Pennsylvania Code & Bulletin

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 54 Pa.B. 2336 (April 27, 2024).

Pennsylvania Code



155.1.    Principle.
155.2.    Organization options.
155.3.    Director of psychiatric services.
155.4.    Organization and staffing.
155.5.    Personnel.
155.6.    Nursing services.
155.7.    Therapeutic environment.
155.8.    Policies and procedures.


   The provisions of this Chapter 155 issued under section 2102(g) of The Administrative Code of 1929 (71 P.S. §  532(g)); and section 803 of the Health Care Facilities Act (35 P.S. §  448.803), unless otherwise noted.


   The provisions of this Chapter 155 adopted December 3, 1982, effective December 4, 1982, 12 Pa.B. 4129, unless otherwise noted.

Cross References

   This chapter cited in 55 Pa. Code §  6100.2 (relating to applicability).

§ 155.1. Principle.

 When a hospital provides psychiatric services, they shall be provided in a manner sufficient to meet the psychiatric needs of the patients. The hospital shall meet the requirements of the Mental Health Procedures Act of 1976 (50 P.S. § §  7101—7503). Inpatient psychiatric services shall be coordinated with psychiatric clinic and partial hospitalization program as appropriate.

§ 155.2. Organization options.

 Psychiatric services may be provided in an identified psychiatric unit or in beds dispersed throughout the hospital.

§ 155.3. Director of psychiatric services.

 The director of the psychiatric service shall be a member of the medical staff who is certified by the American Board of Psychiatry and Neurology or an equivalent board or who is eligible for board certification or who has successfully completed an approved residency training program in psychiatry.

§ 155.4. Organization and staffing.

 Organized psychiatric services within the hospital shall be provided by a qualified staff of adequate size to meet patient needs and under qualified psychiatric direction.

§ 155.5. Personnel.

 Psychiatric services such as nursing, psychology, social services, and adjunctive therapies shall be under the direction of persons licensed or registered in their respective fields and employed either full time or part time to implement the patient’s individualized treatment plan. Designated treatment components may be performed insofar as is consistent with law by supportive personnel who have completed an organized training or an on-the-job training program to qualify them for the performance of their duties.

§ 155.6. Nursing services.

 (a)  Nursing services shall be provided in accordance with Chapter 109 (relating to nursing services) and the provisions of this section.

 (b)  Psychiatric nursing services shall be under the direction and supervision of a registered nurse qualified by training or experience in psychiatric nursing.

 (c)  All nursing personnel shall have education and nursing skills which are appropriate to their duties and assignments.

 (d)  Sufficient number of nursing personnel shall be on duty at all times to provide adequate psychiatric treatment consistent with the individualized treatment plans.

§ 155.7. Therapeutic environment.

 (a)  There shall be adequate space, facilities, and equipment to meet the needs of the patients for privacy and for group interaction.

 (b)  Where a quiet room is used, facilities shall provide for the safety and visibility of the patient.

§ 155.8. Policies and procedures.

 (a)  Written policies and procedures for the psychiatric service shall be developed and revised annually.

 (b)  Each patient shall have an individualized treatment plan based on the assessment of clinical needs.

 (c)  Progress notes shall document the implementation of the treatment plan.

 (d)  Inpatient treatment and aftercare plans shall be developed consistent with patient needs.

 (e)  In addition to the hospital’s Patients Bill of Rights, the psychiatric service shall conform to the Bill of Rights as described in the Mental Health Procedures Act of 1976 (50 P.S. § §  7101—7503).

 (f)  Admissions and commitments to the psychiatric service shall be consistent with the provisions of the Mental Health Procedures Act.

 (g)  Written policies and procedures governing the use of seclusion and restraints shall be developed and revised annually.

 (h)  Confidentiality shall be assured to each patient receiving treatment.

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