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Regulatory Bulletin

Regulatory Bulletin DEPARTMENT OF MENTAL HEALTH DIVISION OF CLINICAL AND PROFESSIONAL SERVICES LICENSING DIVISION – BULLETIN #20-01 MARCH 31, 2020

Date: 03/21/2020
Organization: Massachusetts Department of Mental Health
Referenced Sources: 104 CMR 27.00: Licensing and Operational Standards for Mental Health Facililties

COVID-19 EMERGENCY GUIDANCE: MINIMUM REQUIRED NURSING CARE HOURS, FACILITY LICENSE EXTENSION.

In an effort to reduce regulatory burden for DMH Licensed Entities during the COVID-19 pandemic, but to assure continued adequacy and safety of Inpatient Facility milieu, we are issuing the following guidance:

Table of Contents

Nursing Care Hours

Strict adherence to the DMH Licensing minimum required nursing care hours per patient day requirements may be reduced if necessary due to workforce challenges as long as the following are always in place:

  • Attempts have been made to cover all staffing shortages with on call, per diem, or agency staff when applicable.
  • An RN must be present on all units and all shifts, and if this is the only licensed person, the nurse must be able to reasonably fulfill responsibilities for all medication administration, admission assessments, as well as oversight of the unlicensed staff on the unit, given the current and anticipated census of the unit. 
  • A staff person must be assigned to conduct patient safety checks at all times on every unit, without the addition of other assigned duties.
  • Any ordered constant observations of patients must be fully assigned throughout every shift.
  • There must be adequate staff in addition to the above to meet the needs of the patients being served at the current and anticipated census of the unit on that shift, including the provision of meals, outdoor access, and any assigned programming for patients.
  • Active clinical programming must continue to be provided that is beyond the nursing staff assigned to the unit.
  • The staffing levels throughout a multi-unit hospital must allow for an adequate emergency response, without leaving any staff person alone on an inpatient unit.
  • All staff working and providing care on a shift must have a documented assignment in written form which accurately reflects what was completed by each person throughout the shift.

Facility Licensing Extension

  • Programs and facilities whose licenses are in good standing that would otherwise expire during the state of emergency will remain in effect for a period of 90 days after the termination of the state of emergency.  If your license expired prior to the issuance of this order, but you submitted your request for license renewal, action on your renewal application will likewise be suspended for this period of time, as will corrective action plans that are not directly related to life/safety issues.  DMH will be issuing letters to each facility affected by this order clarifying its status.  DMH will retain necessary regulatory authority to ensure the safety and integrity of the programs and facilities it licenses during this time.
  • Any hospital or unit with an outstanding corrective action plan or order of correction that is not related to a health and safety deficiency may individually request an extension of the due date for responses.
  • We will continually reassess the emergency situation and if needed provide additional guidance.

Contact

Any questions regarding this bulletin should be directed to the DMH Licensing Division at 617-626-8117 or by email to Teresa.J.Reynolds@massmail.state.ma.us 

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