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DMH Licensing Division Bulletins

Bulletin #22-02 - COVID-19 Emergency Guidance Concerning Practice of Physician Assistants

In an effort to reduce regulatory burden for DMH Licensed Entities during the COVID-19 pandemic, but to assure continued adequacy and safety of the Inpatient Facility milieu, we are issuing the following guidance to implement COVID-19 Public Health Emergency Order No. 2022-02 concerning the practice of Qualified Physician Assistants.

Bulletin #22-01 - Clinical Competencies/Operational Standards Related to Infection Control in Response to the COVID-19 Pandemic

The Massachusetts Department of Mental Health (DMH) continues to work with our state and local partners to address Coronavirus Disease 2019 (COVID-19), caused by the virus SARS-CoV-2, and we continue to appreciate the essential role you have in responding to this evolving situation. We recognize that providing care for individuals seeking inpatient psychiatric treatment who test positive for COVID-19 may prove to be especially challenging for mental health care practitioners and facilities. In consideration of continued increasing indicators of community transmission including emergence of the Omicron variant of SARS-CoV2, DMH is issuing this revised bulletin to licensed facilities for admitting and caring for patients with presumed or confirmed COVID-19 to help mitigate the spread of COVID-19. The information in this bulletin is intended to complement each hospital’s internal infection control expertise. This update replaces the September 1, 2020 version and incorporates new isolation and quarantine guidance.

Bulletin #21-01 - COVID Dedicated Units

February 12, 2021 - In light of the continuing COVID-19 pandemic, this bulletin highlights the potential need for facilities to stand up COVID-19 Dedicated Units for the admission of persons who require inpatient psychiatric treatment and also are in need of an environment able to meet the infection control needs of active COVID-19 infection. Such units are required to support behavioral health patients who are diagnosed with active COVID-19 infection that does not require inpatient medical treatment.

This bulletin announces a process for Tier 2 hospitals and some Tier 1 hospitals (see DMH Licensing Bulletin #20-05R for a full description of Tier 1 and Tier 2 hospitals) to develop COVID-19 Dedicated Units when the need exists for these units.

DMH bulletin #20-06 - Resumption of DMH Facility Licensing Surveys

November 4, 2020 - In light of the current COVID-19 pandemic, this bulletin highlights current regulations and changes to orders extending the expiration dates of DMH Licenses. This bulletin applies to all inpatient Facilities licensed, operated or contracted by the Department of Mental Health (DMH). This bulletin rescinds portions of DMH Licensing Bulletin #20-01 as it relates to Facility Licensing Extensions.

DMH Licensing Bulletin #20-04R - COVID-19 Pandemic Guidance

Updated November 16, 2020 - In light of the current COVID-19 pandemic, this bulletin highlights current regulations and policies that support behavioral health patients leaving Emergency Departments as soon as possible once it is determined that a psychiatric inpatient level of care is required. In recognition of the vital role of acute psychiatric facilities in providing safe appropriate care for individuals in psychiatric crisis, DMH is highlighting licensed facilities’ obligations to admit and treat patients meeting admission criteria within their license class. The Department of Mental Health (DMH) is also enhancing its capacity to provide assistance through the Expedited Psychiatric Inpatient Admission process (EPIA), so we may all play our role in keeping patients and health care workers safe.

DMH Licensing bulletin #20-03 - Admission and Treatment

May 1, 2020 - This bulletin concerns the admission and treatment of patients who are confirmed positive for COVID-19, or who are identified as Persons Under Investigation/presumed positive (Patients with COVID-19). It also addresses the use of isolation, seclusion and restraint for Patients with COVID-19 when such interventions are necessary to reduce the risk of exposure to the coronavirus. This bulletin applies to all inpatient Facilities licensed, operated or contracted by the Department of Mental Health (DMH).


Bulletin #19-01 - Clinical Competencies/Operational Standards for DMH Licensed Inpatient Facilities

Bulletin #18-01 – New Unit Conditions and Denial of Inpatient Care Regulations

November 23, 2018 (Revised for contact info only on April 16, 2020) - This bulletin outlines changes to Regulation 104 CMR 27.00 to establish DMH’s role, through its licensing function, to help assure that facilities admit any patient meeting the criteria for admission for whom it has the clinical competency and staffing to appropriately treat.

Bulletin #17-01 - New Investigations Regulations 104 CMR 32.00

January 10, 2017 - This bulletin outlines changes to these regulations to organize material in a manner reflecting how investigations actually flow through the Department.

Bulletin #16-01 - Use of Telemedicine to Comply with 24/7 Physician Coverage/Designated Physician Requirements

Revised 12/28/2018 - This bulletin, which was revised late in 2018, outlines the criteria and procedures for use of telemedicine by DMH Licensed Inpatient Facilities to comply with provisions of 104 CMR 27.00 that require 24/7 physician coverage for admission examinations by designated physicians for individuals admitted pursuant to GL ch. 123 § 12(b), including assessment of capacity when such individuals wish to apply for conditional voluntary status; and/or, in limited in lieu of an in-person examination by an authorized physician within one hour of restraint or seclusion provided that the episode of restraint or seclusion has fully resolved before one hour has elapsed. The use of telemedicine for examination of patients who had been restrained or secluded for less than one hour was the purpose of the 2018 revision.

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