No. 26925 (Amendment): R501-2. Core Standards

DAR File No.: 26925
Filed: 01/30/2004, 03:29
Received by: NL

 

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose for the amendment to Rule R501-2 is to make the rule clearer and more easily understood and broaden the base on who is required to have a background screening completed and approved, which includes all staff, management, and board members that may have any contact with the clients.

 

Summary of the rule or change:

The reorganization of Rule R501-2 is to make the content more easily understood, with a clarification of the terms used in the rule, the safety of the clients, and having documents posted properly and in plain view so the clients, their family, and visitors are aware of the standing of the facility with the Office of Licensing.

 

State statutory or constitutional authorization for this rule:

Section 62A-2-106

 

Anticipated cost or savings to:

the state budget:

Other than for the cost of copying the revised rule, there will be no additional cost or savings to the State Budget.

 

local governments:

Local governments have no additional cost because the changes in the rule have been for clarification and broader definition of the already existing rule and other that the facilities complying with local government's regulations, there is no additional cost to local governments.

 

other persons:

The changes in this rule will produce no additional costs or savings to other persons because the rule changes are for clearer understanding and expanded definition and not for physical changes.

 

Compliance costs for affected persons:

Because the changes made in this rule are more for clarification and better definition of terms, it was determined that there would be no additional cost or savings to the affected persons unless they opt to make changes.

 

Comments by the department head on the fiscal impact the rule may have on businesses:

With the type of changes made with this rule, there will not be a fiscal impact on businesses.

 

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Human Services
Administration, Administrative Services, Licensing
120 N 200 W
SALT LAKE CITY UT 84103-1500

 

Direct questions regarding this rule to:

Jan Bohi at the above address, by phone at 801-538-4153, by FAX at 801-538-4553, or by Internet E-mail at [e-mail]

 

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

03/16/2004

 

This rule may become effective on:

03/17/2004

 

Authorized by:

Ken Stettler, Director

 

 

RULE TEXT

R501. Human Services, Administration, Administrative Services, Licensing.

R501-2. Core [Standards.]Rules.

R501-2-1. Definition.

Core [Standards]Rules are required[the license requirements] for Human Service Programs, [as ]listed in R501-2-14. Where there is duplication of review by another oversight agency, the Office of Licensing, [hereinafter referred to as Office, ]shall accept that documentation as proof of compliance. Pursuant to 62A-2-106, the Office of Licensing will not enforce rules for licensees under contract to a Division in the Department of Human Services in the following areas:

A. the administration and maintenance of client and service records;[ and]

B. staff qualifications; and

C. staff to client ratios.

 

R501-2-2. Program Administration.

A. The program shall have a written statement of purpose to include the following:

1. program philosophy,

2. description of long and short term goals, this does not apply to social detoxification or child placing adoption agencies,

3. description of the services provided,

4. the population to be served,

5. fee policy,

6. participation of consumers in activities unrelated to treatment plans, and

7. program policies and procedures which shall be submitted prior to issuance[at time] of an initial licensing.

B. Copies of the above statements shall be available at all times to the Office of Licensing upon request. General program information shall be available to the public.

C. The program shall have a written quality assurance plan. Implementation of the plan shall be documented.

D. The program shall have clearly stated guidelines and appropriate administrative procedures, to include the following:

1. program management,

2. maintenance of complete, accurate and accessible records, and

3. record retention.

E. The governing body, program operators, management, employees, consultants, volunteers, and interns shall read, understand, follow and sign a copy of the current Department of Human Services Provider Code of Conduct.

F. The program shall comply with State and Federal laws regarding abuse reporting in accordance with 62A-4a-403 and 62A-3-302, and shall post copies of these laws in a conspicuous place within the facility.

G. All programs which serve minors or vulnerable adults shall submit identifying information for background screening [for]of all [staff]adult persons associated with the licensee and board members who have access to children and vulnerable adults in accordance with R501-14 and R501-18.

H. The program shall comply with all applicable National Interstate Compact Laws.

I. A licensed substance abuse treatment program shall complete the [Uniform Facility Data Set Survey]National Survey of Substance Abuse Treatment annually. Substance abuse treatment programs shall also comply with Confidentiality of Alcohol and Drug [a]Abuse Patient Records, 42 CFR Part 2.

J. The program's license shall be posted where it is easily read by consumers, staff and visitors[in a conspicuous place on the premises]. See also R501-1-5-F. The program shall post Civil Rights License on Notice of Agency Action, abuse and neglect reporting and [Americans With Disabilities Act, referred to as ADA,]other notices as applicable.

K. The program shall not handle the major personal business affairs of a consumer, without request in writing by the consumer and legal representative.

L. Programs providing foster or proctor care services shall adhere to the following:

1. approve homes that comply with Foster Care Rules, R501-12. The agency shall be required to recruit, train, and supervise foster parents as defined by R501-12.

2. foster families meeting requirements shall be approved or certified by the agency. The agency must maintain written records of annual home approval. The approval process shall include a home study evaluation and training plan.

3. the agency must have a procedure to revoke or deny home approval.

4. the agency must have a written agreement with the foster parents which includes the expectations and responsibilities of the agency, staff, foster parents, the services to be provided, the financial arrangements for children placed in the home, the authority foster parents can exercise on children placed in the home, actions which require staff authorization.

5. planning, with participation of the child's legal guardian for care and services to meet the child's individual needs.

6. obtaining, coordinating and supervising any needed medical, remedial, or other specialized services or resources with the ongoing participation of the foster parents.

7. providing ongoing supervision of foster parents to ensure the quality of the care they provide.

 

R501-2-3. Governance.

A. The program shall have a governing body which is responsible for and has authority over the policies, training and monitoring of staff and consumer activities for all phases of the program. The[ir] governing body's responsibilities shall include the following:

1. to ensure program policy and procedures compliance,

2. to ensure continual compliance with relevant local, state and federal requirements,

3. to notify the Office of Licensing within 30 days of changes in program administration and purpose,[ according to R501-2-2.]

4. to ensure that the program is fiscally and operationally sound, by providing documentation by a financial professional that the program is a "going concern",

5. to ensure that the program has adequate staffing as identified on the organizational chart,

6. to ensure that the program has general liability insurance, professional liability insurance as appropriate, vehicle insurance for transport of consumers, and fire insurance, and

7. for programs serving youth, the program director or designee shall meet with the Superintendent or designee of the local school district at the time of initial licensure, and then again each year as the programs renews it's license to complete the necessary student forms including youth education forms.

B. The governing body shall be one of the following:

1. a Board of Directors in a non-profit organization; or

2. commissioners or appointed officials of a governmental unit; or

3. Board of Directors or individual owner or owners of a for-profit organization[, and

4. for Child Placing Adoption Agencies, a Board of Directors. The Board members shall not be owners, employees, or paid consultants of the agency].

C. The program shall have a list of members of the governing body, indicating name, address and term of membership.

D. The program shall have an organization chart which identifies operating units of the program and their inter-relationships. The chart shall define lines of authority and responsibility for all program staff and identifies by name the staff person who fills each position on the chart.

E. When the governing body is composed of more than one person, the governing body shall establish written by-laws, and shall hold formal meetings at least twice a year, Child Placing Agencies must meet at least quarterly, maintain written minutes, which shall be available for review by the Office of Licensing, to include the following:

1. attendance,

2. date,

3. agenda items, and

4. actions.

 

R501-2-4. Statutory Authority.

A. A publicly operated program shall document the statutory basis for existence.

B. A privately operated program shall document its ownership and incorporation.

 

R501-2-5. Record Keeping.

The program shall have, [if available and appropriate, ]a written record for each consumer to include the following:

A. [d]Demographic information to include Medicaid number as required,

B. [b]Biographical information,

C. [p]Pertinent background information, including the following;

1. personal history, including social, emotional, psychological and physical development,

2. legal status,

3. emergency contact with name, address and telephone number, and

4. photo as needed.[,]

D. [h]Health records of a consumer including the following:

1. immunizations, [this is not applicable to adult programs]for children only,

2. medication,

3. [records of ]physical examinations, dental, and visual examinations, and

4. other pertinent health records and information[,].

E. [s]Signed consent forms for treatment and signed Release of Information form,

F. [c]Copy of consumer's individual treatment or service plan,

G. [a]A summary of family visits and contacts, and

H. [a]A summary of attendance and [leaves]absences.

 

R501-2-6. Direct Service Management.

A. Direct service management, as described herein, is not applicable to social detoxification[, residential support or child placing adoption agencies]. The program shall have on file for public inspection a written eligibility policy and procedure, approved by a licensed clinical professional to include the following:

1. legal status[ according to State law],

2. age and sex of consumer,

3. consumer needs or problems best addressed by program,

4. program limitations, and

5. appropriate placement.

B. The program shall have a written admission policy and procedure to include the following:

1. appropriate intake process,

2. age groupings as approved by the Office of Licensing,

[2]3. pre-placement requirements,

[3]4. self-admission,

[4]5. notification of legally responsible person, and

[5]6. reason for refusal of admission, to include a written, signed statement.

C. Intake evaluation.

1. At the time of intake an assessment shall be conducted to evaluate health and family history, medical, social, psychological and, as appropriate, developmental, vocational and educational factors.

2. In emergency situations which necessitate immediate placement, the intake evaluation shall be completed within seven days of admission.

3. All methods used in evaluating a consumer shall consider age, cultural background, dominant language, and mode of communication.

D. A written agreement, developed with the consumer, and the legally responsible person if applicable, shall be completed, signed by all parties, and kept in the consumer's record, with copies available to involved persons. It shall include the following:

1. rules of program,

2. consumer and family expectations,

3. services to be provided and cost of service,

4. authorization to serve and to obtain emergency care for consumer,

5. arrangements regarding absenteeism, visits, vacation, mail, gifts, and telephone calls, when appropriate, and

6. sanctions and consequences.

E. Consumer treatment plan shall be individualized, as applicable according to the following.

1. A staff member shall be assigned to each consumer having responsibility and authority for development, implementation, and review of the plan.

2. The plan shall include the following:

a. findings of intake evaluation and assessment,

b. measurable long and short term goals and objectives,

1) goals or objectives clearly derived from assessment information,

2) goals or objectives stated in terms of specific observable changes in behavior, skills, attitudes or circumstances,

3) evidence that consumer input was integrated where appropriate in identifying goals and objectives, and

4) evidence of family involvement in treatment plan, unless clinically contraindicated,

c. specification of daily activities, services, and treatment, and

d. methods for evaluation,

3. Treatment plans[:]

a. [P]plans shall be developed within 30 days of consumer's admission by a treatment team and reviewed by a [licensed ]clinical professional if applicable. Thereafter[,] treatment plans shall be reviewed by the licensed clinical professional if applicable as often as stated in the treatment plan.[ Plans for non-Medicaid consumers shall be clinically reviewed within six months of admission and at least annually thereafter.

b. Where applicable, treatment or program plans shall be written to include the required components of Division of Services for People With Disabilities program plan.]

4. All persons working directly with the consumer shall be appropriately informed of the individual treatment plan.

5. Reports on the progress of the consumer shall be available to the applicable Division, the consumer, or the legally responsible person.

6. Treatment record entries shall include the following:

a. identification of program,

b. date and duration of services provided,

c. description of service provided,

d. a description of consumer progress or lack of progress in the achievement of treatment goals or objectives as often as stated in the treatment plan, and

e. documentation of review of consumer's record to include the following:

1) signature,

2) title,

3) date, and

4) reason for review.

7. Transfer and Discharge

a. [A]a discharge plan shall identify resources available to consumer.

b. [T]the plan shall be written so it can be understood by the consumer or legally responsible party.

c. [W]whenever possible the plan shall be developed with consumers participation, or legally responsible party if necessary. The plan shall include the following:

1) reason for discharge or transfer,

2) adequate discharge plan, including aftercare planning,

3) summary of services provided,

4) evaluation of achievement of treatment goals or objectives,

5) signature and title of staff preparing summary, and

6) date of discharge or transfer.

d. The program shall have a written policy concerning unplanned discharge.

8. Incident or Crisis Intervention records

a. The program shall have written policies and procedures which includes: reporting to program manager, documentation, and management review of incidents such as deaths of consumers, serious injuries, fights, or physical confrontations, situations requiring the use of passive physical restraints, suspected incidents of abuse or neglect, unusual incidents, strip searches [for the reporting and documentation of deaths of consumers, injuries, fights, or physical confrontations, situations requiring the use of passive physical restraints, suspected incidents of abuse or neglect, unusual incidents,] and other situations or circumstances affecting the health, safety, or well-being of consumers.

b. [R]records shall include the following:

1) summary information,

2) date, time of emergency intervention,

3) action taken,

4) employees and management responsible and involved,

5) follow up information,

6) list of referrals,

7) signature and title of staff preparing report, and

8) records shall be signed by management staff.

c. [T]the report shall be maintained in individual consumer records.

d. [W]when an incident involves abuse, [or ]neglect, serious illness, violations of the Provider Code of Conduct [of a consumer,] or death of a consumer, a program shall:

1) [prepare a preliminary written report within 24 hours of the incident, and]notify the Office of Licensing, legally responsible person and any applicable agency which may include law enforcement.

2) [notify the Office, the legally responsible person, and the appropriate law enforcement authority]a preliminary written report shall be submitted to the Office of Licensing within 24 hours of the incident.[

F. Intensive Supervision and Tracking: For those programs providing intensive supervision services, a designated staff member shall provide services to the consumer as frequently as determined in the treatment plan or contract. A consumer's record shall document, in activity logs, the date, amount of time spent, and the specific activity provided to the consumer. If any one consumer has more than one staff assigned to provide intensive supervision, this action shall be justified in the consumer's record and cleared by the licensed clinical supervisor.]

 

R501-2-7. Behavior Management.

A. [Behavior management methods, as described herein, are not applicable to child placing adoption agencies. ]The program shall have on file for public inspection, a written policy and procedure for the methods of behavior management. These shall include the following:

1. definition of appropriate and inappropriate behaviors of consumers,

2. acceptable staff responses to inappropriate behaviors, and

3. consequences.

B. The policy shall be provided to all staff, and staff shall receive training relative to behavior management at least annually[, or more often if needed].

C. No management person shall authorize or use, and no staff member shall use, any method designed to humiliate or frighten a consumer.

D. No management person shall authorize or use, and no staff member shall use nor permit the use of physical restraint with the exception of passive physical restraint. Passive physical restraint shall be used only as a temporary means of physical containment to protect the consumer, other persons, or property from harm. Passive physical restraint shall not be associated with punishment in any way.

E. [Staff who shall be responsible for the design and supervision of the behavior management procedure shall be at least 21 years of age.]Staff involved in an emergency safety intervention that results in an injury to a resident or staff must meet with the clinical professional to evaluate the circumstances that caused the injury and develop a plan to prevent future injuries.

F. Programs using time out or seclusion methods shall comply with the following:

1. The program will have a written policy and procedure which has been approved by the Office of Licensing to include:

a. Time-out or seclusion is only used when a child's behavior is disruptive to the child's ability to learn to participate appropriately, or to function appropriately with other children or the activity. It shall not be used for punishment or as a substitute for other developmentally appropriate positive methods of behavior management.

b. Time-out or seclusion shall be documented in detail and provide a clear understanding of the incident which resulted in the child being placed in that time-out or seclusion.

c. If a child is placed in time out or seclusion more than twice in any twenty-four hour period, a review is conducted by the clinical professional to determine the suitability of the child remaining in the program.

d. Any one time-out or seclusion shall not exceed 4 hours in duration.

e. Staff is required to maintain a visual contact with a child in time-out or seclusion at all times.

f. If there is any type of emergency such as a fire alarm, or evacuation notification, children in time-out or seclusion shall follow the safety plan.

g. A child placed in time-out or seclusion shall not be in possession of belts, matches, weapons, or any other potentially harmful objects or materials that could present a risk or harm to the child.

2. Time-out or seclusion areas shall comply with the following:

a. Time-out or seclusion rooms shall not have locking capability.

b. Time-out or seclusion rooms shall not be located in closets, bathrooms, or unfurnished basements, attic's or locked boxes.

c. A time-out or seclusion room is not a bedroom, and temporary beds, or mattresses in these areas are not allowed. Time-out and seclusion shall not preclude a child's need for sleep, or normal scheduled sleep period.

d. All time-out or seclusion rooms shall measure at least 75 square feet with a ceiling height of at least 7 feet. They shall have either natural or mechanical ventilation and be equipped with a break resistant window, mirror or camera that allows for full observation of the room. Seclusion rooms shall have no hardware, equipment, or furnishings that obstruct observation of the child, or that present a physical hazard or a suicide risk. Rooms used for time out or seclusion shall be inspected and approved by the local fire department

G. The program's licensed clinical professional shall be responsible for supervision of the behavior management procedure.

 

R501-2-8. Rights of Consumers.

A. The program shall have a written policy for consumer rights to include the following:[, numbers 10-13 do not apply to child placing adoption agencies:]

1. privacy of information and privacy for both current and closed records,

2. reasons for involuntary termination and criteria for re-admission to the program,

3. freedom from potential harm or acts of violence to consumer or others,

4. consumer responsibilities, including household tasks, privileges, and rules of conduct,

5. service fees and other costs,

6. grievance and complaint procedures,

7. freedom from discrimination,

8. the right to be treated with dignity,

9. the right to communicate by telephone or in writing with family, attorney, physician, clergyman, and counselor or case manager except when contraindicated by the licensed clinical professional[ or supervisory personnel],

10. a list of people, whose visitation rights have been restricted through the courts,

11. the right to send and receive mail providing that security and general health and safety requirements are met,

12. defined smoking policy in accordance with the Utah Clean Air Act, and

13. statement of maximum sanctions and consequences, reviewed and approved by the Office of Licensing.

B. The consumer shall be informed of this policy to his or her understanding verbally and in writing. A signed copy shall be maintained in the consumer record.

 

R501-2-9. Personnel Administration.

A. The program shall have written personnel policies and procedures to include the following:

1. employee grievances,

2. lines of authority,

3. orientation and on-going training,

4. performance appraisals,

5. rules of conduct, and

6. sexual and personal harassment.

B. The program shall have a director, appointed by the governing body, who shall be responsible for management of the program and facility. The director or [a responsible staff member]or designated management person shall be available at all times during operation of program.

C. The program shall have a personnel file for each employee to include the following:

1. application for employment,

2. applicable credentials and certifications,

3. initial medical history if directed by the governing body,

4. tuberculin test if directed by the governing body,

5. food handler permit, where required by local health authority,

6. training record,

7. annual performance evaluations,

8. I-9 Form completed as applicable,

9. comply with the provisions of R501-14 and R501-[15]18 for background screening, and

10. a signed copy of the current Department of Human Services Provider Code of Conduct.

[D. Staff shall have access to his or her personnel file in accordance with State and Federal law.

E]D. The program shall follow a written staff to consumer ratio, which shall meet specific consumer and program needs. The staff to consumer ratio shall meet or exceed the requirements set forth in the applicable categorical rules as found in R501-3, R501-7, R501-8, R501-11, and R501-16.

[F]E. The program shall employ or contract with trained or qualified staff to perform the following functions:

1. administrative,

2. fiscal,

3. clerical,

4. housekeeping, maintenance, and food service,

5. direct consumer service, and

6. supervisory.

[G]F. The program shall have a written job description for each position, which includes a specific statement of duties and responsibilities and the minimum level of education, training and work experience required.

[H]G. Treatment shall be provided or supervised by professional staff, whose qualifications are determined or approved by the governing body, in accordance with State law.

[I]H. The governing body shall ensure that all staff are certified and licensed as legally required.

[J]I. The program shall have access to a medical clinic or a physician licensed to practice medicine in the State of Utah.

[K. Nursing services, when provided, shall be in accordance with technical skills defined in the Utah Nurse Practice Act.

L]J. The program shall provide interpreters for consumers[;] or refer consumers to appropriate resources as necessary to communicate with consumers whose primary language is not English.

[M]K. The program shall retain the personnel file of an employee after termination of employment, in accordance with accepted personnel practices.

[N]L. A program using volunteers, substitutes, or student interns, shall have a written plan to include the following:

1. direct supervision by a program staff,

2. orientation and training in the philosophy of the program, the needs of consumers, and methods of meeting those needs,

3. background screening,

4. a record maintained with demographic information, and

5. signed copy of the current Department of Human Services Provider Code of Conduct.

[O]M. Staff Training

1. Staff members shall be trained in all policies of the program, including the following:

a. orientation in philosophy, objectives, and services,

b. emergency procedures,

c. behavior management,

[d. statutory responsibilities of the program, including rights for people with disabilities according to the Americans With Disabilities Act,

e]d. current program policy and procedures, and

[f]e. other relevant subjects.

2. Staff shall have completed and remain current in a certified first aid and CPR, such as or comparable to American Red Cross[ program as required].

3. Staff shall have current food handlers permit as required by local health authority.

4. Training shall be documented and maintained [in individual personnel files]on-site.

 

R501-2-10. Infectious Disease.

The program shall have policies and procedures designed to prevent or control infectious and communicable diseases in the facility in accordance with local, state and federal health standards.

 

R501-2-11. Emergency Plans.

A. The program shall have a written plan of action for disaster and casualties to include the following:

1. designation of authority and staff assignments,

2. plan for evacuation,

3. transportation and relocation of consumers when necessary, and

4. supervision of consumers after evacuation or relocation.

B. The program shall [inform]educate consumers on how to respond to fire warnings and other instructions for life safety including evacuation.

C. The program shall have a written plan which personnel follow in medical emergencies and arrangements for medical care, including notification of consumer's physician and nearest relative or guardian.[

D. Death, serious illness, or injury of a consumer or staff at the program shall be reported within 24 hours to a guardian and to the Office.]

 

R501-2-12. Safety.

A. Fire drills in non-outpatient programs, shall be conducted at least quarterly and documented. Notation of inadequate response shall be documented.

B. The program shall provide access to an operable 24-hour telephone service. Telephone numbers for emergency assistance, i.e., 911 and poison control, shall be posted.

C. The program shall have an adequately supplied first aid kit in the facility such as recommended by American Red Cross.

D. [Programs maintaining weapons at the facility shall assure that the weapons and ammunition are securely locked. Weapons kept at the facility and on the premises will be inaccessible to consumers at all times and rendered inoperable if possible]All persons associated with the program having access to children or vulnerable adults who have firearms or ammunition shall assure that they are inaccessible to consumers at all times. Firearms and ammunition that are stored together shall be kept securely locked in security vaults or locked cases, not in glass fronted display cases. Firearms that are stored in display cases shall be rendered inoperable with trigger locks, bolts removed, or other disabling methods. Ammunition for those firearms shall be kept securely locked in a separate location. This does not restrict constitution or statutory rights regarding concealed weapons permits, pursuant to UCA 53-5-701 et seq.

 

R501-2-13. Transportation.

A. The program shall have written policy and procedures for transporting consumers.

B. In each program or staff vehicle, used to transport consumers, there shall be emergency information which includes at a minimum, the name, address and phone number of the program [or]and an emergency telephone number.

C. The program shall have means, or make arrangement for, transportation in case of emergency.

D. Drivers of vehicles shall have a valid drivers license and follow safety requirements of the State.

E. Each vehicle shall be equipped with an adequately supplied first aid kit such as recommended by American Red Cross.

 

R501-2-14. Categorical [Standards]Rules.

In addition to Core [Standards]Rules, Categorical [Standards]Rules are specific regulations which must be met for the following:

A. Child Placing Adoption Agencies R501-7,

B. Day Treatment R501-20,

C. Intermediate Secure Treatment Programs for Minors R501-16,

D. Outdoor Youth Programs R501-8,

E. Outpatient Treatment R501-21,

F. [Outpatient Domestic Violence Perpetrator Treatment]Foster Care R501-12,

G. Residential Treatment R501-19,

H. Residential Support R501-22,[ and]

I. Social Detoxification R501-11[.] and

J. Assisted Living for DSPD Residential R710.

 

R501-2-15. Single Service Program [Standards]Rules.

Core [Standards]Rules of the Office of Licensing do not apply to single service programs.

Single services program [standards]Rules are the regulations which must be met for the following:

A. Adult Day Care, which [standards]Rules are found in R501-13,

B. Adult Foster Care, which [standards]Rules are found in R501-17.[, and

C. Child Foster Care, which standards are found in R501-12.]

 

KEY: licensing, human services

[May 6, 2003]2004

Notice of Continuation November 25, 2002

62A-2-101 et seq.