thank you for the opportunity to provide comments, offer suggestions, and ask questions.

Definitions:
P. 3 Behavior interventions – this is unclear when it applies. Concerns raised that ES and MCRs will not be developing ISPs and will not have these docs to reference in the acute response, typically
Community Based Crisis Stabilization--recommend using “community stabilization” to be more consistent with DMAS language and service definitions; non-center based location in an individual’s natural environment[ as possible]
Contracted Employee / Contractor – Recommend strike Employee and just use Contractor only.
CEPP – rephrase to “behavioral crisis” which is more person centered than behavioral loss of control
p.5 - Initial Assessment – This is stating that an assessment is not a service, but it is, we have to do that in order to provide any on-going interventions, and we bill for it to DMAS. So perhaps this could be more consistent with DMAS language since the process should be consistent whether DBHDS is describing it or DMAS is.
Initial ISP - Also, the timeframe states 24 hours but we need to double-check that this is consistent in all specific services as we were thinking that CSU gives 48 hours to complete the crisis ISP. (see pg. 16)
Please define Crisis ISP in the definitions list; is the Crisis ISP intended to be Initial ISP?
There is CEPP and Safety Plan language throughout and we assume that the intention is not to require both.

Pg. 9 Paragraph 1: Recommend the following licenses:
• Crisis Receiving Center
• Community-based Stabilization
• Mobile Crisis Response
• Emergency Services
• REACH Mobile Response and Stabilization
• REACH Crisis Therapeutic Home
• Crisis Stabilization Unit
Pg. 9 Paragraph 2: Line 7, a nursing assessment is required, however; on page 19 under “Nursing Assessment” the regulation states that nursing assessments are not required for Crisis Receiving Centers.
Pg. 9 Paragraph 2: Lines 11-12, a CRC shall have policy to address custody of children accompanying a parent for treatments, but shall not be responsible for maintaining those children’s safety on the unit. Additionally, there should be a requirement for addressing children being assessed at the CRC and accompanied by their parents.
Pg 9 Paragraph 3: See comments related to confusion of lumping multiple services under one license above.
Pg. 9 Paragraph 3: Pre-admission screening and Emergency Services should be properly defined under a unique license to reflect the codified responsibilities and training unique to this service.
Pg. 10 Paragraph 1: Lines 9-10, See Comment 6 above.
Pg. 10 Paragraph 2: Lines 7-8, Individuals utilizing substances are not prohibited from enrollment in REACH services.

P. 10 Staffing:
B. Community Based Crisis Stab – we recommend add “crisis” assessment and strike CEPP language
B6. Recommend changing from QMHP-E to QMHP-T for consistency
C5 – No need for this added language
P.11 – Initial Contact- We ask for clarification because this doesn’t seem to be broad enough to capture what happens in crisis services. the Crisis Center would not capture all of the information mentioned in this section with someone who walks in just to get resources. Also, making service linkages / referrals would not necessarily be in scope (from an inquiry only) depending on the service type that is being contacted unless a service is rendered to the individual.
P. 12 D – Assessment – Crisis Assessment is not able to be comprehensive due to the nature of the service and available records in a crisis.
P. 13 b- for crisis stab units and comm based crisis stab; recommend that we allow for an addendum to a recent assessment to meet the requirements; If pre-screening is completed within the last 72 hours, allow for an addendum (recommend aligning more closely with DMAS). It’s not person-centered / trauma-informed to re-assess numerous times
P. 13 H- record retention – should this be included in licensing regs? There are LOV regs that we follow already.
P. 16 D1 & 2- Recommend not to include the underlined portions. Undue burden on providers to continue attempting to obtain beyond 48 hours ; puts focus on the client signing documents than on clinical treatment. We attempt to obtain signature for first 48 hours but documenting refusals to sign and / or receive should be sufficient; ongoing attempts can damage therapeutic relationship / trust and places focus on the wrong aspect of care.
P. 17 – Recommend that Emergency Services’ Pre-Screening process be pulled out as a completely separate and discrete service
P. 17 – Reassessments and Review of Safety Plans and Crisis ISPs- Clearly define what services this applies to; recommend that this not apply to a 72 hour or less
p. 17 – Progress Notes or Documentation:
A. Recommend further clarifying this or striking all together; redundant to item B which includes specifics of what should be included in progress notes;
B. Recommend removing item 3; every note may not
p. 18. Discharge Planning
A. In general, this entire section is unclear and contradictory in terms of what services are required to do what discharge planning steps.
G- Recommend that we document progress towards Crisis ISP and versus language related to “criteria for discharge” which adds additional burden for crisis services that exceeds what even longer term services are providing.
P. 19 – Written Policies
C4 – Remove “face sheet” terminology as the emergency medical information is present in different locations depending on the agency EHR
P. 19-20 Nursing Assessment
A – Doesn’t align with DMAS regs which requires the nursing assessment at admission for any residential service and the 23 hour programs.
C- Specify prior to admission to [specify which service types]
D- “A staff member” should be replaced by a qualified medical professional or remove this sentence
D- Clarify type of service as resources vary by service type. We would also recommend removing everything between “transfer to a more intensive level of care” and the last sentence where the examination is documented and signed or significant clarification of the intent of this section; nurses are not responsible for diagnosing underlying conditions.
H- add qualifier “unless the provider has access to a shared electronic health record.”

Health care policy:
B2: Crisis ISPs will address ANY medical/dental – that is broad to address ANY medical care needs in a short term service. Is this meant to be about related medical or dental serious issues that impact the crisis?
B3: Seems too broad – do they mean for immediate needs? Change routine to emergent/urgent. Leave 3/take out 4
C – is this in general chapter for licensed services?
Vital Signs:
Interesting that it specifies taking vitals at time of discharge.
CRC’s are not there for lengthy period, so how often are we going to be checking BP
We’re having to develop procedure, but we’re going to go by a doctor’s order, which could vary by patient
Emergency preparedness and response plan:
This is in general chapter as well, why is it being added to specific chapters. By embedding in separate chapters, it’s more maintenance for licensing to touch every reg for review when something changes and causes administrative burden and we would recommend not adding. And there is nothing here that is specific to crisis services.
Nutrition:
1 – not consistent with existing regulations
1 a - We don’t get dietary orders for a “normal diet”
1 b and 2 - This is complex for a short term service and is going above and beyond for a crisis service. Providing methods to learn seems to infer that we need to give cooking classes. We don’t document what individuals eat daily and how are you going to document the outcome of menus?
Beds/recliners:
B. this is helpful (having ability to have cots)
C: individuals often prefer to do their own laundry and should be able to.
G: suggestions: Let individuals know that if they want linens changed during their stay to let us know, but requiring them to be changed at 7 days is cumbersome for the constantly changing roster. Admissions are revolving and this would be an administrative burden to track. E. covers G.
Physical space:
D: Is there a grandfather clause for existing spaces that do no meet these regs?
E: suggest "reduce risk from harming self" instead of "prevent."
I and J: Is this referencing children’s residential services such as PRTF and TGH? If this CRCSU and CTH, does this mean separate wings or rooms?. This seems to be referencing children’s residential services and CRCSU’s are licensed as CSU’s, not under children’s residential services.
Physical environment:
F: Water temperature does not match current general chapter and how there are inconsistencies when chapters are copied over. Temperature is currently capped at 110.
M 2 – not all facilities are “ligature free” because they strive to be home like. Suggest replace the word prevent with "reduce risk."
O. Providers of children’s residential services – strike out all info below as CRCSU’s are not licensed as children’s residential services, they are licensed as CSU’s.
P1: upon admission instead of before the individual is record – because there are cameras on the outside of the buildings, wording should be changed to add the time of admission
Fire inspections – repealed code section
Lighting:
Not consistent with other sections or chapters
Goes into more details than in other places
Clarify if you’re going to say that artificial lighting should be by electricity – will we get cited for solar power, candles, lamps?