The mental health professional shall take the following additional preventive measures in a mental health establishment to contain the use of restraint to the absolute minimum,namely:- 30 ǐबहार गजट (असाधारण), 20 िसतà बर, 2023
(a) S/he shall give periodic training to the staff of the mental health establishment in learning and adopting alternatives to the use of restraints;
(b) S/he shall discuss the option of sedation with the person with mental illness or his/her nominated representative in accordance with the provisions of section 89 and section 90 of the Act of Government of India to manage the crisis andto avoid restrain;
(c) S/he shall submit the monthly report to the Board, under subsection (7) of section 97 of the Act Government of India,which shall be a calendar month report and shall contain the details in FormD which shall besigned by the person in charge of the mental health establishment;
(d) S/he shall forward the restraint report to the respective Board on a monthly basis within the first week of the next month.
THE SCHEDULE [See regulations 10 and 14]
1. Minimum Standards for Registration of Mental Health Establishments:
(I) Psychiatric hospitals/Psychiatric nursing homes and de-addiction centers Standard 1:The premises shall–
(a) Be a pucca structure;
(b) Be equipped with functional windows and doors with strong and intact vertical grills and wire meshes to avoid attempts for suicide or self-harm;
(c) Have a lift with a generator or power backup for area shaving more than four floors;
(d) Have sufficient ventilation and natural light;
(e) Separate wards for mentally ill female in patients and mentally ill male inpatients;
(f) each ward shall have a safe electric connection and adequate lighting. An adequate number of fans and lights shall be provided;
(g) have sufficient illumination after sunset for reading without causing strain to the eyes;
(h) have illuminated passages leading to toilets and emergency exits during the night;
(i) have inverters or power back-up for emergency lights during power failures;
(j) have periodic maintenance of the mental health establishment;
(k) have heaters and coolers subject tothe safety and health of residents, according to seasons;
(l) the maximum number of beds in a common ward shall not be more than twenty-five; and
(m) outpatient department and inpatient facilities shall have sitting arrangements for patients and accompanying family members, registration, help, cash counters, drinking water facilities, and separate toilets for males and females.
31 ǐबहार गजट (असाधारण), 20 िसतà बर, 2023 Standard 2: The living conditions shall be comfortable with–
(a) the plinth area of the establishment shall ordinarily occupy only half of the land area of the plot in which it is located. In situations where there is genuine difficulty to provide this much of open land area, 10% to 30% of the total carpet area prescribed for patients shall be provided as an additional living area;
(b) each patient shall be provided with an area of 60 sq. feet as a dormitory and a further 30 sq. feet as living room-cum-dining room area;
(c) separate cots, mattresses,pillows,and blankets(with due regard to the season) for each patient placed in a manner that there is at least three feet of space between each bed;
(d) each patient shall be provided with a locker to store personal belongings;
(e) adequate dimension to ensure comfortable passage and safe evacuation in case of emergencies;
(f) ward bed and surrounding space not less than one meter on all sides
(g) residents must not be made to sleep on the floor; and
(h) there shall not be any extra floor beds.
Standard 3: Hygiene, cleanliness, and sanitation shall be maintained by
(a) daily sweeping, swabbing, and a dusting of the entire premises;
(b) sanitation to be maintained in all the areas including toilets and bathrooms using disinfectants;
(c) separate toilets and bathrooms for male and female in patients, and disposal facilities for sanitary napkins;
(d) there shall be one bathroom and one toilet each for every eight male patients and for every six female patients;
(e) adequate availability of running water in wash basins, bathrooms, and toilets;
(f) periodic fumigation, pest control, and fixing of wire meshes on all doors and windows to keep outpests;
(g) patients must have round-the-clock access to safe drinking water;
(h) cleaning and changing the linen regularly;
(i) every institution shall have an automated laundry service, or a separate area for washing and drying clothes, with adequate manpower, so that the laundry is collected, washed, dried, and returned to the residents the same dayor byout-sourcing the laundry service; and
(j) adequate arrangements for the safe disposal of biomedical waste.
Standard 4: Wholesome, sumptuous, and nutritive food and potable drinking water shall be provided in comfortable settings
(a) food shall be served in a respectable and comfortable manner;
(b) hygienic and nutritious food shall be served;
(c) cooks and persons involved in the preparation and serving of food must undergo mandatory health check-ups periodically; aprons, masks,and headgear must be provided to all;
32 ǐबहार गजट (असाधारण), 20 िसतà बर, 2023
(d) food must be served at frequent intervals under the supervision of a sufficient number of attendants so that there shall be no long gap between meal times;
(e) the food served to each patient must meet their unique dietary requirements; meal plan sand diet charts must be prepared by a dietician; and
(f) a special diet based on special nutritional requirements must be given to women who are elderly, pregnant, lactating, or have recently under gone an abortion or miscarriage.
Standard 5: Facilities shall be provided for social, cultural, leisure, and recreational activities including
(a) entertainment programs, socials, and excursions for inpatients;
(b) furnished visitors’ rooms for families coming to meet them inpatients; and
(c) common room, where possible, which has television, newspapers, magazines, and indoor games, and the chairs provided are 1:4 ratio.
Standard 6: Adequate number of health professionals shall be employed to provide proper treatment
(a) Every Mental Health Establishment shall have to adhere to the human resources norms as follows:
(i) A psychiatric hospital/psychiatric nursing home, child/adolescent psychiatry clinic, and guidance units shall have at least a full-time psychiatrist for every hundred patients and parts thereof;
(ii) de-addiction centres should have the service of a consultant psychiatrist visiting the hospital, examining the inpatients, and conducting outpatient at least two hours twice a week and will be available on call to attend to emergencies;
(iii) a psychiatric hospital/psychiatric nursing home, deaddiction centers, child/adolescent psychiatry clinic, and guidance units shall have at least a full-time mental health professional assistant/social worker for every hundred patients and parts thereof;
(iv) A psychiatric hospital/psychiatric nursing home, deaddiction centres, child/adolescent psychiatry clinic, and guidance units shall have a full-time/part-time clinical psychologist according to the need thereof;
(v) psychiatric hospital/psychiatric nursing home, de-addiction center, a general hospital with psychiatry units/beds, and child/adolescent psychiatry clinic and guidance unit should have one Psychiatric nurse for every ten beds and round-theclock service of at least one staff nurse should be made available in each ward;
(vi) a psychiatric hospital/psychiatric nursing home, deaddiction centre, General Hospital with Psychiatry Units/beds and child/adolescent psychiatry clinic guidance 33 ǐबहार गजट (असाधारण), 20 िसतà बर, 2023 units should have medical officers having recognized M.B.B.S. Degree for every fifty patients and parts thereof and round-the-clock service of one Medical Officer should be available in the facility;
(vii) at least, one Doctor (Psychiatrist or Medical Practitioner) and oneNurse shall be available in the ward round-the-clock.
(viii) a psychiatric hospital/psychiatric nursing home, deaddiction centre, general hospital with psychiatry units/beds, and child/adolescent psychiatry clinic and guidance unit, should have one attendant for every ten patients/beds, and the minimum number of attendant required for an institution will be three;
Provided that if no qualified mental health professionals such as a clinical psychologist or psychiatric social worker are available, then a psychologist or social worker trained in mental health services, as the case may be, or if no psychiatric nurse is available, then a general nurse trained in mental health services and psychiatry, may be posted
(b) the in patients seen on a regular basis by a mental health professional;
(c) the trained human resources in mental health shall be made available to provide mental health services;
(d) provisions must be made for emergency treatment; and
(e) medical and para-medical staff shall be engaged in accordance with the specified requirements.
(i) nurses engaged for shift duty shall be in conformity with the norms made by the Indian Nursing Council from time to time;
(ii) attendants shall be engaged after an adequate induction training programme.
Standard 7: Equipment and articles shall be procured and used for inpatients inaccordance with the requirements of a mental health establishment
(a) medical equipment and instruments, commensurate with the scope of services and the number of beds;
(b) anesthesia equipment and oxygen cylinders with flow meters for establishments providing electro-convulsive therapy services in acute care services;
(c) equipment and inventory kept in a good usable condition;
(d) sufficient sets of basic equipment such as blood pressure apparatus, stethoscope, weighing machine, thermometer, and other equipment;
(e) sufficient stock of drugs, medical devices, and consumables;
(f) first aid box with standard contents; a daily check is done for replenishments; and
(g) anexamination table with footsteps.
34 ǐबहार गजट (असाधारण), 20 िसतà बर, 2023 Standard 8: Alternate methods shall be used in place of restraint to de-escalate crise ssituations:-
(a) physical restraints to be used only to prevent inpatients from hurting themselves or others, with the permission of the medical practitioner on duty or consultant psychiatrist and the circumstances shall be recorded in a separate register kept for this purpose;
(b) nursing staff shall be trained to use de-escalation techniques to prevent patients from harming themselves and others;and
(c) an adequate number of security staff must be hired, with an equal number of female guards.
Standard 9: There shall be the protection of privacy, dignity, safety, and security of patients, especially of women, and their confidentiality and-
(a) no discrimination on the grounds of religion, race, caste, sex, creed, place of birth and economic condition,or on any other ground in the matter of admission or treatment of patients;
(b) reasonable freedom and facility for pursuing religious beliefs;
(c) physical examination or treatment of female patients shall be in the presence of a female attendant or female nursing staff if conducted by male medical staff inside the hospital;
(d) independent lockers provided to patients to keep their personal belongings;
(e) necessary procedures exist to meet fire and non-fire emergencies and safe exit of inpatients andothers;
(f) appropriate display of directional fire exit signage,at least in two languages,one of which is local;
(g) all fire safety measures taken including fire prevention, detection, mitigation, evacuation, containment, and mock drills;
(h) firefighting equipment is to be periodically inspected, chemicals replenished, and shall be kept inusable condition;
(i) residents must be provided with an adequate number of clean undergarments and disposable sanitary napkins that are marked for personal usein public mental health establishments;and
(j) each individual resident must be provided with basic hygiene articles such as slippers, towels and combs, bathing and washing soap on a fortnightly basis, and atleast two shampoo sachets everyweek; basic cosmetics such as powder,cream, bindis and kumkum and other items should be provided in sufficient quantity.
35 ǐबहार गजट (असाधारण), 20 िसतà बर, 2023 Standard 10: Every mental health establishment shall comply with the provisions of the Right of Persons with Disabilities Act, 2016 (49 of 2016).
(II) CONVALASCENT HOME:
Organization and conduct of convalescent homes.-
(a) Service of a social worker or clinical psychologist or psychologist: On admission to a convalescent home, each mentally ill person shall be attached to a social worker who will be in charge of the rehabilitation of such mentally ill person.
(b) Monitoring of medication: Attendants on duty shall look after the personal needs of mentally ill persons admitted in any of the convalescent centers and also ensure that they take the prescribed medicines.
(c) Periodic health check-up: Periodic health check-ups shall be carried out to all inmates at least once in six months and physical illness shall be attended to immediately.
Part-timepsychiatrists shall be available and the psychiatrist shall not be in charge of more than four Convalescent homes situated nearby and must be accessible and available on-call in emergencies.
Whenever any patient in a convalescent home develops a psychiatric emergency, he shall be shifted to acute care centre.
(III) The Residential Half Way Home or Quarter way Home (Hostel):-
(i) Staff:
(a) the ratio between the visiting psychiatrist or mental health professional and the clients shall be 1:100
(b) the psychiatrist shall visit the center at a frequency of three half-day sessions a week and will be available on-call at emergencies
(c) there shall be at least one Psychiatric social worker available on all days.
(d) clinical psychologist (part-time or full time according to the need)
(e) there shall be one psychiatric nurse for every fifty patients.
(f) the medical practitioner shall be accessible and available on-call in emergencies.
Provided that if no qualified mental health professionals such as clinical psychologist or psychiatric social worker is available, then a psychologist or social worker trained in mental health services, as the case may be, or if no psychiatric nurse is available, then a general nurse trained in mental health services and psychiatry, may be posted.
(ii) Infrastructure:
(a) cots and mattresses one per person, three sets of linen, i.e., sheets, towels, pillow covers, blankets, etc.; staff supervision shall be required to maintain cleanliness.
(b) the buildings/space facility shall be located for easy accessibility to the general hospital/Primary Health Centre/Psychiatric facility, and transport facility. The building shall have proper ventilation and natural light and space for a garden.
(c) separate dormitory facilities for male and female residents (preferably 36 ǐबहार गजट (असाधारण), 20 िसतà बर, 2023 rooms to three to five residents) with three feetdistance between the cots.
(d) one bathroom and toilet for every ten patients with protected drinking water, fan, and light.
(iii) Support / Facilities:
(a) there shall be medical interventions, psycho-social interventions, vocational training, behavioral interventions, family education, and skills training. Facility to refer to the emergency care unit of a general hospital /psychiatric ward, when needed.
(b) pro-forma of a case record for each patient shall be maintained according to Form E. A record of family interventions shall be maintained.
(c) a discharge summary shall be given to each patient or guardian at the time of discharge, and a copy of the same shall be maintained by the hospital. If families or consumer site visit by self-interested in changing to another consultant, he shall be provided with a discharge summary and the application for discharge shall be maintained in Form F
(d) adequate facilities shall be provided for dining, recreation, and entertainment.
(IV) PROVISIONS FOR TREATING OUTPATIENTS
(1) All psychiatric hospitals and psychiatric nursing homes shall have outpatient sections open for not less than two hours per day for six days a week.
(2) Specialized psychiatric centers like child and adolescent psychiatric centers shall have an outpatientsection working for not less than two hours twice days in a week.
(3) rehabilitation centers, psychiatric day-care homes, and other partial psychiatric units shall have two hours out-patient sessions within a week
(4) out-patient section will be manned by a psychiatrist and the presence of one psychiatric social worker, one clinical psychologist, and one psychiatric nurse is to be ensured as far as possible:
Provided that if no qualified psychiatric social worker or clinical psychologist is available then a social worker or psychologist trained in mental health services, as the case be, or if no psychiatric nurse is available, then a general nurse trained in mental health services and psychiatry, may be posted.
(3) All admissions shall be made through the outpatient section as far as possible. When admissions are made outside of the outpatient section, the psychiatrist incharge shall record on the patient’s case sheet, the reasons for resorting to such a procedure.
37 ǐबहार गजट (असाधारण), 20 िसतà बर, 2023 (V) MAINTENANCE OF RECORDS The following registers shall be uniformly maintained in all psychiatric hospitals and psychiatric nursing homes and other mental health care institutions:
(1) An inventory of all physical resources available in the institutions such as buildings, equipment, etc.;
(2) An establishment register showing details about various categories of personnel including their qualification, experience, and service conditions;
(3) Out-patient register;
(4) Inpatient register;
(5) Census / nominal register;
(6) Case records in standard format ;
(7) Treatment registers.
By Order of Governor of Bihar, Sd/- Illigible, Secretary of Government.
38 ǐबहार गजट (असाधारण), 20 िसतà बर, 2023 FORM– A [See regulation3] FORM FOR MAKING, AMENDING/REVOKING, AND CANCELLING ADVANCE DIRECTIVE
1. Name (Attach a copy of photo identity document proof):
2. Age (Attach a copy of age proof for being above 18 years of age):
3. Father’s/Mother’s Name:
4. Address (Attach a copy of proof):
Note.-Any valid identity proof like Birth Certificate, Driving License, Voter’s Card, Passport, Aadhaar card, etc. Shall be admissible as an address proof and age proof.
5. Contact number(s): ______________________________
6. Registrati on no.of previous advance directive (to be filled in case of amendment/revocation/cancellation of advance directive): _____________
7. I wish to be cared for and treated as under (not to be filled in case of revocation/cancellation of advance directive): _________________________ ________________________________________________________________________ ____________________________
8. I wish not to be cared for and treated as under (not to be filled in case of revocation/cancellation of advance directive): _____________________ ________________________________________________________________________ ______________________________
9. Any history of allergies, known side effects, Or other medical problems ________________________________________________________________________ ________________________________
10. I have appointed the following persons in order of precedence (Enclosed photo ID and age proof),who are above 18 years of age to act as my nominated representatives to make decisions about mymental illness treatment, when I am incapable to do so (not to be filled in case of revocation/cancellation of advance directive):
(a) Name: ________ Age: ______________________ Father's/Mother’sname:
Address:
Contact number(s):
Signature:___________________________ Date:_______
(b) Name:
Age:
Father's/Mother’s name:
Address:
Contact number(s):
Signature: ________________________Date:
[Any number of nominated representatives can be added]
11. Signature of applicant:_____________________ Date:_____________
12. Signature of witnesses: ____________________________________
13.Mr./Ms.____________________Has the mental capacity to make/amend/ revoke/cancel an advance directive at the time of signing this form and has signed it in our presence of his/her own free will.
39 ǐबहार गजट (असाधारण), 20 िसतà बर, 2023 Witness1:(Name)……………………(Signature)………………..Date………........
Witness2:(Name)…………………….(Signature)………….…….Date…………….
Enclosure(s):
Note:-Please strike off those which are not required.
40 ǐबहार गजट (असाधारण), 20 िसतà बर, 2023 Form-B [See regulation 12(1)] Basic Medical Records:
The mental health establishment shall maintain specific minimum records at their level for various types ofpatients they are dealing with. The requirement of records to be maintained for in-patients, out patients and community outreach may vary and is accordingly specified below. A graded approach in minimum records to be maintained may be followed:
Community outreach register shall consist of information from (a) to (h) of the basic medical record of out patient specified in paragraph 1 below.
1. Basic Medical Record ofall out-patients (at hospitals, nursing homes, private clinics, camps, mobile clinics, primary health care centers and other community out reach programmes, and the like matters):
(In hard copy format)
(a) Name of the mental health esta