UF Health Psychiatric Hospital
Unit Scope

The purpose of the Hospital’s Scope of Services is to describe the framework by which the leadership of UF Health Psychiatric Hospital (SPH) will plan, direct, coordinate and improve the services provided to the community. This plan is based on the assumption that the Hospital is a network of integrated processes. The Scope of Services is supported by the hospital’s strategic plan, the annual budget plan, the departmental plans, and referenced administrative policies. The Scope of Services will be reviewed at least annually during the hospital’s planning process. Changes in patient care needs or findings from Continuous Quality Improvement (CQI) activities, risk management, infection control, safety and other internal assessments may also initiate a review and revision.

Hospital Description

SPH is an 81-bed private, not-for-profit institution that specializes in behavioral health care and is a distinct part unit of SPH, serving as the psychiatric and substance use treatment program. SPH is a designated Baker Act Receiving Hospital. The facility has 5 inpatient units. The average daily census between the 5 units is approximately 58.9 patients. The inpatient units operate 24-hours a day, 7 days a week. The beds are a combination of private and semi-private. There are no negative air pressure rooms. The units currently in operation are:

Adult Psychiatric Units: a 48-bed units, treating adult inpatients with psychiatric disorders or dual diagnosis disorders (psychiatric and substance use disorder) and medical co-morbidities.

Child/Adolescent Psychiatry: a 15-bed unit that treats children and adolescents (ages 9 through 17) with psychiatric or dual diagnosis disorders.

Dual Diagnosis and Addiction Medicine: an 18-bed unit, treating inpatient adults with substance use disorders and dual diagnoses.

Outpatient (OP) Services

  • Electroconvulsive Therapy (ECT)
  • Employee Assistance Program (EAP) services
  • Psychiatric Adult IOP

SPH’s primary service area is CHPA 3, a 16-county area in North Central Florida. These include Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee and Union Counties. However, SPH’s service area draws patients locally, statewide, nationally and internationally.

SPH supports the mission of UF Health:

  • To provide excellent patient care
  • To collaborate in improving community health
  • To create an environment that supports education and research in the health sciences

Mission Statement

SPH’s Mission is to:
Provide effective and efficient behavioral health care that promotes restoration of health on an inpatient and outpatient basis to eligible individuals who are in need of this treatment in the North Central Florida area.

Values Statement

Our governing values are the principles guiding our ethical behavior every day at Shands Healthcare.

The following values help University of Florida Health achieve its mission:

  • Accountability
  • Collaboration
  • Compassion
  • Communication
  • Competence
  • Creativity
  • Empowerment
  • Excellence
  • Integrity
  • Trust
  • Respect


To be the premier provider of patient and family centered behavioral health care in our region.

The philosophy of SPH is based on the belief that the patient and the patient’s family or support system is at the center of the interdisciplinary team effort. Each team member is believed to be vital to the functioning of the team, through the assessment, treatment plan development, provision of care and evaluation of treatment outcomes. (In the outpatient area, care delivery is often discipline specific and may not involve a treatment team approach).

Trauma Informed Care

UF Health Psychiatric Hospital and UF Health Psychiatry are committed to creating a Trauma-Informed behavioral health environment. This commitment means (1) developing a trauma-informed workforce, including recruiting, hiring and retaining trauma-informed staff; (2) providing continuous training on evidenced based and emerging trauma-informed best practices; (3) developing competencies specific to trauma-informed care and providing trauma-informed supervision to all members of the workforce; (4) implementing trauma-informed polices; and (5) adapting the physical environment to promote safe and trauma-informed spaces. UF Health Psychiatric Hospital and UF Health Psychiatry are dedicated to preventing and addressing secondary trauma in our behavioral health care providers.

Creation of a trauma-informed behavioral health environment is based on key principles of safety, trustworthiness and transparency, collaboration, empowerment, peer support, and will consider cultural, historical and gender issues.

The implementation of the Trauma-Informed Care is overseen by a steering committee which is made up of leadership, medical staff, and other hospital department staff including nurses, mental health technician, support technician, peer specialist, therapist, intake counselor, environment of care personnel, and security.

Definition of Patient Care, Patient Services, and Patient Support

Patient services at SPH occur through an organized and systematic process designed to ensure the delivery of safe, effective, timely, and Trauma Informed Care and treatment. These patient services are limited to those departments that have direct contact with patients. The full scope of patient care is provided only by those professionals who are charged with the additional functions of patient assessment and planning patient care based on findings from assessments. Patient services and patient care are provided primarily by licensed staff. Patient support is provided by a variety of individuals and departments that may not have direct contact with patients, but that support the care provided by hands-on care providers.

Professional nursing care is delivered by Registered Nurses, Licensed Practical Nurses and Mental Health Technicians (MHT) also provide patient care under the direction of the Registered Nurse and in accordance with the Plan for the Provision of Nursing Care.

Monitoring for patient safety is a basic component of the milieu approach. The safety of the environment is the responsibility of all members of the team, with the registered nurse ultimately responsible for maintaining the milieu.

Patient Care Departments

Patient Care Departments provide inpatient and outpatient patient services and/or patient care according to the definition above, with the types of staff described above. The patient care units are Adult Psychiatry, Child/Adolescent Psychiatry, Dual Diagnosis/Addiction Medicine, and Geriatric Psychiatry.

Patient Service Departments

  • Admissions
  • Case Management
  • Diagnostic Services: Radiology, Phlebotomy and EKG
  • Food & Nutrition Services – Dietitian
  • Intake
  • Nursing
  • Pharmacy
  • Recreation Therapy
  • Occupational Therapy
  • ECT
  • Adult Psychiatric IOP

Any other services can be accessed through SPH.

Professional Patient Care Staff: Roles and Functions

Staff Assessment Planning Interventions /Treatment Patient Rights Continuum of Care Planning Nutritional Care Psychosocial Support Patient Teaching
Staff Yes Yes Yes Yes Yes No Yes Yes
Case Managers Yes Yes No Yes Yes No Yes Yes
Intake No No Yes Yes Yes Yes Yes Yes
LPN No No Yes Yes No No No Yes
Medical Tech No Yes No Yes Yes No No Yes
Pharmacist No No Yes Yes No No No Yes
Radiologic / Lab Tech No No Yes Yes No No Yes Yes
Recreation Therapist No No No No No No No No
Registered Dietitians Yes Yes Yes Yes Yes Yes Yes Yes
RN Yes Yes Yes Yes Yes Yes Yes Yes
Social Worker Yes Yes Yes Yes Yes No Yes Yes
Therapists / Counselors Yes Yes Yes Yes Yes No Yes Yes
Occupational Therapy No No Yes Yes No No Yes Yes

This does not include patient support positions that are not licensed (Chaplain, CNA, MHT, Peer Specialist)

The interdisciplinary commitments of all departments in the provision of patient care are demonstrated through collaborative policy/procedure development, open communication, participation in Continuous Quality Improvement.

Patients with the same health care needs can expect to receive the same level of care throughout SPH. Each patient care/services area collaborates with the medical staff to provide effective patient care.

Support Services

Other hospital services will be available and are provided to ensure that direct patient care and services are maintained in an uninterrupted and continuous manner by coordinating identified organizational functions such as: leadership / management, information systems, health information management, human resources, environment, infection control and organizational quality assessment and improvement. These services support the comfort and safety of the patient and the efficiency of services available. These services are integrated with the patient services of the hospital.

Planning for Patient Care Services

SPH plans for the services provided in response to the needs of the community it serves. This planning is consistent with the organization’s mission and values. Patients may self-refer or be referred by a physician or community provider. SPH incorporates input from each department, relevant information specific to a particular unit, area, or department is provided as input, where appropriate.

Guidelines for Provision of Patient Care

Professional nursing care is delivered by Registered Nurses, Licensed Practical Nurses and Mental Health Technicians (MHT) also provide patient care under the direction of the Registered Nurse and in accordance with the Plan for the Provision of Nursing Care.

Monitoring for patient safety is a basic component of a therapeutic milieu. The safety of the environment is the responsibility of all members of the team, with the registered nurse ultimately responsible for maintaining a Trauma Informed therapeutic milieu.

Consultations and Referrals for Patient Services

As a distinct part unit of SUF, SPH offers a full range of medical, behavioral health and professional services to meet the needs of our patients. Consults for assessments and services are ordered by the patient’s Licensed Independent Practitioner (LIP) and may be recommended in collaboration with the interdisciplinary team. If questions arise regarding the appropriateness of consultations, these issues can be referred to the medical director.

A psychiatry consult may be ordered for patients in the addiction program and an addiction consult may be ordered for a patient in the psychiatry programs. Physicians practicing at SPH provide these consults.

Staff Education

All employees receive a formal orientation consistent with the scope of responsibilities defined by their job description and the patient population for which they will be caring. Staff are required to complete mandatory trainings which is department specific on an annual basis per calendar year. All clinical and security receive annual training on nonviolent crisis intervention training

Scope of Care

Each patient care/service department will have a defined scope of care and goals available that support the operation of the organization.

All inpatient services are open 24 hours a day, 7 days a week. All patients are seen in Intake and receive a level of care determination prior to admission. Staff are trained to meet the needs of the clients served.

Extent to which Level of Care or Service Provided Meets Patient’s Needs

  • The assessment process looks at the whole person: bio-psycho-social (body, mind, spirit). The primary focus of care is the psychiatric and/or substance use disorder(s). Patients are admitted to the appropriate level of care given this assessment.
  • The age range of patients served at SPH includes children through geriatrics. The age range should be from age 9 and above.
  • Patient diagnoses may include but are not limited to: major depression, alcohol use disorder, polysubstance use disorder, bipolar disorder, schizophrenia, psychosis NOS, ADHD, situational disturbance, various anxiety disorders including panic disorder, opiate dependence, alcohol dependence and polysubstance dependence.
  • Suicide risk, aggressive speech and behavior, withdrawal symptoms, disturbances of mood, hyperactive behavior, paranoia, disorganized speech and behavior are common problems exhibited by our inpatient patient populations. In the outpatient area, the symptoms frequently seen include disturbances of mood, anxiety disorders, situational disturbance.
  • For inpatients, concurrent active medical problems are addressed by attending medical staff directly and via consults. Individuals requiring more intense medical/surgical care than can be arranged at SPH are transferred to a medical/surgical hospital, generally UF Health Shands Hospital (SUF) on a medical unit or Unit 52 psychiatric services. The patient/family preferences are part of this decision-making process. In the event of a medical emergency, the County Emergency Medical Service is contacted and the patient is transported to an emergency room.
  • Types of services most frequently provided at SPH include: assessment/evaluation, medication management, nursing care, milieu approaches, education and therapy groups, family approaches including therapy, activity or recreational therapy, occupational therapy, and discharge planning
  • Length of stay in the inpatient and partial hospital programs varies, with a range from hours to several months. The average inpatient length of stay is approximately 5-7 days in the Psychiatry programs. The average inpatient length of stay in the Addiction Program is approximately 5-7 days.
  • Discharge planning includes follow-up appointments with community providers, planning for less intensive levels of care that may include assisted living settings, home care, follow up for medical problems, medication management, supportive therapy, and psychotherapy as needed.
  • For those patients in the substance use disorder program who require residential treatment, referrals are made to such a program.
  • For adult psychiatry patients who require long-term state psychiatric hospitalization, the admission process is completed and, when accepted, the patient is discharged and transported to Northeast Florida State Hospital or other long term care hospital.
  • ECT is available on Monday/Wednesday/Friday from 5:30a, – 12:00pm for both inpatient and outpatient individuals. The average number of treatments is up to twelve. For medically complex patients requiring electroconvulsive therapy, treatment is provided at Unit 52.

Standards/Regulations impacting services.

  • The Baker Act regulates admissions and treatment for all psychiatric patients. The Marchman Act regulates involuntary admission for substance treatment. As required by Florida Statute, the rights of patients are closely monitored. As deemed clinically necessary, the process for involuntary placement and treatment is followed, including identification of a guardian advocate for the individual, if appropriate. Patients then have a civil court hearing onsite. The patient(s) is escorted by staff, and an attending physician and case manager also attend.

In the event of a medical emergency at SPH, staff on site stabilize the patient as appropriate per Basic Life Support (BLS) training and 911 is called. This facility does not have the capacity in terms of trained staff or equipment to meet the clinical needs of a person experiencing a medical emergency.

Medical staff coverage is provided by the University of Florida Department of Psychiatry physicians. When a physician is not onsite, an on-call protocol is followed.

Staffing Plans

Staffing plans for patient care/service departments are developed based on the level and scope of care provided, the frequency of the care provided, and a determination of the level of staff necessary to provide required care.

Patient Care / Organizational Quality Assessment and Improvement

All departments are responsible for following the hospital’s Performance Measures, Quality and Patient Safety Plan including planned quality assessment and improvement activities, initiating activities designed to follow-up on unusual occurrences or specific concerns/issues which may include formal quality improvement initiatives, following policies and procedures for ensuring staff competence, and follow-up as appropriate on patient/family complaints and patient questionnaire results. Input and feedback from patients, staff and physicians guide the improvement processes. Each department, as appropriate, may be represented on CQI teams for the organization.

Integration of Patient Care and Support Services

A collaborative interdisciplinary approach, which takes into account the unique knowledge, judgment, and skills of a variety of disciplines in achieving desired patient outcomes, serves as a foundation for integration. Open lines of communication exist between departments providing patient care, patient services and support services within the hospital, and, as appropriate, with community agencies, to ensure efficient, effective and continuous patient care.

Contractural Relationship for Patient Care with External Organizations

When SPH enters a contract agreement, consideration is given to the organization’s ability to provide the same or comparable level of care.

Patient Care Units


  • Scope of Care: Nursing staff are present 24 hours a day, 7 days a week. The nursing model used is a patient centered care model. The Registered Nurse is responsible for and oversees the nursing care of patients from admission to discharge.
  • Nursing and Patient Services: (Refer to Staffing Plan.)

Addictions Therapist

  • Scope of Care: Assesses, plans, and implements treatment and assists in outcome evaluation of patients with substance use disorder and dependence. Works with patients and families within an interdisciplinary team model. Provides therapeutic and educational activities utilizing individual and group modalities, including family work when possible. Develops and implements discharge plans including referrals. Responsible for documenting patient care in accordance with regulatory and hospital standards. Works with a high degree of independence.

Patient Care Departments

Pathology and Hospital Laboratories

  • Scope of Care: Pathology and hospital laboratory services are provided by a SUF Clinical Laboratory.Diagnostic personnel are available to perform phlebotomies and specimen preparation for transfer to a SUF clinical lab for processing. In the absence of diagnostic personnel Registered Nurses perform the phlebotomies. UF Health Pathology Laboratories operate to: provide diagnostic and therapeutic information or products to the physician, nurse and patient by: performing laboratory procedures; preparing medical students, house staff, medical technologists and technicians for professional responsibilities by providing educational programs; advancing medical science by engaging in applied research and development; improving methodologies and offering new tests. Some of the services provided are: chemistry, hematology, microbiology, virology, serology, histocompatibility for immunology transplants, stat laboratory testing, anatomic pathology, cytopathology, histopathology, hematopathology, and Blood Bank (transfusion services). When patients’ clinical needs differ from those which this facility can offer, several alternatives are explored. When the patient requires testing or consultation not available at this setting, arrangements are made for such appointments. If necessary, travel arrangements to that site are also made.
  • Skill Level of Personnel: Staff and technical positions must meet Federal (CLIA) and State (AHCA) licensure requirements prior to assuming patient care responsibilities. Competencies are checked upon completion of initial training (orientation at six months and annually thereafter). Competency may be deemed (in the absence of a formal competency assessment) when a staff routinely engages in an activity and there is an absence of problems within an environment that includes systems for detection of random and systematic areas.
  • Staffing Plan: Staffing levels are determined according to patient care requirements.


  • Scope of Care: Radiology services all inpatients. Non-invasive radiology films only are performed on-site.
    Emergency procedures are provided 24 hours per day by transporting patients to SUF or to the closest facility who can provide these services. Procedural services may also be scheduled via SUF, or other locations as appropriate.
  • Skill Level of Personnel: Graduate of an AMA approved school of radiographic technology required. A minimum of one year experience in radiology. Experience in phlebotomy, basic lab functions and electrocardiography desired. Current Florida licensure as a Radiology Technician required. Current American Registry of Radiology Technology license required. Radiology techs are cross-trained for phlebotomy, x-ray and EKG.
  • Staffing Plan: Refer to Department Plan or Policy, as applicable.

Registered Dietitian

  • Scope: The Registered Dietitians (RDs) of the Department of Food and Nutrition Services provides medical nutrition therapy to patients of all ages with a variety of disease states, acuity, physical and mental limitations to optimize nutritional status. The nutritional status of inpatients is monitored so that individualized nutrition and clinical services can be provided. Patient education and consultation is provided by the RD through documented referrals and consults. Education may be provided to inpatients, families, significant others, students, and staff.Meal service is individualized to meet personal and nutritional needs. Cultural, religious, and ethnic preferences are reflected in the patient’s menu and meal plan. Write-ins on menus will require RD approval to assure compliance with the prescribed therapeutic diet. To ensure patient satisfaction approved write-ins will be supplied in a timely manner. Meal services are provided at traditional times according to established schedules.
  • Skill Level of Personnel: RDs must have graduated from an accredited four-year college or university in clinical dietetics. Completion of an American Dietetic Association (ADA) approved dietetic program or Master’s degree. Minimum of one-year’s previous experience in dietetics practice. Must have passed the ADA registration exam. Must be State of Florida licensed dietitian/nutritionist or eligible for the same.
  • Staffing Plan: Refer to Department Plan or Policy, as applicable.


  • Scope of Care:
    Evaluation Counselors are responsible for the screening and intake functions for inpatient and outpatient programs. Interfacing with patients, family members, visitors, and referring providers, they collect patient data prior to and upon arrival at the facility. Using current diagnostic tools, the Evaluation Counselor and the appropriate admitting physician determine the patient’s level of care. Initial insurance authorizations are completed by Evaluation Counselors once the level of care has been determined. A Registered Nurse(RN) and Mental Health Tech(MHT) are also part of the intake department. The RN conducts medical screenings on potential and current patients. With current patients, the screening by the RN includes obtaining vital signs and conducting contraband checks. The MHT is responsible for clerical support as well as vital signs if the RN is unavailable. The Intake Department is staffed 24 hours a day, 7 days per week.
  • Skill Level of Personnel: Evaluation Counselors possess a Master’s Degree in social work, mental health counseling, psychology, or other health related field. The intake nurse is licensed as a Registered Nurse (RN) and the Mental Health Tech (MHT) is licensed as a Certified Nursing Assistant (CNA).
  • Staffing Plan: Refer to Department Plan or Policy, as applicable.

Occupational Therapy

  • Scope of Care: The primary goal of the Occupational Therapy is to provide evaluation, planning, and provision of treatment and/or instruction of human beings to detect, assess, prevent, correct, alleviate or limit functional deficits due to potential or present physical deficits due to potential or present physical disability, developmental delay and/or psychosocial, emotional, or behavioral problems.
  • Skill Level of Personnel: Bachelors and/or Master’s degree in Occupational Therapy. Licensed as an Occupational Therapist in the State of Florida.
  • Staffing Plan: Refer to Department Plan or Policy, as applicable.


  • Scope of Care: The goal of the Pharmacy Department is to provide and ensure medications prescribed by physicians, physician assistants, and nurse practitioners address and prevent drug related problems, to educate students and health care providers on appropriate use of drugs and drug use control. Pharmacy services are provided to all inpatients.The most frequent services provided by the Pharmacy Department include: facilitating an interdisciplinary review of medications and determining which therapies offer a therapeutic, pharmaceutical, or economic advantage over alternative therapy, and developing criteria for use of new and existing medications; reviewing medication orders to verify appropriate dosing; creating drug therapy plans for selected patient populations; preparation and filling of medication orders; assist in medication reconciliation; participation in rounding and/or patient conferences as needed; and creating and maintaining drug use control systems which decrease the opportunity for inappropriate use of medications and medication errors. Hours of service are Monday through Friday, 6:00 AM to 11:00 PM; weekend/holidays, 7:00 AM to 5:30 PM. After hour pharmacy services are provided by SUF Department of Pharmacy Services.
  • Skill Level of Personnel: Pharmacists must have a license in the State of Florida; Pharmacy Technicians must be licensed as a as a pharmacy technician in the State of Florida. Certification is preferred.
  • Staffing Plan: Refer to Department Plan or Policy, as applicable.

Recreational Therapy

  • Scope of Care: Recreational Therapy services are part of the interdisciplinary team. Recreation Therapy services assess, plan and implement recreational therapy approaches and assists in outcome evaluation of psychiatric and/or substance use disorder patients. Provides therapeutic, educational activities utilizing individual and group modalities. Therapy approaches include leisure activities, exercise, coping skills groups, and reminiscence groups.
  • Skill Level of Personnel: Staff Recreational Therapists must possess a Bachelor’s degree in Recreational Therapy or related degree required. Previous clinical experience preferred. National Certification in Recreational Therapy is preferred.
  • Staffing Plan: Refer to Department Plan or Policy, as applicable.

Social Worker/Therapy/Case Management

  • Scope of Care: Provides inpatient psychosocial evaluation, treatment planning, coordination of discharge and follow up services. Responsible for assuring compliance with Florida Mental Health Law (The Baker Act). Assists with utilization review functions as required. Provides or coordinates patient/family education in these areas. The Case Management/ Social Worker/Therapist provides comprehensive case management, discharge planning and service-based care to patients identified as needing specific levels of care. This care is provided for all age populations from all acuity levels. All patients are assessed and monitored as indicated throughout their in-patient stay. Case Management is available daily.
  • Skill Level of Personnel: Master’s degree in social work (MSW) or other related field from accredited university required or successful completion of RN degree program. If qualified as an RN, Florida licensure as RN required. If qualified as an MSW, licensure as an LCSW is preferred. If qualified as a MHC, licensure as an LMHC is preferred.
  • Staffing Plan: Staffing levels are determined according to patient care requirements.

Utilization Management

  • Scope of Care: Responsible for management, coordination and documentation of utilization and external review activities to ensure an active and effective utilization management program. All duties are performed in accordance with the utilization review plan, Federal and State rules, regulations and guidelines, as well as The Joint Commission and CMS standards. In collaboration with members of the SPH clinical teams, is responsible for the coordination of resource utilization management and for patient/family education regarding resource allocation decision-making.
  • Skill Level of Personnel: Master’s degree in social work (MSW) or other related clinical field from accredited university required. RNs must be a graduate of an accredited School of Professional Nursing and have a current license in the State of Florida.
  • Staffing Plan: Staffing levels are determined according to patient care requirements.

Pastoral Services

  • Scope of Care: In response to the needs of patients and their families, staff will contact a representative of the patient’s spiritual choice.

Patient Representatives

  • Scope of Care: All staff will attempt to manage patient and/or family concerns regarding quality of care or services and facilitate their resolution. In addition, staff members provide guidance on issues related to patients’ rights and responsibilities and assist in institutional risk management through early identification and referral of grievances. The Director of Quality/Risk Management serves as the Patient Advocate and/or his/her designee will manage all patient grievances.
  • Skill Level of Personnel: Employees trained in customer service and patient satisfaction.


  • Scope: The Admissions Department’s role is to clarify coverage and financial decisions and, in the case of managed care, the insurer is contacted. The Admissions Department gathers demographic and insurance information along with any additional financial information, determines benefits, administers initial Medicare rights forms, collects co-pays, obtains consent to treat forms, and determines financial responsibility. There is a financial staff member available from 8:30 AM to 11:00 PM, Monday through Friday and 4:30 PM to 12:00 AM on Saturday and Sunday. An Office Representative is available from 8:30 AM to 4:30 PM on Saturday and Sunday.

Environmental Services

  • Scope: Environmental Services Department provides comprehensive cleaning services. In addition to cleaning and disinfection duties, Environmental Services is responsible for the collection, removal, transportation, and handling of biomedical waste, regular trash, and soiled linen from the facility. The Department also oversees the recycling program, cleanliness in all patient rooms and throughout all areas of the hospital.

Facilities Operations – Clinical Engineering

  • Scope: The Clinical Engineering Department ensures the reliability of specific patient care equipment by its coordination, evaluation, installation, calibration, inspection, preventative maintenance and repair programs. Equipment typically excluded from direct support includes diagnostic equipment in the Diagnostic Area. Coordination of the purchase of specific patient care equipment is accomplished through the review of capital budgets and ongoing purchases. Standardization of equipment (where possible) is used to control program and life cycle costs. Both of these activities lower the life cycle cost and support cost for the enterprise. The calibration, inspection, preventative maintenance and repair programs are all coordinated through the equipment database.

Facilities Maintenance and Operation

  • Scope: Facilities Maintenance and Operation is responsible for preventative and corrective maintenance services for the buildings and building equipment within the Hospital. Management of utility services (electricity, domestic water, HVAC system, chilled water, and medical gases) is provided.The department is responsible for customer related building and equipment repair service issues. The department also identifies equipment and building repair issues and corrects them in a timely manner. Preventative maintenance activities are comprised of scheduled assignments that span all over the building systems and involve all positions. It is comprised of a series of specific tasks, set at specific frequencies, with the intent of insuring safety plus minimizing system and equipment downtime. Staffing Plan: Staffing levels are determined according to an established work schedule.

Patient Transport/Courier

  • Scope: Transport/Courier provides patient transportation, as available. Provides courier services for mail, labs, and supplies, as available.

Food and Nutrition Services

  • Scope: The Department of Food and Nutrition Services provides food services to all patients with varying diseases, acuity, physical, and mental limitations. Clinical nutrition is provided to all inpatients through the Registered Dietitian. Education is provided to Food/Nutritional Service (FNS) staff to ensure a safe and sanitary work environment and to improve organizational performance.
  • Staffing Plan: Staffing levels are determined according to an established work schedule.
  • Meal services are provided at traditional times according to established schedules.

Health Information Management

  • Scope: Health Information Management (HIM) is open Monday through Friday from 8:00 AM to 4:30 PM and is responsible for the following services:
    • Maintaining and providing patient records/health information as needed for continuing patient care, release of information, billing, research and other approved uses.
    • Analyzing patient records for compliance with bylaws, accrediting, and regulatory standards and assist the caregivers in completing records within specified timeframes.
    • Providing end-user training in the use of the electronic medical record for compliance with medical/clinical staff documentation.
    • Using trained coders, HIM codes and abstracts patient records. This information is used for billing and forms a clinical database used for decision-making, research and other purposes.
    • HIM conducts coding and medical billing audits regularly to verify coding and billing accuracy.
    • Through qualified medical transcriptionists and outsourced services, HIM provides transcription of dictation for a variety of patient care reports.
    • Monitoring HIPAA Privacy and Security compliance in coordination with Core Compliance/Legal teams.
      Staffing Plan: Staffing levels are determined according to an established work schedule.

Infection Control

Scope: The Infection Control Program encompasses all departments and services. The liaison provides information, education, and consultation for hospital employees, house staff, and attending physicians. In addition, this person serves as liaison to the health department in regard to Infection Control issues of concern to the community.

Information Services

Scope: Information Services (IS) maintains computer and patient care equipment and interfaces, and provides support for many computer systems that assist in patient care. IS maintains systems involving many functions such as the electronic medical record, admitting, transferring or discharging a patient and abstracting and coding clinical information from the medical record. In addition, IS provides administration and clinicians with data, analysis, and ad hoc reports using patient and industry level demographic, financial, and clinical information. This data is used to assist with decision-making ranging from process improvement to strategic planning.

Quality Management

Scope: The Quality Management Department guides and supports committees and departments of the Medical Staff and Hospital as they seek to ensure that we are “doing right things right for our customers and ourselves.” The QM department is responsible for CQI education and training of employees, managers, physicians, and facilitators, coordination and support for CQI teams, data aggregation and reporting to various committees, and coordination of the Sentinel Event/Near Miss process.

Risk Management

Scope: The Risk Management Program provides for an incident reporting system, conducts investigations, analyses, and evaluations of risks and formulates risk management/loss prevention strategies to reduce or eliminate those risks. Serious incidents are reported to the state as required by law. Sentinel events are identified and root cause analysis is performed. In addition, the program provides resources and support systems for the quality assurance and risk management functions related to patient care and safety.

Safety and Security

Scope: The Safety and Security Department provides direct oversight and support of The Joint Commission defined Environment of Care areas of Safety, Security, and Hazardous Material and Emergency Preparedness as well as assistance, support and corporate oversight of Life Safety, Equipment and Utilities Management. Security services are staffed 24 hours a day, 7 days a week. The department also manages patient valuables and belongings and supports the environment of care plan (EOC).

Scope of Service Addendum

Medical Criteria Review


UF Health Psychiatric Hospital cannot accept, for admission, patients with the following conditions or equipment:

  • Cardiac Monitoring
  • Total Care without intact cognition
  • External Cardiac Life Vest Defibrillato
  • Diabetic Ketoacidosis
  • Total Parenteral Nutrition (TPN)/NG Feeding Tube
  • Infused Chemotherapy
  • Hospice
  • Peritoneal Dialysis
  • Tracheostomy
  • Stage III or IV wounds

UF Health Psychiatric Hospital can accept under certain conditions, for admission, patients with the following conditions or equipment:

  • Sleep Apnea/CPAP – patients must bring their own CPAP machine
  • Insulin Pumps – pump must have capacity to shut off
  • Pain Pumps – pump must have capacity to shut off
  • IVs that cannot be discontinued – needs Physician review
  • Autism/MR – depends on ability to participate in treatment, and needs Physician review
  • Dialysis
  • Stage I or II wounds will be assessed on case-by-case basis

UF Health Psychiatric Hospital can accept, for admission, patients with the following conditions or equipment, including, but not limited to:

  • Port-A-Cath for Meds
  • Hickman Line
  • Foley or Indwelling Catheter
  • 3rd Trimester Pregnancy
  • Oxygen