6007 Inpatient Hospitalization

Georgia State Seal

Georgia Division of Aging Services
Public Guardianship for Adults Manual

Chapter:

6000 Mental and Behavioral Health

Effective Date:

03/01/2022

Section Title:

Inpatient Hospitalization

Reviewed or Updated in:

MT 2022-02

Section Number:

6007

Previous Update:

MT 2019-02

Purpose

This policy defines the responsibilities of Public Guardianship Office (PGO) staff when a person under guardianship is examined or evaluated for or committed to inpatient mental health care, including the actions staff must take and the information and documents that must be obtained and placed in the case record.

A guardian must make decisions about and arrange services and providers for the health and welfare of the person under guardianship. Also, a guardian must know the capacities, limitations, needs, opportunities, and the status of the physical and mental health of the person under guardianship. O.C.G.A. § 29-4-22 (a)-(b)

Guardians must give consents or approvals that may be necessary for the professional care, counsel, treatment, or service for the person under guardianship. O.C.G.A. § 29-4-23

Basic Information

Facility Information

There are different types of psychiatric hospitals in Georgia, such as state-owned hospitals, federally operated facilities, and private hospitals. Regardless of the type of facility, if mental health care is provided in a hospital setting, it is called “inpatient.”

Psychiatric facilities can apply to be licensed as emergency receiving facilities, evaluation facilities, and/or hospital units. Each facility type plays a different role in mental health care. The terminology, rules, and deadlines associated with each type of facility are different.

Emergency Examination

An emergency receiving facility (ERF) is often the first facility in contact with a person who may need inpatient treatment. A person can go to an ERF voluntarily. A person may be sent to the ERF involuntarily.

Authority for Involuntary Examination

There are three sources of authority for involuntary examination. The first source of authority is by certificate of a mental health care provider. Many people refer to the certificate by its form number, “1013.” The Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD) creates and maintains this and other forms. To see what the form looks like, visit DBHDD’s policy website, currently located at gadbhdd.policystat.com/policy/1136700/latest/

A “1013” is a certificate completed by a physician, psychologist, clinical social worker, licensed professional counselor, or clinical nurse specialist in psychiatric/mental health. In the certificate, the mental health care provider certifies that she or he has personally examined the person in need of services and that the person meets the criteria for inpatient psychiatric care. O.C.G.A. § 37-3-41(a). A form 2013 is used when the basis of the need for services is based on a substance use disorder.

The second source of authority for involuntary examination is by court order. The probate court may issue an order for law enforcement to take custody and transport a person to be examined, even if the person does not consent. O.C.G.A. § 37-3-41 (b).

The third source for involuntary examination is by law enforcement, but only when the person is committing or is suspected to be committing a crime. If the officer believes that the person is committing a crime and that the person is mentally ill and in need of involuntary treatment, the officer may transport the person for examination. O.C.G.A. § 37-3-42. If the person is not breaking the law, law enforcement, without a certificate from a physician or an order from a court, does not have authority to take custody or transport a person for the sole purpose of having that person involuntarily examined for mental health care. Boatright v. State, 327 Ga. App. 785, 788 (2014).

Timeframes for Emergency Examination

Within 48 hours of a person entering an ERF, the facility must determine if the person needs further evaluation, needs hospitalization, or should not be admitted for inpatient care.

If the facility determines that a person needs hospitalization and the person consents, the person can be admitted voluntarily to a psychiatric hospital for treatment.

Evaluation

If the person is not willing to undergo treatment, but the facility has determined that inpatient treatment is needed, the facility has 24 hours to complete another certificate, DBHDD form 1014. In the 1014, the mental health care provider documents that the person was examined and needs further evaluation for possible admission to a hospital unit for treatment.

If a person is admitted involuntarily for evaluation at an evaluating facility, the facility has five business days to determine whether the person needs hospitalization. If the person does need hospitalization but does not consent to voluntary admission, a petition must be filed with the probate court.

After reviewing the case, the probate court determines whether the person will receive involuntary treatment, and if so, if the treatment will be inpatient or outpatient. An initial order for involuntary inpatient commitment can be for no longer than six months. The court may order involuntary outpatient treatment for up to one year. O.C.G.A. § 37-3-81.1

Criteria for Inpatient Hospitalization

The criteria for inpatient hospitalization for mental health treatment is the same for involuntary and voluntary admissions. Inpatient hospitalization is appropriate when:

  • The individual has a mental illness consisting of a disorder of thought or mood which significantly impairs judgment, behavior, capacity to recognize reality, or ability to cope with the ordinary demands of life (traumatic brain injury does not qualify as a mental illness)

  • Hospitalization is the least restrictive level of care available for the individual; and,

  • The individual presents a substantial risk or harm to himself/herself or others, as manifested by recent overt acts or recent expressed threats of violence that present a probability of physical injury to himself/herself or others, or

  • The individual is so unable to care for his/her own physical health and safety as to create an imminently life-endangering crisis. DBHDD Policy 03-502, “Criteria for Mental Health Admissions of Adults to DBHDD Hospitals.”

In the context of psychiatric hospitalization, the term “legal status” means two things:

  • The type of hospitalization, voluntary or involuntary, and

  • The source of authority for involuntary examination, evaluation, or treatment.

The legal status of a patient determines the notices that must be provided to the patient and the rights the patient has for discharge. If the patient is an adult under guardianship, the rights the patient has determines the power and duties the guardian has in providing for the person’s mental health care.

If the person under guardianship needs inpatient treatment, PGO staff must discuss the need for treatment with the person under guardianship to determine if she or he consents to treatment and document the conservation in the case record.

Voluntary Admission

If the person agrees to treatment, PGO staff must take all the actions listed below. At admission,

  • Select the hospital to which the person will be admitted for treatment

  • Apply for admission and provide any information or documents the facility may need for admission, such as medical records or ID cards

  • Ensure that the facility documents in the patient chart that the person is under guardianship and has PGO staff’s contact information

  • Discuss with the person the rights during treatment, which include the right to request to be discharged

  • Make sure that the person has clothing, grooming, and permitted personal items during the stay in the facility

  • Verify that the hospital inventories the person’s belongings at admission and any items that are provided to the person throughout the duration of the stay at the facility and obtain a copy of the inventory

  • Inform the person’s case manager (or other primary contact at the hospital) that the consent of the guardian must be obtained for all medical care.

Voluntary Treatment

During the course of treatment, PGO staff must:

  • Monitor the person’s legal status and obtain copies of the person’s chart showing the legal status

  • Ensure that an Individualized Recovery Plan (IRP) is developed that is appropriate for the person

  • Obtain and place in the case record a copy of the IRP

  • Review updates to the IRP and attend as many IRP meetings as possible

  • Review and obtain copies of the person’s chart

  • Maintain contact with the person and make in-person visits in accordance with PGO Policy Section 2020, “Monthly Contacts”

  • Advocate for changes to the IRP if the course of treatment is not effective or appropriate

  • Request any medical treatments that may be needed

  • Anticipate and plan for discharge options as early as admission.

Discharge on Voluntary Status

During voluntary hospitalization, the person or the guardian can request discharge. If PGO staff, as guardian, believes that discharge is appropriate, PGO staff must:

  • Discuss with the person readiness and willingness to discharge and service and treatment options available after discharge

  • Notify the person’s case manager or psychiatrist that the guardian is requesting the discharge

  • If required by the facility, complete a form requesting discharge; and,

  • Follow up with the facility to make sure that a decision is made on request within 72 hours of submission of the form (or request if no form is required).

If the facility approves the discharge, PGO staff must:

  • Ensure that the person discharges to an appropriate placement

  • Obtain a sufficient supply of medications or prescriptions for medication that will last until new prescriptions or refills can be obtained

  • Schedule appointments with outpatient psychiatrists, counselors, etc.

  • Arrange for transportation for the person upon discharge

  • Verify that the person discharges with all personal belongings

  • Contact the person within 24 hours of discharge.

Mental Health Care Decisions When the Guardian and the Person Under Guardianship Disagree

If the person does not agree to treatment, PGO staff must document the conversation with the person in the case record. If the guardian believes that the person needs inpatient treatment, but the person under guardianship does not consent to treatment, the guardian does not have the legal authority to override the person’s refusal of treatment. Likewise, if a person receiving inpatient care voluntarily requests discharge, the guardian does not consent to discharge, but the facility approves the discharge, the facility may discharge the person without the permission of the guardian. If the safety or well-being of the person is at risk, the guardian still must take action to ensure that proper mental health care is sought.

If PGO staff believes that the safety of the person under guardianship is at risk due to an inability to obtain inpatient psychiatric care, PGO staff must:

  • Consult her or his supervisor to determine whether a petition under O.C.G.A. § 37-3-41 or § 37-3-61 for involuntary treatment is needed

  • If advised by the supervisor, refer the matter to the Department of Human Services (DHS) Associate General Counsel (AGC) assigned to the Division of Aging Services (DAS) following the procedure outlined in DAS Administration Manual Section 1010

  • Arrange for and encourage the person to participate in outpatient services

  • Discuss treatment options with any mental health care providers, updating the providers promptly if there is a change in the person’s condition or symptoms

  • Educate the person, or provider, on what to do in the event of a mental health crisis, such as calling 911, going to the closest emergency room, or calling the Georgia Crisis & Access Line at 1-800-715-4225

  • Monitor the person closely, increasing phone or in-person contact as necessary

  • If appropriate, engage the support of the person’s loved ones to encourage treatment.

Involuntary Inpatient Status

If the person under guardianship does not consent to inpatient treatment, but an entity having authority to do so initiates involuntary examination, evaluation, or commitment of the person under guardianship, PGO staff must monitor the process to ensure that the person’s rights are protected.

Involuntary Examination

In addition to those duties, if the person under guardianship enters an emergency receiving facility to be examined for possible inpatient care, PGO staff must:

  • Ensure that the facility examines the person and determines the course of treatment within the 48 hours provided by law

  • If the facility determines that the person should not be held further for inpatient evaluation or care, discharges the person within 48 hours of arrival of the ERF

  • If the facility determines that the person requires further evaluation, that DBHDD form 1014 is completed within 48 hours of the person’s arrival to the ERF and the person is transported to the evaluating facility within 24 hours after completion of the 1014

  • If the facility fails to follow these timeframes, PGO staff must notify the PGO Section Manager or designee of the facility’s failure to act in a timely fashion. The PGO Section Manager or designee will determine whether a referral to DHS’ AGC for DAS is necessary.

Involuntary Evaluation

If the person is admitted for evaluation at an evaluating facility, PGO staff must:

  • Ensure that the facility performs necessary evaluations and within five business days, files a petition in probate court for involuntary commitment or,

  • Discharges the person within five business days after admission for evaluation

Involuntary Admission and Treatment

If the person is committed to inpatient treatment involuntarily, PGO staff must follow all the same procedures required for voluntary admission and voluntary treatment, except for filing the application for treatment. PGO staff must:

  • Determine whether a request should be made to have the person’s legal status converted from involuntary to voluntary

  • Speak with the person about her or his readiness and willingness to remain in treatment voluntarily

  • Review the chart for proof that the person is improving and would benefit from voluntary treatment, such as improvement in the severity of symptoms, a decrease in dangerous behaviors, or a willingness to continue receiving treatment

  • Speak with the members of the person’s treatment team, to gather their professional opinions about the need for continued involuntary treatment

  • If PGO determines that transferring to voluntary status would be beneficial, request that the person’s status be converted.

In addition to those duties, PGO staff must also take action as the order for involuntary inpatient care nears expiration. Before the order expires, the facility must convene a review team, called the Committee for Continued Involuntary Treatment (CCIT), to determine if the person continues to need involuntary inpatient treatment. The findings of the CCIT will then be reviewed by the chief medical officer (CMO or the clinical director, “CD”) of the facility. If the CMO/CD agrees with the findings, the CMO/CD must file a petition with the Georgia State Office of Administrative Hearings for a continued treatment. DBHDD Policy 24-106(E), “Legal Status for DBHDD Hospitals.”

PGO staff must:

  • Note the date that the order for involuntary inpatient treatment expires

  • If the person is not ready for discharge 40 days before the order expires, contact the hospital social worker or primary contact at the facility to request to be notified of the decisions of the CCIT and if applicable, the CMO/CD

  • Report to the PGO Section Manager or designee if the facility does not follow the procedures for holding the person for involuntary treatment so that a referral can be made to the DHS AGS for DAS, if necessary.

Transfer from Voluntary to Involuntary Status

If a person under guardianship who is receiving inpatient care voluntarily requests, with or without the consent of the guardian, to discharge, but the facility does not approve a discharge, the person’s legal status converts to involuntary status. If this occurs, PGO staff must follow the procedures outlined above for involuntary inpatient treatment.