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Agenda 06/13/2023 Item #16D10 (Resolution - Transportation plan for acute care services for adults and children in Collier County FY 2023-2026)06/13/2023 EXECUTIVE SUMMARY Recommendation to adopt a Resolution approving the transportation plan for acute care services for adults and children in Collier County for the State Fiscal Years 2023-2026. OBJECTIVE: To implement an integrated and coordinated transportation plan for adults and children under the Baker Act and/or Marchman Act. CONSIDERATIONS: During the 2016 State of Florida Legislative Session Senate Bill 12 was passed, requiring communities to develop a coordinated transportation plan to serve those suffering from acute substance abuse and mental health issues, particularly for those persons involuntarily committed under the Baker Act, F.S. 394, Part 1 Florida Mental Health Act or Marchman Act, Florida Statute 397 Hal S. Marchman Alcohol or Other Drug Services Act of 1993. The intent of the legislation was for communities to develop a plan that provides safe and well - coordinated transportation to the nearest designated receiving facility. Collier County Board of County Commissioners (Board) adopted the prior 2020-2023 plan at the July 14th, 2020, Board meeting (Agenda Item #I6D13). The plan expires in June 2023. Collier County is part of the Department of Children and Families Suncoast Region. The transportation plan was developed by community stakeholders, who include, but are not limited to, the City of Naples, Collier County Sheriffs Office, Collier County EMS, National Alliance for Mental Illness, David Lawrence Center, and the Community Behavioral Health Advisory Committee (CBHAC). The agencies and organizations involved in this plan include Collier County Sheriffs Office and other law enforcement agencies as applicable, David Lawrence Center, Naples Community Hospital, Physician Regional Medical Center, and other treatment facilities as applicable. The plan specifically addresses: 1. Method of transportation within the designated receiving facility system for those requiring involuntary commitment. 2. Specialized transportation for patients to and from receiving facilities and to treatment centers. 3. Specify the way persons will be transported to, from, and between facilities, including transportation of those persons unable to pay for the cost of transportation pursuant to F.S. 394.462(2). 4. Describe those arrangements made by the facilities tailored to meet the needs of those persons with unique special needs such as those with visual or hearing impairments and/or the elderly with physical frailties. The cost of the transportation will be incurred by the Collier County Sheriff's Office and other law enforcement agencies, and Collier EMS for those persons with an acute medical condition or the treatment facility post - admission to another facility. This plan requires the approval of the Board, the Managing Entity for Substance Abuse and Mental Health, the Central Florida Behavioral Healthcare Network (CFBHC), and the Florida Department of Children and Families. This plan is a policy document and does require acknowledgment and participation on behalf of Collier County. Approval of this Item will satisfy and serve the legislative intent and shall be known as the Collier County Transportation Plan. FISCAL IMPACT: The proposed action described in this Executive Summary has no Fiscal impact. GROWTH MANAGEMENT IMPACT: There is no Growth Management impact associated with this Executive Summary. LEGAL CONSIDERATIONS: This item has been approved as to form and legality and requires majority Packet Pg. 1197 06/13/2023 vote for approval -DDP RECOMMENDATION: To adopt a Resolution approving the transportation plan for acute care services for adults and children in Collier County for the State Fiscal Years 2023-2026. Prepared By: Loretta Blanco, Grant Coordinator, Community and Human Services Division ATTACHMENT(S) 1. Resolution - 052523 - Transportation Plan (PDF) 2. Parties of Agreement for COLLIER COUNTY acknowledgment form_CAO (PDF) Packet Pg. 1198 16.D.10 06/13/2023 COLLIER COUNTY Board of County Commissioners Item Number: 16.13.10 Doc ID: 25471 Item Summary: Recommendation to adopt a Resolution approving the transportation plan for acute care services for adults and children in Collier County for the State Fiscal Years 2023-2026. Meeting Date: 06/13/2023 Prepared by: Title: — Community & Human Services Name: Tami Bailey 05/09/2023 8:32 AM Submitted by: Title: Manager - Federal/State Grants Operation — Community & Human Services Name: Kristi Sonntag 05/09/2023 8:32 AM Approved By: Review: Community & Human Services Tami Bailey Additional Reviewer Community & Human Services Kristi Sonntag CHS Review Operations & Veteran Services Jeff Weir OVS Director Review Community & Human Services Kelli Wolin Additional Reviewer Community & Human Services Kim Frazier Additional Reviewer Public Services Department Todd Henry PSD Level 1 Reviewer Public Services Department Tanya Williams PSD Department Head Review County Attorney's Office Derek D. Perry Level 2 Attorney Review County Attorney's Office Jeffrey A. Klatzkow Level 3 County Attorney's Office Review Office of Management and Budget Debra Windsor Level 3 OMB Gatekeeper Review Office of Management and Budget Blanca Aquino Luque Additional Reviewer County Manager's Office Dan Rodriguez Level 4 County Manager Review Board of County Commissioners Geoffrey Willig Meeting Pending Completed 05/09/2023 8:47 AM Completed 05/11/2023 5:55 PM Completed 05/12/2023 9:15 AM Completed 05/15/2023 1:47 PM Completed 05/16/2023 12:11 PM Completed 05/18/2023 12:15 PM Completed 06/05/2023 7:17 AM Completed 06/05/2023 5:02 PM Completed 06/06/2023 8:48 AM Completed 06/06/2023 9:04 AM Completed 06/06/2023 3:42 PM Completed 06/06/2023 4:23 PM 06/13/2023 9:00 AM Packet Pg. 1199 16.D.10.a RESOLUTION NO.2023 - A RESOLUTION OF THE BOARD OF COUNTY COMMISSIONERS OF COLLIER COUNTY, FLORIDA, ADOPTING THE TRANSPORTATION PLAN FOR ACUTE CARE SERVICES FOR ADULTS AND CHILDREN IN COLLIER COUNTY FOR STATE FISCAL YEAR 2023-2026. WHEREAS, in 2016, the Florida Legislative passed Senate Bill 12 (Ch. 2016-241, Laws of Fla.), requiring communities to develop a coordinated transportation plan to serve those suffering with acute substance abuse and mental health issues. The intent of the legislation is for communities to develop plans that provide safe and well -coordinated transportation to the nearest designated receiving facility; and WHEREAS, Collier County, as a member of the Department of Children and Families Suncoast Region, and through its participation in the Community Behavioral Health Advisory Committee, has a transportation plan in place to serve this vulnerable population; and WHEREAS, the Board of County Commissioners desires to adopt this transportation plan to meet the legislative requirement set forth in Senate Bill 12 (Ch. 2016-241, Laws of Fla.). NOW, THEREFORE, BE IT RESOLVED BY THE BOARD OF COUNTY COMMISSIONERS OF COLLIER COUNTY, FLORIDA, that the Collier County Transportation Plan 2023-2026, as attached hereto as Exhibit "A" and made part hereof, is hereby adopted in accordance with Senate Bill 12 (Ch. 2016-241, Laws of Fla.). THIS RESOLUTION ADOPTED after motion, second and majority vote favoring same, this 13th day of June 2023. ATTEST: BOARD OF COUNTY COMMISSIONERS CRYSTAL K. KINZEL, CLERK COLLIER COUNTY, FLORIDA in Deputy Clerk Rick LoCastro, Chairman Approved as to form and legality: Attachments: Exhibit "A" — Collier County rl_,J`j Transportation Plan 2023-2026 Derek D. Perry Assistant County Attorney J Page 1 of 1 Packet Pg. 1200 16.D.10.a EXHIBIT "A" r ti N r C O .y O C R d C O R L O Q N C L M N LO N LO O a Packet Pg. 1201 16.D.10.a DEPARTMENT OF CHILDREN AND FAMILIES SUNCOAST REGION SUBSTANCE ABUSE AND MENTAL HEALTH COLLIER COUNTY TRANSPORTATION PLAN 2023-2026 Packet Pg. 1202 16.D.10.a Page Introduction 2 Purpose 2 Community Behavioral Health Advisory Committee 3 Goals/Objectives 3 System Capacity 3 Baker Act Transportation 4 Medical Treatment 4 Criminal Charges 5 Transportation between Facilities 5 System Oversight 5 Inter -organizational Collaboration 6 Index 7 1 Packet Pg. 1203 16.D.10.a Collier County Transportation Plan Introduction In accordance with Florida Statute Chapter 394, Part 1, Florida Mental Health Act or the "Baker Act", Florida Statute Chapter 397, Hal S. Marchman Alcohol and Other Drug Services Act of 1993, and Senate Bill 12, a plan has been developed to organize a centralized approach for access to acute care services, and to describe how the community shall support and facilitate safe and well- coordinated transportation to the nearest receiving facility system. This plan has been developed by community stakeholders, as described herein, and referred to as the Collier County Community Behavioral Health Advisory Committee (CBHAC). This transportation plan requires approval by the Collier County Board of County Commissioners, Central Florida Behavioral Health Network (CFBHN), and the Department of Children and Families (DCF). Upon approval, this document will serve as the transportation plan for Collier County per legislative intent and be referred to as the Collier County Transportation Plan (CCTP). The Collier County Transportation plan will: 1. Describe methods of transport to a facility within the designated receiving system for individuals subject to involuntary examination under s. 394.463 or involuntary ti admission under s. 397.6772, s. 397.679, s. 397.6798, or s. 397.6811. N 2. Describe the commitment to ensuring a specialized transportation system that provides an �. efficient and humane method of transporting patients to receiving facilities, among receiving facilities, and to treatment facilities. ° A 3. Describe arrangements by which a facility may provide, in addition to require psychiatric and addiction services, an environment and services which are uniquely tailored to the needs of an identified group of persons with special needs, such as persons with hearing impairments or visual impairments, or elderly persons with physical frailties. a 4. Specify how persons shall be transported to, from, or between participating facilities when c necessary and agreed to, including persons unable to pay the expense of transportation, pursuant to s. 394.462(2). c The plan, along with an accurate inventory of designated receiving facilities and related public resources to provide care for persons in need of behavioral health acute care services, shall be maintained and available to law enforcement and to first responders, per s. 394.4573(2)(b). Purpose In the continued best interest of persons in need of public behavioral healthcare in Collier County, it is agreed that this plan will continue the successful established Baker Act/Marchman Act transportation system, known as the Collier County Transportation Plan. The Plan will ensure that individuals on an involuntary Baker Act/Marchman Act will obtain immediate access to acute care services and will reduce the need for inter -hospital transfers for psychiatric and addiction services. Coordination of services among providers in Collier County will meet the individualized needs of persons experiencing a behavioral health/substance use crisis, with timely access to care. The Plan calls for all law enforcement agencies in Collier County to transport: 1. Adults and youth on an involuntary Baker Act to the David Lawrence Center's Emergency Services Assessment Center (ESAC). 2. Adults on an involuntary Marchman Act to Collier County Jail Center. 3. Youth under the age of 18 years on an involuntary Marchman Act to the nearest local hospital emergency room. 2 Packet Pg. 1204 16.D.10.a The following objectives are expected to be met by establishing this Transportation Plan for Collier County: • Implement an integrated and coordinated system of transportation and access to psychiatric services for children and adults under a Baker Act order and appropriate and available substance use services for adults or children under a Marchman Act order for Collier County • Provide specialized services to children and the elderly. • Assist law enforcement in the efficient transport of individuals in need of services to the most appropriate facility. • Enhance the ability to fully utilize the capacity of acute care services in the county and reduce the unnecessary delay of transfers between facilities. • Ensure timely access to care, continuity of care, and provide integrated and client -centered coordination of care among providers. Community Behavioral Health Advisory Committee: The purpose of the Community Behavioral Health Care Advisory Committee is to discuss the operations of the Collier County Transportation Plan 0 and to establish ongoing communication for the implementation of best practices and quality behavioral health services via a community collaborative approach. The committee meets regularly to discuss Iq grievances, public satisfaction, and assurance of patient rights as related to this plan. The Community Ln N Behavioral Health Care Advisory Committee is composed of, but not limited to, representatives of the following agencies: 7 • Central Florida Behavioral Health Network o_ • City of Naples Police Department A • Collier County Emergency Medical Services. • Collier County Sheriffs Office • CPE Mobile Crisis Response Team • David Lawrence Centers • Department of Children and Families Substance Abuse and Mental Health office • Florida Department of Corrections • Hazelden-Betty Ford Foundation -Naples Q. • Marco Island Police Department c National Alliance on Mental Illness L • NCH Healthcare System ' M • Park Royal Hospital LO • Physicians Regional Medical Center to • The Willough of Naples c System Capacity • David Lawrence Centers (DLC), located at 6075 Bathey Lane, Naples, FL is a public receiving facility licensed by the Agency for Health Care Administration (AHCA) to operate 30 Crisis Stabilization Unit beds for adults and 15 beds for minors. DLC also operates a 15-bed adult substance use detox facility, and 18 adult substance use residential beds. At all times, DLC will maintain the current number of publicly funded beds serving the needs of Collier County residents. • NCH Healthcare System (NCH) and Physicians Regional Medical Center (PRMC) are not receiving facilities, but are responsible to evaluate, treat, and transfer persons in need of mental health and addiction treatment as part of their emergency departments. This is in accordance with federal Emergency Medical Treatment and Labor Act (EMTALA) emergency care rules and the medical treatment aspect of the plan applies to NCH and PRMC. 3 Packet Pg. 1205 16.D.10.a The receiving facilities within the County, and in nearby sister counties, will notify the Community Behavioral Health Advisory Committee of any changes in system capacity. Overflow: The David Lawrence Center (DLC) CSU is licensed by the Agency for Health Care Administration for 45 total beds, which includes adults and children. At no time will the David Lawrence Center's census status prevent the acceptance of a law enforcement Baker Act. When DLC is at capacity, the following overflow plan will be utilized to ensure services continue to be provided in the most timely and human manner. o To efficiently manage overflow, representatives from the local community hospitals will provide notification of their respective census to DLC daily. If or when DLC is at capacity, Overflow Status, DLC will notify the local hospitals of overflow status. DLC will attempt to transfer any law enforcement baker act while DLC is on overflow status. DLC will utilize the 3 ESAC beds as "overflow beds" during transfer process and at such time that all 3 ESAC beds are full DLC will be unable to accept hospital transfers under the Baker Act. o While DLC is on overflow status local community hospitals will refer individuals at the hospital who are under the Baker Act to out of county receiving facilities, if no beds are Ln found within the 12 hours post medical clearance, local hospitals will notify DCF as stipulated in FL § 394. Baker Act Transportation • Law enforcement agencies in Collier County will remain the responsible parties to transport those individuals in need of mental health services under the Baker Act to the nearest receiving facility. Transportation to, from, or between facilities may be required due to several factors, including medical necessity, inpatient acute care capacity, or individual choice. The receiving facility, and the facility that the person is being transported to or from shall coordinate these transportation arrangements. If an individual has a medical issue that needs to be addressed or an intoxication level that is medically compromising, Emergency Medical Services are required to transport the individual being detained under a Baker Act order to the nearest emergency care center for medical stabilization. When the individual has been stabilized and has been accepted by the Baker Act receiving facility, the Baker Act receiving facility will notify law enforcement to transport the individual to the receiving facility as outlined below. Once an individual has been medically cleared by the hospital and accepted by the receiving facility: • Individuals under the Baker Act will be transported to the Bathey Lane campus of David Lawrence Center by the Collier County Sheriff's Office, unless an active felony criminal charge is present, which requires transfer to the Collier County Jail (see Criminal Charges section below). • Adults under the Baker Act who are medically stabilized and who have Medicare insurance will be offered transfer to the nearest Medicare -receiving facility (e.g., Park Royal Hospital) utilizing a contracted transportation service such as Ambitrans or Medicab, or via DLC staff transportation. Medical Treatment The Community Behavioral Health Advisory Committee will review medical exclusionary guidelines for the receiving facility that will be used to assist in determining the most appropriate inpatient setting for 4 Packet Pg. 1206 16.D.10.a psychiatric patients requiring hospitalization. These guidelines will be shared among all the community partners to ensure that individuals who are assessed to need medical care are treated in an emergency care center or medical facility. When medically necessary, persons are treated for high -risk physical health care conditions either at an emergency department or appropriate health care facility (either NCH Health Care System or Physicians Regional Medical Center). In the event a person arrives at an emergency room, it is the expectation that the hospital will abide by federal Medicare Guidelines Section 1867, (COBRA) Examination and Treatment for Emergency Medical Conditions and Women in Labor (EMTALA) to screen, examine, stabilize, treat and transfer individuals appropriately. In turn, the designated receiving system shall work with the emergency department to coordinate the ongoing care of the individual, whether it is an outpatient discharge or referral or inpatient treatment. Criminal Charees: L_ m Law enforcement will be required to transport individuals in need of mental health services under the Baker Act directly to the Collier County Jail if charged with a felony crime. If charged with a �j misdemeanor, the arresting law enforcement agency will transport the individual directly to the appropriate receiving facility with the required "Jail Hold" form. Once the individual charged with a felony has completed the booking procedure, the Jail medical Ln N personnel will be required to notify the receiving facility of the nature of the crime and to request prior approval before arranging a transfer. The receiving facility will review each felony Baker Act referral c case -by -case to ensure that the facility can safely manage the needs of the individual. The Baker Act A facility may determine that the felony Baker Act referral is not appropriate for transfer/ to the receiving facility and will provide a letter of written refusal of the Baker Act felony referral in such cases. Other �• arrangements for servicing the Baker Act in these cases will be coordinated between the facilities. Upon completion of treatment for individuals who are designated "Jail Hold" as a result of being arrested prior to treatment, the receiving facility will be required to contact the Collier County Sheriff's Office to arrange for transportation to the Collier County Jail. Transuortation between Facilities Post -Admission to the Receiving Facility: Once an individual is in the care of the receiving facility, there may be occasions when that individual needs to be transferred from one facility to another. If transfer is needed but a medical emergency is not present, the Baker Act receiving facility will arrange for trained staff from the facility to provide transportation when indicated, to include arranging for transfer to the State Hospital facility. For individuals transferred out of county to a private facility based on choice, the receiving facility will coordinate transfer arrangements with contracted approved transportation providers and in coordination with the out of county private receiving facilities. When such arrangements are not available or suitable, trained staff from the receiving facility may provide transfer out of county to another receiving facility. In the case of medical emergencies, the local EMS system will provide transportation to the nearest and appropriate local hospital facility, with the Baker Act receiving facility providing a copy of the Baker Act to accompany the individual. When an individual needing transfer is designated as "Jail Hold," the receiving facility must contact the local law enforcement agency to ensure an appropriate escort of the individual to the local hospital for safety. Law enforcement is not responsible to transport individuals from one facility to another after admission to the receiving facility unless the individual has criminal charges and is returning to jail. 5 Packet Pg. 1207 16.D.10.a System Oversight/Accountability In an effort to resolve complaints, grievances, and disputes which may arise during implementation of the plan, personnel from above referenced agencies will meet. The Community Behavioral Health Advisory Committee will implement necessary actions in response to its ongoing review and any public or Central Florida Behavioral Health Network (CFBHN) or Department of Children and Families review. The Suncoast Region Department of Children and Families, Substance Abuse and Mental Health Program Office and CFBHN is responsible for providing oversight to the Transportation Plan. The Department of Children and Families and CFBHN have the authority to resolve issues concerning the Transportation Plan, approve interagency agreements, as well as coordinate other services needed for individuals beyond acute care services. The Regional office also has a working relationship with the Agency for Health Care Administration if issues arise beyond the department's authority. The Suncoast Region Substance Abuse and Mental Health Program Office telephone number in Tampa is 813-337-5700. Interorganizational Collaboration Implementing an effective Transportation Plan on behalf of persons in need of behavioral health services requires a significant amount of cooperation, commitment and collaboration from all parties involved. Besides having the strong support of law enforcement and the behavioral health providers, Collier County Ln N hospitals have engaged in a public planning process which has strengthened the relationships between all parties responsible for implementing the Transportation Plan in Collier County. 77 Packet Pg. 1208 16.D.10.a Index of Attachments to Collier County Transportation Plan A. Definitions B. Acute Care Services Overview C. David Lawrence Mental Health Center, Inc. Certificate of Liability Insurance (Note: Certificate will be attached with final PDF version. Includes minimum of $100,000 as specified in Checklist.) D. Collier County Sheriffs Office MOU/Transportation Plan 7 Packet Pg. 1209 16.D.10.a Attachment A DEFINITIONS Baker Act: The Florida Mental Health Act Marchman Act: The Hal S. Marchman Alcohol and Other Drug Services Act c a Receiving Facility: Any public or private facility designated by the Department of Children and Families to receive and hold involuntary patients under emergency conditions or for psychiatric evaluation and to provide short-term treatment. 3 Private Receiving Facility: Any hospital or facility operated by a for -profit or not -for -profit O corporation or association that provides mental health services and is not 2 a public facility. �j Public ReceivingF,acility: Any facility that has contracted with the Department of Children and Families to provide mental health services to all persons, regardless of Ln N their ability to pay, and is receiving state funds for such purpose. c 0 Law Enforcement: Means any person who is elected, appointed, or employed full time by A any municipality or the state or any political subdivision thereof; who is vested with authority to bear arms and make arrests; and whose primary responsibility is the prevention and detection of crime or the enforcement of the penal, criminal, traffic, or highway laws of the state. This a definition includes all certified supervisory and command personnel c whose duties include, in whole or in part, the supervision, training, guidance, and management responsibilities of full-time law enforcement c officers, part-time law enforcement officers, or auxiliary law w enforcement officers but does not include support personnel employed by the employing agency. Law Enforcement Agencies Serving Collier County: Collier County Sheriffs Office Naples Police Department Marco Island Police Department Florida Highway Patrol Seminole Police Department 0 Packet Pg. 1210 16.D.10.a Attachment B Acute Care Services A. INTRODUCTION David Lawrence Mental Health Center, Inc., d.b.a. David Lawrence Centers, is a private, not -for - profit community mental health center whose primary mission is to provide a wide range of mental health, alcohol and substance abuse services to meet the needs of the citizens of Collier County. David Lawrence Centers' mission is restoring and rebuilding lives by providing compassionate, advanced, and exceptional mental health, substance use, and integrated healthcare solutions, available to all. The vision of the David Lawrence Centers is to lead the way in transformational care so every individual assisted can achieve what is possible. David Lawrence Centers' Board of Directors and management staff are committed to a planning and performance improvement process consistent with the overall mission of the agency. Emergency Services Assessment Center (ESAC)is staffed with Emergency Service (ES) clinicians who are available to provide clinical triage services for emergency referrals. Services include CrisisIq Assessment, Risk Assessment, Crisis Intervention, Crisis Support referral for Urgent Care Services N or other appropriate service(s) within or outside the agency, and/or referral for admission to an 77 7" appropriate Acute Care Unit. The Emergency Services Assessment team works collaboratively c with the Acute Care team, where ongoing clinical triage/assessment occurs off hours and on o weekends. The ESAC serves as the Collier County Baker Act receiving facility. A The Adult Crisis Stabilization Unit (CSU) is a 30-bed, locked, non -hospital inpatient mental health unit that provides brief voluntary and involuntary evaluation and stabilization treatment services for individuals experiencing a psychiatric crisis who meet the criteria defined under the Florida Mental Health Act. The Children's Crisis Stabilization Unit (CCSU) is a 15-bed, locked, non -hospital inpatient mental health unit, which provides brief voluntary and involuntary evaluation and stabilization services for children who are in a psychiatric crisis. B. REFERRAL SERVICES Emeraencv Services Assessment Center. Adult & Children's Crisis Stabilization Unit: Referrals to the Emergency Services Assessment Center (ESAC) include self -referrals, professionals within or outside of the David Lawrence Center and/or law enforcement. Individuals may access walk-in crisis services 24 hours a day, seven days a week. ESAC provides telephone triage and crisis intervention outside the normal business hours and during regular business hours. Baker Act admissions and law enforcement cases are received 24n. Involuntary admission to the CSU may be through appropriate professionals, law enforcement or ex-parte court orders, identified in the Florida Mental Health Act (Baker Act). The Crisis Stabilization Units serve any person who without care or treatment of a mental illness, may cause harm to his/herself or others as evidenced by recent behavior or who, without care or treatment, is likely to suffer from neglect, refuse to care for his/herself, or pose a real and present threat of substantial harm to personal well-being. Individuals admitted will be determined to meet the Baker Act criteria, as per the Florida Mental Health Act (Ch. 394). Individuals may be admitted under voluntary or involuntary status. 0 Packet Pg. 1211 16.D.10.b Parties of Agreement for COLLIER COUNTY TRANSPORTATION PLAN 2023-2026 Acknowledgment Form The Collier County Sheriff's Office does hereby confirm (Agency Name) that we have received a written copy of the Collier County Transportation Plan 2023-2026 and have reviewed, understand, and approve the plan. COPY PROVIDED COPY REFUSED Collier County Sheriff's Office Agency Name Print Name Date Signature Date IN10 Packet Pg. 1212