13-011 Code Vt. R. 13-150-011-X - RULES FOR THE ADMINISTRATION OF NONEMERGENCY INVOLUNTARY PSYCHIATRIC MEDICATIONS

Section 1. Policy Statement.

The Department of Mental Health (DMH) is committed to providing voluntary mental health care in a service system that respects individuals' health, safety, and dignity. DMH recognizes the right of a legally competent person to make decisions regarding medication. At the same time, DMH acknowledges that involuntary care is currently unavoidable in certain circumstances as set forth in Title 18 of the Vermont Statutes Annotated. DMH continues to work toward the development of a service system in which coercion and involuntary care will no longer be necessary. Until that ideal is achieved, DMH will strive to provide involuntary care found to be necessary in a manner that affords as much protection as possible for the respect, dignity, and rights of the individual.

Section 2. Authority.

This rule is adopted pursuant to 18 V.S.A. § 7628 and Act 27 (2023).

Section 3. Definitions.

3.1. The Commissioner: The Commissioner of DMH or a designee as authorized by 18 V.S.A. § 7401(13).

3.2. Competence: A person is competent if a person is able to make a decision regarding medication and to appreciate the consequences of that decision.

3.3. Court Order: An order from the criminal court or the family court authorizing the DMH to administer involuntary medication to the person named in the order.

3.4. Designated Facility: A hospital, forensic facility, medical psychiatric unit in a correctional facility, or other facility authorized by statute to administer nonemergency involuntary psychiatric medications. A designated facility shall meet the requirements of this rule, including the requisite trained staff, medical personnel and physical space and be designated by the Commissioner to provide care for a patient with mental illness.

3.5. DMH: The Department of Mental Health.

3.6. Forensic Facility: A residential facility, licensed as a therapeutic community residence as defined in 33 V.S.A. § 7102(11), for an individual with a mental health condition or intellectual disability, depending on what is deemed appropriate by the General Assembly, who is charged with a crime of violence against another person and the individual is assessed not competent to stand trial or was adjudicated not guilty by reason of insanity and who requires treatment or programming within a secure setting for an extended period of time, provided, however, that if a definition is added to 18 V.S.A. part 8 it shall take precedence to the extent that a conflict between the definitions exists. As used in this definition, "secure" has the same meaning as in 18 V.S.A. § 7620.

3.7. Impartial Evaluator: A contracted individual not employed by DMH or under the supervision of the Commissioner, who has no prior personal knowledge of the circumstances under review.

3.8. Medical Personnel:

a) A person licensed by the State of Vermont as a Physician, physician assistant, advance practice registered nurse, or registered nurse; or

b) a psychiatric technician/mental health specialist

3.9. Person: An individual who is the subject of a court order authorizing DMH to administer involuntary medication to that individual.

3.10. Qualified Practitioner or QP: An advance practice registered nurse or physician assistant who is licensed by the State of Vermont and who is appropriately credentialled to provide the psychiatric services described in this rule.

3.11. Treatment Team: The person's community and/or treating psychiatrist(s), or other QP, case manager and any other individual the community treatment team deems clinically appropriate. If the person does not have a treatment team in the community, the members of the team will be the person's inpatient or residential facility treating psychiatrist, or other QP, case manager and any other individual deemed clinically appropriate.

Section 4. Notice of Intent to Administer Medication.

4.1. Prior to executing a court order authorizing the administration of involuntary medication;

4.1.1. DMH shall:

a. Allow the person's legal counsel twenty-four hours to inform the person of the court's order; and

b. Notify the person's treatment team of the court order.

4.1.2. The person's treating physician or QP shall meet with the person:

a. After the person has been informed by the person's legal counsel of the court order; or

b. After the person's legal counsel has had twenty-four hours to inform the person of the court order, regardless of whether the legal counsel has chosen to meet with the person.

4.1.3. The treatment team must:

a. Inform the person orally and in writing in a language and in a manner understandable to the person of:

i. the type of medication to be administered;

ii. the dose that will be administered;

iii. the method of delivery;

iv. the route of delivery;

v. the frequency of delivery;

vi. the intended effects;

vii. any risks in keeping with standard medical practice, including likely side effects, unlikely but serious side effects, health problems that might be encountered, common drug interactions including those of street drugs and alcohol, and in the case of all women of child bearing age, the effects of neuroleptics on a fetus or nursing child; and

b. Offer the person an opportunity to take oral medication unless the court order authorizes the administration of a long-acting medication which can only be administered by injection.

Section 5. Administration of Nonemergency Medication.

5.1. The physician or QP writing the medication order for the medication shall be responsible for assessing and documenting the following:

5.1.1. The person's current physical health status;

5.1.2. Whether the person is currently taking any other medications;

5.1.3. The person's history of side effects from medication;

5.1.4. Whether the individual is pregnant;

5.1.5. The person's medical history, including any history of substance abuse; and

5.1.6. That the medication order is in compliance with the court's medication order with respect to the type of medication, the dosage, the length of administration and the method of administration.

5.2. The treating physician or QP shall conduct monthly reviews of the medication to assess the continued need for involuntary medication, the effectiveness of the medication, the existence of any side effects, and shall document this review in detail in the person's chart.

5.3. The treating physician or QP shall provide written notice to the court to terminate the medication order when involuntary medication is no longer required.

5.4. The treatment team shall:

5.4.1. Make best efforts to obtain the person's preference on the manner of medication administration after the court issues an order granting the application and immediately prior to the administration of medication;

5.4.2. Consider the current, written medical history of the patient that includes whether the patient has a history of trauma;

5.4.3. Have at least one member present when the medication is administered and at the time of release; and

5.4.4. Ensure that the person has the opportunity to choose a support person, to be present to offer emotional support when the medication is administered. If the chosen support person is not available within a reasonable period of time or interferes with the administration of medication, or the frequency of administration precludes the presence of the support person each time, medication may be administered without the support person's presence.

5.5. Location

5.5.1. Medications must be administered at a designated facility. The medication must be administered in an area of that facility that provides the person with privacy.

A sheriff may transport the person to or from the designated facility if, and only if, the person's treating physician, QP, or another member of the treatment team makes an individualized determination, documented in the person's chart, that physical restraint is necessary to prevent the person from inflicting serious physical injury to themselves or others.

5.5.2. If the person is transported by a sheriff, a member of the treatment team shall be present when the sheriff picks up the person for transport and will accompany the person during the transport, if the parties agree.

5.6. Oral Medication

5.6.1. The medical personnel or QP who administers medication to the person shall be trained in the administration of medication when treating a resistant person.

5.6.2. The medical personnel or QP shall:

a. Verify that the person is the subject of a current involuntary medication order; and

b. Follow clinically appropriate practices and procedures for the administration of oral medication.

5.6.3. The Medical Personnel or Qualified Practitioner may perform a mouth check to verify that the person has swallowed the medication.

a. If the person refuses to comply with a mouth check, then the treatment team is not required to offer voluntary oral medication the next time medication is administered but may do so at their discretion.

b.

5.6.4. After administering the medication, a staff member shall personally observe the person long enough to ensure there are no adverse side effects and to ensure safety.

5.7. Injectable Medication

5.7.1. The medical personnel or QP who administers the medication to the person shall be trained in the administration of administration of medication when treating a resistant person.

5.7.2. The medical personnel or QP shall:

a. Verify that the person is the subject of a current involuntary medication order;

b. Verify that the proper medication is prepared in the proper dosage;

c. Fully inform the person of all aspects of the procedure;

d. Give the person a choice of clinically appropriate injection sites and follow that preference if medically safe;

e. Follow clinically appropriate practices and procedures for the administration of injectable medication;

f. Be of the gender chosen by the person receiving the medication if at all possible;

g. Ensure that a physician is immediately accessible; and

h. Be responsible for assuring that a support person of the person's choosing is present when the medication is administered, unless the support person interferes with the administration of the medication or, the frequency of administration precludes the presence of the support person each time.

5.7.3. The medical personnel or QP shall be accompanied by at least one health professional of the gender chosen by the person.

5.7.4. After administering the medication, a staff member shall:

a. personally observe the person long enough to ensure there are no adverse side effects endangering safety;

b. offer emotional support to the person.

5.7.5. All procedures shall be documented in accordance with standard medical practice.

Section 6. Future Administration of Involuntary Medication.

6.1. Where the court's medication order authorizes future administration of involuntary medication, the treating physician shall execute and file with the Commissioner a certification executed under penalty of perjury stating the following:

6.1.1. The person has refused medication;

6.1.2. The person is not competent to make a decision regarding medication and to appreciate the consequences;

6.1.3. The proposed medications, the dosage range, length of administration and method of administration; and

6.1.4. The substantial probability that in the near future the person will pose a danger of harm to self or others if not involuntarily medicated.

6.2. Within 24 hours of receipt of the physician's certification, the Commissioner shall provide the amount of notice required by the court order to the person, the person's legal counsel and the court.

6.2.1. The notice shall state that the person may request an immediate hearing to contest the order.

6.2.2. The person may be admitted to a designated facility on the date specified in the notice for up to 72 hours in order to administer involuntary medication.

6.3. The procedures set forth in Section 6 of these rules shall be followed for any person subject to a future administration of involuntary medication.

Section 7. Use of Restraints When Administering Nonemergency Involuntary Medication.

7.1. Restraints may be used only pursuant to the Regulation Establishing Standards for Emergency Involuntary Procedures which can be found on DMH's website.

Section 8. Discharge of Person Not Subject to Order of Hospitalization.

8.1. If a person is brought into the designated facility only pursuant to a medication order, a physician or QP must determine the amount of time that the person will be required to stay at that facility prior to discharge, but in no case longer than the time period allowed in the court order. This decision shall be based on appropriate clinical practices and procedures regarding the discharge of a person who has received the type of medication administered to the person.

8.2. Prior to discharge, the person shall receive the necessary counseling and assistance to support the person's comfort.

8.3. Prior to discharge, a member of the treatment team shall provide the person with written instructions regarding:

8.3.1. Side effects;

8.3.2. Required after-care;

8.3.3. A name and phone number to contact if the person has any questions or concerns or starts to experience side effects;

8.3.4. Grievance procedures; and

8.3.5. Follow-up with the community mental health center.

8.4. A physician or QP must approve the person's release after making a determination that there are minimal clinical risks.

8.5. A member of the treatment team shall arrange transportation to return the person to their residence. If the person does not have housing available, a member of the treatment team shall arrange temporary housing for the person.

Section 9. Compliance and Enforcement.

9.1. A member of the treatment team shall report to the Commissioner every time a person is administered involuntary medication in a designated facility within seventy-two hours of entering the facility.

9.2. The Commissioner shall review on a periodic basis every instance of a person being administered involuntary medication in a designated facility.

9.3. The Commissioner shall conduct periodic reviews of every person who is subject to an involuntary medication order.

9.4. The Commissioner may revoke a facility's designated status for noncompliance with this rule.

9.5. Any person who is subject to an involuntary medication order may file a grievance with the appropriate agency alleging a violation of this protocol. The grievance must be filed within ninety (90) days of the action that is being grieved. This time limit may be extended if the person did not know or understand the right to appeal. The agency shall report the filing and substance of a grievance to the Commissioner within seventy-two hours of receiving the grievance.

9.6. Within thirty (30) days of receiving the grievance, the designated facility shall notify the person of its decision in writing, in a language and manner understandable to the person, including the reasons for the decision.

9.7. The decision made by the designated facility concerning the grievance may be appealed to the Commissioner. Any such appeal must be filed within thirty (30) days of the day the person received written notice of the decision.

9.8. Upon receipt of the appeal, the Commissioner shall assign an impartial evaluator to conduct a review of the appealed incident. Within thirty (30) days of receipt of the appeal assignment, the evaluator shall recommend to the Commissioner whether to affirm or change the decision of the agency or designated facility. Within ten (10) days of receiving the evaluator's decision, the Commissioner shall notify the person of the Commissioner's decision in writing, in a language and manner understandable to the person, including the reasons for the decision.

Notes

13-011 Code Vt. R. 13-150-011-X

EFFECTIVE DATE:
August 18, 1999 Secretary of State Rule Log #99-41
AMENDED:
1/15/2025 Secretary of State Rule Log #24-049

STATUTORY AUTHORITY:

3 V.S.A. § 801; 18 V.S.A. § 7628