Section R432-101-20 - Inpatient Services(1) Upon admission, a physician or qualified designee shall document the need for admission in accordance with hospital policy to include a brief narrative of the patient's condition that includes: (a) the nurse's admitting notes;(2)(a) A physician or qualified designee shall assess each patient's physical health and conduct a preliminary psychiatric assessment within 24 hours of admission.(b) The physician or designee's history and physical exam shall include: (i) appropriate laboratory work-up;(ii) a determination of the type and extent of special examinations, tests, or evaluations needed; and(iii) when indicated, a thorough neurological exam.(3) A psychiatrist or psychologist or qualified designee shall assess each patient's mental health within 24 hours of admission and ensure there is a written emotional or behavioral assessment of each patient entered in the patient's record.(4) The licensee shall ensure there is a written assessment of the patient's legal status to include: (a) a history with information about competency, court commitment, criminal convictions, and any pending legal actions;(b) the urgency of the legal situation; and(c) how the individual's legal situation may influence treatment.(5)(a) The licensee shall ensure a written individual treatment plan is initiated for each patient upon admission and completed no later than 7 working days after admission.(b) The licensee shall ensure the individual treatment plan is based on the information resulting from the assessment of patient needs, as required in Subsection R432-101-20(1).(c) The licensee shall ensure the person responsible for the patient's care signs the individual treatment plan and administers service according to the individual treatment plan.(d) The licensee shall ensure that each individual treatment plan is reviewed on a weekly basis for the first three months, and thereafter at intervals determined by the treatment team, not to exceed every other month.(e) The licensee shall ensure the written individual treatment plan for each patient is based on a comprehensive functional assessment as outlined in Subsection R432-101-22(7).(f) The licensee shall invite the patient and family to participate in the development and review of the individual treatment plan.(g) The licensee shall document patient and family participation, or reasons why it is inappropriate.(h) The licensee shall ensure the individual treatment plan is available to any personnel who provide care for the patient.(6)(a) The Utah State Hospital is exempt from the time frames required in Subsection R432-101-20(4) and Subsection R432-101-20(4)(d) time frames for initiating and reviewing the individual treatment plan.(b) The Utah State Hospital administrator shall ensure that an individual treatment plan is initiated for each patient admitted within 14 days and the plan is reviewed on a monthly basis.Utah Admin. Code R432-101-20
Amended by Utah State Bulletin Number 2023-22, effective 11/1/2023