social functioning, and community living. The training must include aggression prevention, substance dependence, and their management. A home can contract with an outside entity to provide some or all of the rehabilitation program.

Discharge Plans

A resident's treatment plan must include a discharge plan that addresses reducing the person's symptoms and skills deficits. In the year before discharge, the home must help the individual (1) initiate and comply with the home's mental health services; (2) learn to identify, access, and use community services; (3) identify, apply for, and obtain financial resources; and (4) locate and secure housing.

At least 30 days before a planned discharge, the psychiatric rehabilitation services coordinator must develop a specific post-discharge plan that identifies where the resident will live; available financial resources and community services; community mental health services, including scheduled psychiatric appointments; and the case management system responsible for transition and follow-up.

At discharge, the facility must prepare a discharge summary that includes recommendations for transitional programming and details about the first post-discharge appointment with the aftercare service provider. It must provide this summary to that provider.

MICHIGAN (MI Admin. Code §§ 325.21601 to .21605)

A nursing home that devotes all or a distinct part of its facility to patients with mental illness can receive special Medicaid certification from the Social Services Department. The home must make an agreement with the Mental Health Department to admit only patients with mental illness. Such a home or its specialized unit can treat between 16 and 150 patients.

The home must comply with certain rules to be certified. It must have a staff psychiatrist who serves as a consultant to the home's administrator and medical staff and assists in developing patient care policies and individual patient care plans. He or she must assure that a physician sees and evaluates patients at least every 30 days.

The home's nursing director must have at least one year of experience in caring for people with mental illness or be similarly qualified. An RN or licensed practical nurse with mental health experience must be in charge on each shift. Nursing staff must receive orientation and continuing, specialized in-service training in caring for people with mental illness. And, in addition to the basic licensure staffing requirements, the home must provide additional licensed and unlicensed personnel to average 3.35 hours of daily nursing care per patient.

In addition, the home must (1) provide an organized activity program, (2) arrange to obtain any specialized diagnostic services and other forms of therapy individual patients need, and (3) advise the designated state hospital in the home's region of available beds.

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