STATEMENT OF EMERGENCY
902 KAR 20:320E
This emergency administrative regulation is
being promulgated to address statutory changes to existing psychiatric
residential treatment facility (
ERNIE FLETCHER, Governor
JAMES W. HOLSINGER, Jr., M.D., Secretary
CABINET FOR HEALTH AND FAMILY SERVICES
Office of Inspector General
(Emergency Amendment)
902
KAR 20:320E. Psychiatric residential treatment facility operation and services.
RELATES
TO: KRS
216B.010-216B.130, 216B.450-216B.459,
216B.990, 42
C.F.R. 441.156
STATUTORY
AUTHORITY: KRS 216B.042,
216B.105, 216B.450-216B.459, 314.011(8), 314.042(8), 320.240(14), EO 2004-726
[96-862]
EFFECTIVE:
NECESSITY,
FUNCTION, AND CONFORMITY: KRS
216B.042, 216B.105
and 216B.450-216B.459
mandate that the 96-862, effective July 2, 1996, reorganizes
the Cabinet for Human Resources and places] the Office of Inspector General
and its regulatory authority [programs] under the Cabinet for
Health and Family Services.
Section 1. Definitions.
(1) "Chemical
restraint" means the use of a drug that:
1. Is administered to manage a resident's
behavior in a way that reduces the safety risk to the resident or others;
2.
Has the temporary effect of restricting the resident's freedom of movement; and
3.
Is not a standard treatment for the resident's medical or psychiatric condition.
(2) "Clinical
privileges" means authorization by the governing body to provide certain
resident care and treatment services in the facility specified by the governing
body within well-defined limits, based on the individual's license, education, training,
experience, competence, and judgment.
(3)
[(2)] "Direct-care staff" means residential or
child-care workers who directly supervise residents.
(4)
[(3)] "Freestanding" is defined in KRS 216B.450(3) [means
a completely detached building].
(5)
[(4)] "Governing body" means the individual,
agency, partnership, or corporation, in which the ultimate responsibility and
authority for the conduct of the facility is vested.
[(5)
"Holding" means forced positioning of a resident by staff without use
of mechanical devices.]
(6) "Licensure agency" means
the Cabinet for Health and Family Services, Office of Inspector General
[Division of Licensing and Regulation in the Office of the Inspector General,
Cabinet for Health Services].
(7) "Living unit" means the
area within a single building that is supplied by the facility for daily living
and therapeutic interaction of the residents. There shall be no more than nine
(9) [eight (8)] residents per living unit.
(8) "Mechanical
restraint" means any device attached or adjacent to a
resident's body that he or she cannot easily remove that restricts freedom of
movement or normal access to his or her body.
(9) [(8)] "Mental health associate" is an
individual with a minimum of a bachelor's degree in a mental health related
field; a registered nurse with at least one (1) year's experience in a
psychiatric inpatient or residential treatment setting for children; or an
individual with a high school diploma or an equivalence certificate and at
least two (2) [five (5)] years work experience in a psychiatric
inpatient or residential treatment setting for children [, two (2) years of
which shall be in a supervisory role, and shall have successfully completed the
medicine administration course approved by the Kentucky Board of Nursing for
use in child caring facilities].
(10)
[(9)]"Mental health professional" is
defined in KRS 645.020
[means a person employed and meeting requirements for a position on the
professional staff of a ].
(11) "Personal restraint"
means the application of physical force without the use of any device, for the
purposes of restraining the free movement of a resident's body and does not
include briefly holding without undue force a resident in order to calm or
comfort him or her or holding a resident's hand to safely escort him or her
from one (1) area to another.
(12) [(10)] "Psychiatric residential
treatment facility" or "(4)].
[(11)
"Restraint" means the use of a mechanical device to involuntarily
restrain movement of the whole or a portion of a resident's body as a means of
controlling a resident's physical activities to protect the resident or others
from injury or the use of intravenous, intramuscular, or subcutaneous
administration of any pharmacologic or chemical agent to the resident with the
sole or primary purpose of controlling or limiting the physical activities of
the resident. Restraint is differentiated from mechanisms usually and
customarily employed during medical, diagnostic, or surgical procedures.]
(13)
[(12)] "Seclusion" means the involuntary
confinement of a resident in a room or in an area from [,] which
the resident is physically prevented from leaving [, for any period of time].
(14)
[(13)] "Special treatment procedures" means any
procedure such as chemical restraint, mechanical restraint, personal
restraint or seclusion [and holding] which may have abuse potential or
be life threatening.
(15)
[(14)] "Unusual treatment" means any procedure not
readily accepted as a standard method of treatment by the relevant
professional.
Section 2. Applicability.
(1) A
psychiatric residential treatment facility shall be located in a freestanding
structure [eight (8) bed facility.
(a) An
entity which was licensed as a
(b) An
entity which has obtained approval for a certificate of need for a sixteen (16)
bed
(c) An
eight (8) bed ].
(2) Multiple
(3) [(2)]
If a psychiatric residential treatment facility is located on grounds shared by
another licensed facility other than a
(a) The
residents of the conducted
by a school operated by the local educational authority for residents for whom
it is determined by the local educational authority that the program provided by
the school is appropriate for all residents in the program and is provided in
accordance with Section 12(6) of this administrative regulation, or]
organized recreational activities, or group therapy for children with
similar treatment needs;
(b) Direct-care
staff of the licensed facility with which the
(c) For
continuity of care, at least fifty (50) percent of direct care staff of the ;
(d) If the
provisions of paragraph (a) of this subsection are met, the only services or
components of the physical plant that may be shared are those related to
housekeeping, maintenance, dietary and recreational facilities or grounds].
(4) [(3)]
on the same grounds in accordance
with subsection (1) of this section] may share joint activities and staff.
Section 3. Licensure.
A [The]
psychiatric residential treatment facility shall comply with all the conditions
for licensure contained in 902 KAR 20:008.
Section 4. Governing Body. A Each facility] shall have a governing
body with overall authority and responsibility for the facility's operation.
(1) The
governing body shall be a legally constituted entity in the
(2) A
facility that is part of a multifacility system or is operated by a government
agency shall have a written description of the system's administrative
structure and lines of authority.
(3) The
authority and responsibility of any person designated to function as the
governing body shall be specified in writing.
(4) If a
business relationship exists between a governing body member [member(s)]
and the organization, there shall be a conflict-of-interest policy that governs
the member's participation in decisions influenced by the business interest.
(5) The
responsibilities of the governing body shall be stated in writing and shall
describe the process for the following:
(a)
Adopting policies and procedures;
(b)
Providing sufficient funds, staff, equipment, supplies, and facilities to
assure that the facility is capable of providing appropriate and adequate
services to residents;
(c)
Overseeing the system of financial management and accountability;
(d) Adopting
a program to monitor and evaluate the quality of all care provided and to
appropriately address identified problems in care;
(e)
Electing, appointing, or employing the clinical and administrative leadership
personnel of the facility, and defining the qualifications, authority,
responsibility, and function of such positions; and
(f)
Approving employment of mental health professional staff.
(6) The
governing body shall meet as a whole at least quarterly and keep records that
demonstrate the ongoing discharge of its responsibilities.
(7) When a
facility is a component of a larger organization, the facility staff, subject
to the overall authority of the governing body, shall be given the necessary
authority to plan, organize, and operate the program.
Section 5. Program Director.
(1) A
[The] program director shall be responsible for the administrative
management of the facility.
(2) A
program director:
(a) [The
program director] Shall be qualified by training and experience to direct a
treatment program for children and adolescents with emotional problems;
[.]
(b) Shall
at least have minimum qualifications of [Minimum qualifications shall be]
a master's degree or bachelor's degree in the human services field including:
1. Social
work;
2.
Sociology;
3.
Psychology;
4.
Guidance and counseling;
5.
Education;
6.
Religion;
7.
Business administration;
8.
Criminal justice;
9. Public
administration;
10. Child
care administration;
11.
Christian education;
12.
Divinity;
13.
Pastoral counseling;
14.
Nursing; or
15. Other
human service field related to working with families and children; [.]
(c) [Applicants]
With a master's degree shall have two (2) years of prior supervisory
experience in a human services program; [, and those]
(d) With a
bachelor's degree shall have four (4) years of prior supervisory
experience in a human services program; and [.]
(e) [(d)
The program director] shall:
1.
Have three (3) professional references, two (2) personal references, and a criminal
record check performed every two (2) years through the Administrative Office of
the Courts or the Kentucky State Policy; and
2.
Not have a crime conviction, or plea of guilty, pursuant to KRS 17.165 or a Class A
felony [Have
three (3) professional references; two (2) personal references; and a police
record check.
(e) If
there is a prior crime conviction or pleas of guilty pursuant to KRS 17.165 or
a Class A felony, the applicant shall not be employed].
(3) A
[The] program director shall be responsible to the governing body in
accordance with the bylaws, rules or policies for the following:
(a)
Overseeing the overall operation of the facility, including the control,
utilization, and conservation of its physical and financial assets and the
recruitment and direction of staff;
(b)
Assuring that sufficient, qualified, and appropriately supervised staff
[meeting minimum standards under appropriate supervision] are on duty to
meet the needs of the residents at all times;
(c)
Approving purchases and payroll;
(d)
Assuring that treatment planning, medical supervision, and quality assurance
occur as specified in this administrative regulation;
(e)
Advising the governing body of all significant matters bearing on the
facility's licensure and operations;
(f) Preparing
[Preparation of] reports or items necessary to assist the governing body
in formulating policies and procedures to assure that the facility is capable
of providing appropriate and adequate services to residents;
(g) Maintaining
[Preparation of] a written manual that defines policies and procedures
which is regularly revised and updated; and
(h)
Assuring that all written facility policies, plans, and procedures are followed.
Section 6. Administration and
Operation.
(1) A Written plan.
(a) The
governing body shall formulate and specify the facility's goals and objectives
and describe its programs in a written plan so that the facility's performance
can be measured.
(b) A copy
of the written plan shall be given to each mental health professional and to
the program director.
(c) The
written plan shall be reviewed at least annually and revised as necessary, in
accordance with the changing needs of the residents and the community and with
the overall objectives and goals of the facility when reviewed or revised.
Revisions in the plan shall incorporate, as appropriate, relevant findings from
the facility's quality assurance and utilization review programs.
(d) The
written plan shall include the following]:
(a) [1.]
An organizational chart that includes position titles and the name of the
person occupying the position, and that shows the chain of command;
(b) [2.]
A service philosophy with clearly defined assumptions and values;
(c) [3.]
Estimates of the clinical needs of the children and adolescents in the area
served by the facility;
(d) [4.]
The services provided by the facility in response to needs;
(e) [5.]
The population served, including age groups and other relevant characteristics
of the resident population;
(f) [6.]
The intake or admission process, including how the initial contact is made with
resident and the family or significant others;
(g) [7.]
The assessment and evaluation procedures provided by the facility;
(h) [8.]
The methods used to deliver services to meet the identified clinical needs of
the residents served;
(i) [9.]
The methods used to deliver services to meet the basic needs of residents in a
manner as consistent with normal daily living as possible;
(j) [10.]
The methods used to create a home-like environment for all residents;
(k) [11.]
The methods, means and linkages by which the facility will involve all
residents in community activities, organization, and events;
(l) [12.]
The treatment planning process and the periodic review of therapy;
(m) [13.]
The discharge and aftercare planning processes;
(n) [14.]
The facility's therapeutic programs;
(o) [15.]
How professional services will be provided by qualified, experienced personnel;
(p) [16.]
How mental health professionals and direct-care staff who have been assigned
specific treatment responsibilities are qualified by training or experience and
demonstrated competence and have appropriate clinical privileges; or are
supervised by a mental health professional who is qualified by experience to
supervise such treatment;
(q) [17.]
How the facility will be linked to regional interagency councils, psychiatric
hospitals, community mental health centers, Department for Community Based
[Social] Services offices and facilities, and school systems in the
facility's service area; [and]
(r) [18.]
The means by which the facility provides, or makes arrangements for the
provision of:
1. [a.]
Emergency services and crisis stabilization;
2. [b.]
Discharge and aftercare planning, that promotes continuity of care; and
3. [c.]
Education and vocational services; and
(s)
Services the facility shall provide to improve stability of care and reduce
re-hospitalization including:
1.
How psychiatric and nursing coverage shall be provided to assure the continuous
ability to manage and administer medications in crisis situations but excluding
those that may only be administered by a physician; and
2.
How direct care staffing with supervision shall be provided to manage behavior
problems in accordance with the residents’ treatment plans, including an array
of interventions that are alternatives to seclusion and restraint and the staff
training necessary to implement them.
(2) The
documentation shall be:
(a)
Made available to each mental health professional and to the program director;
and
(b)
Reviewed and revised as necessary, in accordance with the changing needs of the
residents and the community and with the overall objectives and goals of the
facility when reviewed or revised. Revisions in the documentation shall
incorporate, as appropriate, relevant findings from the facility's quality
assurance and utilization review programs. [, whether provided by the facility
or by agreement. Educational services to be provided by local education agency
or a private agency, at a minimum, shall be arranged for sixty (60) days prior
to the need for the service to be provided.]
(3) [(2)]
Professional
staff.
(a) A The facility] shall:
1. Employ a
sufficient number of mental health professionals to meet the treatment
needs of residents and the goals and objectives of the facility; and [.]
2. [(b)
Mental health professionals shall meet all requirements in the licensing,
registration, or certification laws relating to their respective professions.
(c) The
facility shall] Meet the following requirements with regard to
professional staffing:
a.(i) [1.]
A board-eligible or board-certified child psychiatrist or board-certified adult
psychiatrist shall be employed to meet the treatment needs of the residents and
the functions which shall be performed by a psychiatrist specified within this
administrative regulation.
(ii) If a
facility has residents ages twelve (12) and under, the psychiatrist shall be
board-eligible or board-certified in child psychiatry.
(iii) The
psychiatrist shall be present in the facility to provide professional services
to the facility's residents at least weekly.
b. [2.
Except for a ]
A
c. [3. A
a. At
least one (1) full-time mental health professional for a
b. At
least two (2) full-time mental health professionals for a
4.] A mental
health professional shall be available to assist on-site in emergencies on at
least an on-call basis at all times.
d. [5.]
A psychiatrist [physician] shall be available on at least an
on-call basis at all times.
(b) [(d)]
Clinical director. The governing body shall designate one (1) full-time mental
health professional as clinical director for the
1. In
addition to the requirements related to his profession, the clinical director
shall have at least two (2) years of [years'] clinical experience
in a mental health setting that serves children or adolescents with emotional
problems.
2. The
governing body shall define the authority and duties of the clinical director.
3. An
individual may serve as both the clinical director and [may be]
the program director if the qualifications of both positions are met.
4. The
clinical director shall be responsible for:
a. The
maintenance of the facility's therapeutic milieu; and
b. Assuring
that treatment plans developed in accordance with Section 11(3) of this
administrative regulation are implemented.
5. A
full-time mental health professional may be designated as clinical director for
more than one (1) when more than one (1) ].
(4) [(3)]
Direct-care staff.
(a) A The facility] shall employ adequate
direct-care staff to ensure the continuous provision of sufficient regular and
emergency supervision of all residents twenty-four (24) hours a day.
(b) 1.
Direct-care staff shall have at least a high school diploma or equivalency and
two (2) years [years'] experience in a program in the mental
health field serving children or adolescents.
2.
Completion of a forty (40) [twenty-four (24)] hour training
curriculum meeting the requirements of subsection (5)(d) [(4)(c)]
within one (1) month of employment may be substituted for experience, except
that no direct-care staff so qualified shall be given clinical privileges in
his or her first year of employment.
(c) In
order to assure that the residents are adequately supervised and are cared for
in a safe and therapeutic manner, the direct-care staffing plan shall meet each
of the following requirements:
1. At
least one (1) direct-care staff member who is a mental health associate shall
be assigned direct-care responsibilities for a every eight (8) residents] at all times when residents awake and are
not in school;
2. At
least one (1) direct-care staff member [three (3) direct-care staff
members] shall be assigned to direct-care responsibilities for each
three (3) residents during normal waking hours. [during normal waking
hours when the residents are on-site; however, if the number of residents
present on-site is six (6) or fewer, the number of direct-care staff members
may be reduced to two (2);
3. At
least one (1) direct-care staff member shall be assigned to direct-care
responsibilities for each three (3) residents who are twelve (12) and under and
one (1) for each four (4) adolescents who are over twelve (12) during all hours
the residents are awake, not on the living unit, and not in school;]
3. a. [4.]
At least one (1) direct-care staff member shall be assigned direct-care
responsibilities, be awake, and be continuously available on each living unit
during all hours the residents are asleep.
b. A minimum
of one (1) additional direct-care staff member who is a mental health associate
shall be immediately available on the grounds of the
4. [5.]
If a mental health professional is directly involved in an activity with a
group of residents, he or she may meet the requirement for a direct-care
staff member; and
5. [6.]
The direct-care staff member who is supervising residents shall know the
whereabouts of each resident at all times.
(d)
Written policies and procedures approved by the governing body shall:
1. Specify
the clinical privileges, if any, of each member of the direct-care staff;
2. Provide
for the supervision of the direct-care staff; and
3.
Describe the responsibilities of direct-care staff in relation to professional
staff.
(5) [(4)]
Staff development.
(a) Staff
development programs shall be provided and documented for administrative,
professional, direct-care, and support staff.
(b) Full-time
professional and direct-care staff shall meet the continuing education
requirements of their profession or be provided with forty (40) [twenty
(20)] hours per year of in-service training [by the facility.]
(c)
Part-time staff shall have at least twenty-four (24) hours of annual training
specific to tasks to be performed.
(d) [(c)]
Each staff member working directly with residents shall receive annual
training [demonstrate basic knowledge] in the following areas:
1. Child
and adolescent growth and development;
2.
Emergency and safety procedures;
3.
Behavior management, including de-escalation training; and
4. Detection
and reporting of child abuse or neglect.
[2.
Therapeutic principles and modalities used in the facility;
3.
Building and maintaining a positive therapeutic milieu on the living unit;
4.
Techniques of group and child management; and
5.
Detection and reporting of child abuse and neglect.]
(6) [(5)]
Employment practices.
(a) A The facility] shall have employment
and personnel policies and procedures designed, established, and maintained to promote
the objectives of the facility, to ensure that an adequate number of qualified
personnel under appropriate supervision is provided during all hours of
operation, and to support quality of care and functions of the facility.
(b) The personnel
policies and procedures shall be written, systematically reviewed, and approved
on an annual basis by the governing body, and dated to indicate the time of
last review.
(c) The personnel
policies and procedures shall provide for the recruitment, selection, promotion,
and termination of staff.
(d) The
1.a. [facility
shall] Maintain job descriptions approved by the governing body for all
positions specifying the qualifications, duties, and supervisory relationship
of the position.
b. Job
descriptions shall accurately reflect the actual job situation and shall be
revised whenever a change is made in the required qualifications, duties,
supervision, or any other major job-related factor. In addition, salary range
for each position shall be provided.
2.a.
Provide a personnel orientation to all new employees.
b. [(e)]
The personnel policies and procedures shall be available and apply to all
employees and shall be discussed with all new employees.
c. The
governing body shall establish a mechanism for notifying employees of changes
in the personnel policies and procedures.
(e) [(f)]
Information on the following shall be included in the personnel policies
and procedures:
1. Employee benefits;
2. Recruitment;
3. Promotion;
4. Training and staff development;
5. Employee grievances;
6. Safety and employee injuries;
7. Relationships with employee
organizations;
8. Disciplinary systems;
9. Suspension and termination mechanisms;
10. Rules of conduct;
11. Lines of authority;
12. Performance appraisals;
13. Wages, hours and salary
administration; and
14. Equal employment opportunity and,
when required, affirmative action policies.
(f) [(g)]
The personnel policies and procedures shall describe methods and procedures for
supervising all personnel, including volunteers.
(g) [(h)]
The personnel policies and procedures shall require appropriate criminal
history and police record checks for all staff and volunteers to assure that
only persons whose presence does not jeopardize the health, safety, and welfare
of residents are employed and used.
(h) [(i)]
The personnel policies and procedures shall provide for reporting and
cooperating in the investigation of suspected cases of child abuse and neglect
by facility personnel.
(i) [(j)]
A personnel record shall be kept on each staff member and shall contain the
following items:
1. Application for employment;
2. Written references and a record of
verbal references;
3. Verification of all training and
experience and of licensure, certification, registration, or renewals;
4. Wage and salary information, including
all adjustments;
5. Performance appraisals;
6. Counseling actions;
7. Disciplinary actions;
8. Commendations;
9. Employee incident reports; and
10. Record of health exams related to
employment [Initial and subsequent health clearances].
(j) [(k)]
The personnel policies and procedures shall assure the confidentiality
of personnel records and specify who has access to various types of personnel
information.
(k) [(l)]
Performance appraisals shall relate job description and job performance and
shall be written. The criteria used to evaluate job performance shall be
objective.
Section 7. Resident Rights.
(1) A The facility] shall support and protect
the basic human, civil, and constitutional rights of the individual resident.
(2)
Written policy and procedure approved by the governing body shall provide a
description of the resident's rights and the means by which these rights are
protected and exercised.
(3) At the
point of admission, a PRFT [the facility] shall provide the
resident and parent, guardian, or custodian with a clearly written and readable
statement of rights and responsibilities. The statement shall be read to the
resident or parent, guardian, or custodian if either cannot read and shall
cover, at a minimum:
(a) Each
resident's right to access [to] treatment, regardless of race,
religion, or ethnicity;
(b) Each
resident's right to recognition and respect of his personal dignity in the
provision of all treatment and care;
(c) Each
resident's right to be provided treatment and care in the least restrictive
environment possible;
(d) Each
resident's right to an individualized treatment plan;
(e) Each
resident's and family's right to participate [participation] in
planning for treatment;
(f) The
nature of care, procedures, and treatment that the resident [he]
shall receive;
(g) The right
to informed consent related to the risks, side effects, and benefits of all
medications and treatment procedures used; and
(h) The
right, to the extent permitted by law, to refuse the specific medications or
treatment procedures and the responsibility of the facility when the resident
refuses treatment, to seek appropriate legal alternatives or orders of
involuntary treatment, or, in accordance with professional standards, to
terminate the relationship with the resident upon reasonable notice.
(4) The
rights of residents shall be written in language which is understandable to the
resident, his or her parents, custodians, or guardians and shall be
posted in appropriate areas of the facility.
(5) The
policy and procedure concerning resident rights shall assure and protect the
resident's personal privacy within the constraints of his treatment plan. These
rights to privacy shall at least include:
(a)
Visitation by the resident's family or significant others in a suitable private
area of the facility;
(b)
Sending and receiving mail without hindrance or censorship; and
(c)
Telephone communications with the resident's family or significant others at a
reasonable frequency.
(6) If any
rights to privacy shall [must] be limited, the resident and his or
her parent, guardian, or custodian shall receive a full explanation.
Limitations shall be documented in the resident's record and their therapeutic
effectiveness shall be evaluated and documented by professional staff every
seven (7) days.
(7) The
right to initiate a complaint or grievance procedure and the means for
requesting a hearing or review of a complaint shall be specified in a written
policy approved by the governing body and made available to residents, parents,
guardians, and custodians responsible for the resident. The procedure shall
indicate:
(a) To
whom the grievance is to be addressed; and
(b) Steps
to be followed for filing a complaint, grievance, or appeal.
(8) The
resident and his or her parent, guardian, or custodian shall be informed
of the current and future use and disposition of products of special observation
and audio-visual techniques such as one (1) way vision mirrors, tape recorders,
videotapes, monitors, [television, movies,] or photographs.
(9) The
policy and procedure regarding resident's rights shall ensure the resident's
right to confidentiality of all information recorded in his or her
record maintained by the facility. The facility shall ensure the initial and
continuing training of all staff in the principles of confidentiality and
privacy.
(10) A
[The] resident shall be allowed to work for the facility only under the
following conditions:
(a) The
work is part of the individual treatment plan;
(b) The
work is performed voluntarily;
(c) The
patient receives wages commensurate with the economic value of the work;
(d) The
work project complies with applicable law and administrative regulation; and
(e) The
performance of tasks related to the responsibilities of family-like living,
such as laundry and housekeeping, shall not be considered work for the facility
and need not be compensated or voluntary.
(11)
Written policy [and procedure] developed in consultation with
professional and direct care staff and approved by the governing body shall
provide for the measures utilized by the facility to discipline residents.
These measures shall be fully explained to each resident and the resident's
parent, guardian, or custodian.
(12) A The facility] shall prohibit all
cruel and unusual disciplinary measures including the following:
(a)
Corporal punishment;
(b) Forced
physical exercise;
(c) Forced
fixed body positions;
(d) Group
punishment for individual actions;
(e) Verbal
abuse, ridicule, or humiliation;
(f) Denial
of three (3) balanced nutritional meals per day;
(g) Denial
of clothing, shelter, bedding, or personal hygiene needs;
(h) Denial
of access to educational services;
(i) Denial
of visitation, mail, or phone privileges for punishment;
(j)
Exclusion of the resident from entry to his assigned living unit; and
(k)
Restraint or seclusion as a punishment or employed for the convenience of staff.
(13)
Written policy shall prohibit residents from administering disciplinary
measures upon one another and shall prohibit persons other than professional or
direct-care staff from administering disciplinary measures to residents.
(14) a.
Written rules of resident conduct shall be developed in consultation with the
professional and direct-care staff and be approved by the governing body.
b. Residents
shall participate in the development of the rules to a reasonable and
appropriate extent.
c. These
rules shall be based on generally acceptable behavior for the resident
population served.
(15) The
application of disciplinary measures shall relate to the violation of
established rules.
Section 8. Resident Records.
(1) A
(a) [The
facility shall] Have written policies [or procedures] concerning
resident records [developed in consultation with professional staff and a
registered records administrator and] approved by the governing body;
and [.]
(b) [(2)
The facility shall] Maintain a written resident record on each resident, to
be directly accessible to staff members caring for the resident.
(2) [(3)]
The resident record shall contain at a minimum:
(a) Basic
identifying information;
(b) Appropriate
court orders or consent of appropriate family members or guardians for
admission, evaluation, and treatment;
(c) A
provisional or admitting diagnosis which includes a physical diagnosis, if
applicable, as well as a psychiatric diagnosis;
(d) The
report by the parent, guardian, or custodian of the patient's immunization
status;
(e) A
psychosocial assessment of the resident and his family, including:
1. An
evaluation of the effect of the family on the resident's condition and the
effect of the resident's condition on the family; and
2. A
summary of the resident's psychosocial needs.
(f) An
evaluation of the resident's growth and development, including physical,
emotional, cognitive, educational, and social development; and needs for play
and daily activities;
(g) The
resident's legal custody status, when applicable;
(h) The
family's, guardian's, or custodian's expectations for, and involvement in, the
assessment, treatment, and continuing care of the resident;
(i)
Physical health assessment, including evaluations of the following:
1. Motor
development and functioning;
2.
Sensorimotor functioning;
3. Speech,
hearing, and language functioning;
4. Visual
functioning; and
5.
Immunization status.
(3) [(4)]
The resident record shall also include:
(a)
Physician's notes which shall include an entry made at least weekly by the
staff psychiatrist regarding the condition of the resident.
(b)
Professional progress notes which shall be completed following each
professional service except when the service is provided daily to groups of
residents, when weekly summaries may be used. Professional progress notes shall
be signed and dated by the mental health professional who provided the service.
(c) 1. Direct-care progress notes
which shall record implementation of all treatment and any unusual or
significant events which occur for the residents.
2.
Direct-care progress notes shall be completed at least by the end of each
direct-care shift and summarized weekly.
3.
Direct-care notes shall be signed and dated by the direct-care staff making the
entry.
(d)
Special clinical justifications for the use of special and unusual treatment
procedures and reports.
(e)
Discharge summary.
(f) If a
patient dies, the resident record shall include a summation statement in the
form of a discharge summary, including events leading to the death, signed by
the attending physician.
(4) A (5) The facility] shall
maintain confidentiality of resident records. Resident information shall be
released only on written consent of the resident or his parent, guardian, or
custodian or as otherwise authorized by law. The written consent shall contain
the following information:
(a) The
name of the person, agency, or organization to which the information is to be
disclosed;
(b) The specific
information to be disclosed;
(c) The
purpose of disclosure; and
(d) The
date the consent was signed and the signature of the individual witnessing the
consent.
Section 9. Quality Assurance.
(1) A The facility] shall have an organized
quality assurance program designed to enhance resident treatment and care
through the ongoing objective assessment of important aspects of resident care
and the correction of identified problems.
(2) A The facility] shall prepare a
written quality assurance plan designed to ensure that there is an ongoing
quality assurance program that includes effective mechanisms for reviewing and
evaluating resident care, and that provides for appropriate response to
findings.
(3) A The facility] shall record all
incidents or accidents that present a direct or immediate threat to the health,
safety or security of any resident or staff member. Examples of incidents to be
recorded include the following: physical violence, fighting, absence without leave,
use or possession of drugs or alcohol, or inappropriate sexual behavior. The
record should be kept on file and retained at the facility and shall be made
available for inspection by the licensure agency.
Section 10. Admission Criteria.
(1) A The facility] shall have written
admission criteria approved by the governing body and which are consistent with
the facility's goals and objectives.
(2)
Admission criteria shall be made available to referral sources and to parents,
guardians, or custodians and shall include:
(a) Types
of admission (crisis stabilization, long-term treatment);
(b) Age
and sex of accepted;
(c)
Criteria that preclude admission;
(d)
Clinical needs and problems typically addressed by the facility's programs and
services;
(e)
Criteria for discharge; and
(f) Any
preplacement requirements of the resident, his parents, guardians, custodians,
or the placing agency.
(3) (a) Residents admitted to a the facility] shall have obtained age
six (6), but not attained age eighteen (18).
(b) Residents
may remain in care until age twenty-one (21) if admitted by their 18th
birthday.
(c) Admission
criteria related to age at admission shall be determined by the age grouping of
children currently in residence and shall reflect a range no greater than five
(5) years in a living unit.
(4)
Children and adolescents who are a danger to self or others for whom the
facility is unable to develop a risk-management plan shall not be admitted.
Section 11. Resident Management.
(1)
Intake.
(a) A The facility] shall have written
policies and procedures approved by the governing body for the intake process
which addresses at a minimum the following:
1. Referral,
records, and statistical data to be kept regarding applicants for residence;
2.
Criteria for determining the eligibility of individuals for admission;
3. Methods
used in the intake process which shall be based on the services provided by the
facility and the needs of residents; and
4.
Procurement of appropriate consent forms. This may include the release of
educational and medical records.
(b) [The
intake process shall include an initial assessment of the resident performed by
a mental health professional. The results of the assessment shall be explained
to the parent or guardian or custodian if appropriate, and to the resident. As
a condition at admission, the assessment shall conclude that:
1. The
treatment required by the resident is appropriate to the intensity and
restrictions of care provided by the facility; and
2.
Alternatives for less intensive and restrictive treatment are not available or
accessible to the resident.
(c)] The
intake process shall be designed to provide at least the following information:
1.
Identification of agencies who have been involved in the treatment of the
resident in the community and the anticipated extent of involvement of those
agencies during and after the resident's stay in the facility;
2. Legal,
custody and visitation orders; and
3.
Proposed discharge plan and anticipated length of stay.
(c) [(d)]
The intake process shall include an orientation for the parent, guardian, or
custodian as appropriate and the resident which includes the following:
1. The rights
and responsibilities of residents, including the rules governing resident
conduct and the types of infractions that can result in disciplinary action or
discharge from the facility;
2. Rights,
responsibilities, and expectations of the parent, guardian, or custodian; and
3.
Preparation of the staff and residents of the facility for the new resident.
(d) [(e)]
Upon admission each resident of school age shall have been certified or be
referred for assessment as a child with a disability pursuant to 20
U.S.C. 1400.
(2)
Assessment.
(a) A
complete evaluation and assessment shall be performed for each resident which
includes, but is not necessarily limited to, physical, emotional, behavioral,
social, recreational, educational, legal, vocational, and nutritional needs.
(b) The
physical examination of each resident shall be initiated within twenty-four
(24) hours after admission and shall include, but not be limited to, evaluations
of the following:
1. Motor
development and functioning;
2.
Sensorimotor functioning;
3. Speech,
hearing, and language functioning;
4. Visual
functioning; and
5.
Immunization status. If a resident's immunization is not complete as defined in
the report of the Committee on Infectious Diseases of the
(c) If the
resident has had a complete physical examination by a qualified physician
within the previous three (3) months which includes the requirements of
subsection (b) of this section and if the facility obtains complete copies of
the record, that examination may be used to meet the requirement for a physical
examination in subsection (b) of this section.
(d) A
physician shall be responsible for assessing each resident's physical health,
his need for a current examination in spite of one done in the prior three (3)
months, and his need for special clinical examinations and tests within
twenty-four (24) hours of admission.
(e)
Facilities shall have all the necessary diagnostic tools and personnel
available or have written agreements with another organization to provide
physical health assessments, including electroencephalographic equipment, a
qualified technician trained in dealing with children and adolescents, and a
properly qualified physician to interpret electroencephalographic tracing of
children and adolescents.
(f) An
emotional and behavioral assessment of each resident that includes an
examination by a psychiatrist shall be completed and entered in the resident's
record. The emotional and behavioral assessment shall include the following:
1. A
history of previous emotional, behavioral, and substance abuse problems and
treatment;
2. The
resident's current emotional and behavioral functioning;
3. A
direct psychiatric evaluation;
4. When
indicated, psychological assessments, including intellectual, projective, and
personality testing;
5. When
indicated, other functional evaluations of language, self-care, and
social-affective and visual-motor functioning; and
6. An
evaluation of the developmental age factors of the resident.
(g) The
facility shall have an assessment procedure for the early detection of mental
health problems that are life threatening, are indicative of severe personality
disorganization or deterioration, or may seriously affect the treatment or
rehabilitation process.
(h) A
social assessment of each resident shall be undertaken and include:
1.
Environment and home;
2.
Religion;
3.
Childhood history;
4.
Financial status;
5. The
social, peer-group, and environmental setting from which the resident comes;
and
6. The
resident's family circumstances, including the constellation of the family
group; the current living situation; and social, ethnic, cultural, emotional,
and health factors, including drug and alcohol use.
(i) The
social assessment shall include a determination of the need for participation
of family members or significant others in the resident's treatment.
(j) An
activities assessment of each resident shall include information relating to
the individual's current skills, talents, aptitudes, and interest.
(k) An
assessment shall be performed to evaluate the resident's potential for
involvement in community activity, organizations, and events.
(l) For
adolescents age sixteen (16) and older, a vocational assessment of the resident
shall be done which includes the following:
1.
Vocational history;
2.
Education history, including academic and vocational training; and
3. A
preliminary discussion, between the resident and the staff member doing the assessment,
concerning the resident's past experiences with and attitude toward work,
present motivations or areas of interest, and possibilities for future
education, training, and employment.
(m) When
appropriate, a legal assessment of the resident shall be undertaken and shall
include the following:
1. A legal
history; and
2. A
preliminary discussion to determine the extent to which the legal situation
will influence his progress in treatment and the urgency of the legal
situation.
(3)
Treatment plans.
(a) 1.
Within seventy-two (72) hours following admission, a mental health professional
shall develop an initial treatment plan that is based at least on an assessment
of the resident's presenting problems, physical health, and emotional and
behavioral status.
2.
Appropriate therapeutic efforts shall begin before a master treatment plan is
finalized.
(b) A
master treatment plan shall be developed by a multidisciplinary team conference
in conformity with 42
C.F.R. 441.156 within ten (10) days of admission for any resident remaining
in treatment. It shall be based on the comprehensive assessment of the
resident's needs completed pursuant to subsection (2) of this section, include
a substantiated diagnosis and the short-term and long-range treatment needs,
and address the specific treatment modalities required to meet the resident's
needs.
1. The
treatment plan shall contain specific and measurable goals for the resident to
achieve.
2. The
treatment plan shall describe the services, activities, and programs to be
provided to the resident, and shall specify staff members assigned to work with
the resident and the time or frequency for each treatment procedure.
3. The
treatment plan shall specify criteria to be met for termination of treatment.
4. The
treatment plan shall include any referrals necessary for services not provided
directly by the facility.
5. The
resident shall participate to the maximum extent feasible in the development of
his treatment plan, and such participation shall be documented in the
resident's record.
6. a. [The treatment plan shall
specify the ways in which the resident will participate in community
activities, organizations, and events.
7. The treatment plan shall
address ways in which the environment for the resident is normalized.
8.] A specific plan for
involving the resident's family or significant others shall be included in the
treatment plan.
b. The
parent, guardian, or custodian shall be given the opportunity to participate in
the multidisciplinary treatment plan conference where feasible and shall be
given a copy of the resident's master treatment plan.
c. The
master treatment plan shall identify the mental health professional who is responsible
for coordinating and facilitating the family's involvement throughout
treatment.
7. [9.]
The treatment plan shall be reviewed and updated through multidisciplinary team
conferences as clinically indicated, but in no case shall this review and update
be completed later than thirty (30) days following the first ten (10) days of
treatment and every sixty (60) days thereafter.
8. [10.]
Following one (1) year of continuous treatment, the review and update may be
conducted at three (3) month intervals.
(c) The
master treatment plan and each review and update shall be signed by the
participants in the multidisciplinary team conference that developed it.
(4)
Progress notes.
(a)
Progress notes shall be entered in the resident's records, be used as a basis
for reviewing the treatment plan, signed and dated by the individual making the
entry and shall include the following:
1.
Documentation of implementation of the treatment plan;
2.
Chronological documentation of all treatment provided to the resident and
documentation of the resident's clinical course; and
3.
Descriptions of each change in each of the resident's conditions.
(b) All
entries involving subjective interpretation of the resident's progress shall be
supplemented with a description of the actual behavior observed.
(c)
Efforts shall be made to secure written progress reports for residents
receiving services from outside sources and, if [when]
available, to include them in the resident record.
(d) The
resident's progress and current status in meeting the goals and objectives of
his or her treatment plan shall be regularly recorded in the resident
record.
(5) Discharge planning. A The facility] shall have written
policies and procedures for discharge of residents.
(a) 1. Discharge planning shall begin
at admission and be documented in the resident's record.
2. At least
ninety (90) days prior to the planned discharge of a resident from the
facility, or within ten (10) days after admission if the anticipated length of
stay is under ninety (90) days, the multidisciplinary team shall formulate a
discharge and aftercare plan.
3. This plan
shall be maintained in the resident's record and reviewed and updated with the
master treatment plan.
(b) All discharge
recommendations shall be determined through a conference, including the
appropriate facility staff, the resident, the resident's parents, guardian, or
custodian and, if indicated, the representative of the agency to whom the
resident may be referred for any aftercare service [aftercare
service(s)], and the affected local school districts. All aftercare plans
shall delineate those parties responsible for the provision of aftercare
services.
(c) If the
aftercare plan involves placement of the resident in another licensed program
following discharge, facility staff shall share resident information with
representatives of the aftercare program provider if authorized by written
consent of the parent, guardian, or custodian.
(d) A
facility deciding to release a resident on an unplanned basis shall:
1. Have
reached the decision to release at a multidisciplinary team conference chaired
by the clinical director that determined, in writing, that services available
through the facility cannot meet the needs of the resident;
2. Provide
at least ninety-six (96) hours notice to the resident's parent, guardian, or
custodian and the agency which will be providing aftercare services. If
authorized by written consent of the parent, guardian, or custodian, the facility
shall provide to the receiving agency copies of the resident's records and
discharge summary; and [.]
3. Consult
with the receiving agency in situations involving placement for the purpose of
ensuring that such placement reasonably meets the needs of the resident [;
and
4. Provide
a written statement explaining the reasons for discharge to the receiving
agency].
(e) Within
fourteen (14) days of a resident's discharge from the facility, the facility
shall compile and complete a written discharge summary for inclusion in the
resident's record. The discharge summary shall include:
1. Name,
address, phone number, and relationship of the person to whom the resident was
released;
2.
Description of circumstances leading to admission of the resident to the facility;
3.
Significant problems of the resident;
4.
Clinical course of the resident's treatment;
5.
Assessment of remaining needs of the resident and alternative services
recommended to meet those needs;
6. Special
clinical management requirements including psychotropic drugs;
7. Brief
descriptive overview of the aftercare plan designed for the resident; and
8.
Circumstances leading to the unplanned or emergency discharge of the resident,
if applicable.
[(6)
The facility shall request periodic follow-up reports from each agency
providing services to the resident in accordance with the aftercare plan, and
shall be responsible for documenting the outcome of the aftercare plan as
possible.]
Section 12. Services. A The facility] shall provide the
following services in a manner which takes into account and addresses the
social life; emotional, cognitive, and physical growth and development; and the
educational needs of the resident. Services shall include the opportunity for
the resident to participate in community activities, organizations and events
and shall provide a normalized environment for the resident.
(1) Mental
health services.
(a) Mental
health assessments and evaluations shall be provided as required in Section 11
of this administrative regulation.
(b) The
mental health services available through the residential treatment facility] shall include the services listed
below. These mental health services shall be provided by staff of the residential treatment facility]:
1. (i) Case coordination services
to assure the full integration of all services provided to each resident.
(ii) Case
coordination activities include monitoring the resident's daily functioning to
assure the continuity of service in accordance with the resident's treatment
plan and ensuring that all staff responsible for the care and delivery of
services actively participate in the development and implementation of the
resident's treatment plan.
2. (i) Planned on-site verbal
therapies including formal individual, family, and group therapies.
(ii) These
therapies include psychotherapy and other face-to-face verbal contacts between
staff and the resident which are planned to enhance the resident's
psychological and social functioning as well as to facilitate the resident's
integration into a family unit.
(iii) Verbal
contacts that are incidental to other activities are excluded from this
service.
3. (i)
Task and skill training to enhance a resident's age appropriate skills
necessary to facilitate the resident's ability to care for himself and to
function effectively in community settings.
(ii) Task and
skill training activities include homemaking, housekeeping, personal hygiene,
budgeting, shopping, and the use of community resources.
(2) Physical health services.
(a) The
physical health services available through the residential treatment] facility shall include the services listed
below. Physical health services may be provided directly by the facility or may
be provided by written agreement.
1.
Assessments and evaluations as required in Section 11 of this administrative
regulation;
2.
Diagnosis, treatment, and consultation for acute or chronic illnesses occurring
during the resident's stay at the facility or for problems identified during an
evaluation;
3.
Preventive health care services to include periodic assessments in accordance
with the periodicity schedule established by the
4. A
dental examination within six (6) months of admission, periodic assessments in
accordance with the periodicity schedule established by the American Dental
Association, and treatment as needed;
5. Health
and sex education; and
6. An ongoing
immunization program.
(b) When
physical health services are provided by written agreement with a provider of
services other than the facility, the written agreement shall, at a minimum,
address:
1.
Referral of residents;
2.
Qualifications of staff providing services;
3.
Exchange of clinical information; and
4.
Financial arrangements.
(3)
Dietary services.
(a) A The facility] shall have written
policies and procedures approved by the governing body for the provision of
dietetic services for staff and residents which may be provided directly by the
facility staff or through written contractual agreement.
(b)
Adequate staff, space, equipment, and supplies shall be provided for safe
sanitary operation of the dietetic service, the safe and sanitary handling and
distribution of food, the care and cleaning of equipment and kitchen area, and
the washing of dishes.
(c) The
nutritional aspects of resident's care shall be planned, reviewed, and
periodically evaluated by a qualified dietician registered by the Commission on
Dietetic Registration and employed by the facility as a staff member or
consultant.
(d) The
food shall be served to residents and staff in a common eating place and:
1. Shall
account for the special food needs and tastes of residents;
2. Shall
not be withheld as punishment; and
3. Shall
provide for special dietary need of residents such as those relating to
problems, such as diabetes and allergies.
(e)
Residents shall participate in the preparation and serving of food as
appropriate.
(f) At
least three (3) meals per day shall be served with not more than a fifteen (15)
hour span between the substantial evening meal and breakfast. The facility
shall arrange for and make provision for between-meal and unscheduled snacks.
(g) Except
for school lunches and meals at restaurants, all members of a living unit shall
be provided their meals together as a therapeutic function of the living unit.
(4)
Emergency services.
(a) A The facility] shall provide for the
prompt notification of the resident's parents, guardian, or custodian in case
of serious illness, injury, surgery, or death.
(b) The
facility shall provide or arrange for the training of all direct-care and
professional staff in first aid and CPR.
(c) 1. All staff shall be knowledgeable
of a written plan and procedure for meeting potential disasters and emergencies
such as fires or severe weather.
2. The plan
shall be posted.
3. Staff
shall be trained in properly reporting a fire, extinguishing a small fire, and
in evacuation from the building.
4. Fire
drills shall be practiced in accordance with state fire administrative
regulations.
(d) The
facility shall have written procedures to be followed by staff in the event of
a psychiatric, medical, or dental emergency of a resident that specifies:
1.
Notification of designated member of the facility's chain of command;
2.
Designation of staff person who shall decide to refer resident to outside
treatment resources;
3.
Notification of resident's parent, guardian, or custodian;
4. Transportation
to be used;
5. Staff
member to accompany resident;
6.
Necessary consent and referral forms to accompany resident; and
7. Name,
location, and telephone of designated treatment resources.
(e) The facility
shall have designated treatment resources who shall have agreed to accept a
resident for emergency treatment. At a minimum the resources shall include:
1.
Licensed physician and an alternate designee;
2.
Licensed dentist and an alternate designee;
3.
Licensed hospital; and
4.
Licensed hospital with an accredited psychiatric unit.
(5)
Pharmacy services. A The
facility] shall have written policies and procedures approved by the
governing body for proper management of pharmaceuticals that are consistent
with the following requirements:
(a) 1. Medications shall be administered
by a registered nurse, physician, or dentist, except in the case of a licensed
practical nurse, certified medication aide, or direct care staff under the
supervision of a registered nurse.
2. Direct
care staff who administer medications shall have successfully completed a
[the] medicine administration course approved by the Kentucky Board of
Nursing [for use in child caring facilities];
(b)
Medications shall not be given without a written order signed by a physician,
or dentist when applicable, or advanced registered nurse practitioner as
authorized in KRS 314.011(8)
and 314.042(8), or therapeutically-certified optometrist as authorized in KRS 320.240(14). Telephone
orders for medications shall be given only to licensed [registered]
nurses or a pharmacist and signed by the physician, dentist, advanced
registered nurse practitioner or therapeutically-certified optometrist within
twenty-four (24) hours from the time the order is given;
(c)
Psychotropic medications shall be prescribed only when clinically indicated as
one (1) facet of a program of therapy. The facility shall ensure that no
stimulant or psychotropic medication is administered solely for the purpose of
program management or control, and that no medication is prescribed for the
purposes of experimentation or research;
(d) All
medications shall require "stop orders";
(e) All
prescriptions shall be reevaluated by the prescriber prior to its renewal;
(f) There
shall be a systematic method for prescribing, ordering, receipting, storing,
dispensing, administering, distributing and accounting for all medications;
(g) The
facility shall provide maximum security storage of and accountability for all
legend medications, syringes, and needles;
(h)
Self-administration of medication shall be permitted only when specifically ordered
by the responsible physician and supervised by a member of the professional
staff or a mental health associate. Drugs to be self-administered shall be
stored in a secured area and be made available to the resident at the time of
administration;
(i)
Residents permitted to self-administer drugs shall be counseled regarding the
indications for which the drugs are to be used, the primary side effects, and
the physical dosage forms which are to be administered;
(j) Drugs
brought into the facility by residents shall not be administered unless they
have been identified and unless written orders to administer these specific
drugs are given by the responsible physician. Otherwise these drugs are to be
packaged, sealed, and stored, and, if approved by the responsible physician,
returned to the resident, parent, guardian, or custodian at the time of
discharge.
(6)
Education and vocational services.
(a)
Educational and vocational services available through a the facility] shall include the
minimum requirements of Kentucky Revised Statutes and federal laws and
regulations regarding regular education, vocational education, and special
education as appropriate to meet the needs of the residents.
1.
Educational services may be provided by:
a. The
facility;
b. The
local school district in which the facility is located; or
c. A
nonpublic school program which is specially accredited and approved by the
Kentucky Department of Education to provide special education services to
students with disabilities.
2. If the
educational services are provided by the facility, the school program must be
specially accredited and approved by the Kentucky Department of Education to
provide special education services to students with disabilities.
3.
Educational services provided by a local school district may be provided within
the facility or within the local school district.
4. The
facility's multidisciplinary team shall make a recommendation concerning the
delivery site of educational services provided by a local school district that
is based on least restrictive environment determinations for individual
residents.
5. [In
any case,] Education services approved by the Department of Education shall
be available either on the same site or in close physical proximity to the residential treatment facility].
(b) If
[When] the education services are not provided directly by the facility,
there shall be a written plan for the provision of education services. The
education provider shall be a state education department-approved program. The
written plan shall, at a minimum, address:
1.
Qualifications of staff providing educational services;
2.
Participation of educational and vocational staff in the treatment planning
process;
3. Access by
staff of the facility to educational and vocational programs and records; and
4.
Financial and service arrangements.
(c) The
facility shall ensure that residents have opportunities to be educated in the
least restrictive environment consistent with the treatment needs of the
resident as determined by the multidisciplinary team and reflected in the
resident's master treatment plan.
(d) Upon
admission each resident of school age shall have been certified or be referred
for assessment as a child with a disability pursuant to 20
U.S.C. 1400.
(e) The
facility shall ensure that education services are developed and implemented with
input from the child's education staff in conjunction with the master
treatment plan and meet the following requirements:
1. [The
resident's teacher shall be a member of the multidisciplinary team, when
possible.
2.] Each
resident's master treatment plan shall include formal academic goals for remediation
and continuing education.
2. a. [3.]
Each resident eligible for special education services to the handicapped shall
have treatment activities developed by the multidisciplinary team, which may be
incorporated into the individualized treatment plan developed by the local
school district.
b. The
multidisciplinary team shall develop treatment activities which extend into the
classroom as appropriate.
c. The
program director or designee shall request an invitation to attend all
individualized treatment plan meetings.
d. If
allowed, the program director or designee shall attend all individualized
treatment plan meetings.
3. [4.]
To avoid unnecessary duplication and make maximum use of resources, the
services provided by the education and treatment components for children with
disabilities pursuant to 20 U.S.C. 1400. shall be
developed with the opportunity for input from both parties.
(f) 1. The facility shall provide or
arrange for vocational services for residents, as is age appropriate and is in
accordance with the master treatment plan.
2. The
services shall be planned, implemented and supervised by a vocational counselor
or appropriate therapist who may be a full- or part-time employee of the
facility or a consultant.
(g)
Residents may be permitted to accumulate earnings in a bank account established
with the resident by the facility.
(7) Activity services.
(a) A daily
schedule of planned recreational activities shall be prepared for the approval
of the clinical director prior to implementation of the schedule.
1. The
schedule shall be for normal waking hours that residents are not in school, or
in active treatment.
2. The
schedule shall include a full range of activities including physical
recreation, team sports, art, and music; attendance at recreational and
cultural events in the community; and individualized, directed activities like
reading and crafts.
3. Nondirected
leisure time shall be limited to two (2) one-half (1/2) hour periods on school
days and three (3) one-half (1/2) hour periods on nonschool days.
4. The
activity schedule shall identify the professional or direct-care staff who will
lead and support each activity.
5. Changes
made to the schedule as the schedule is implemented shall be indicated on a
copy of each daily schedule maintained as a permanent record by the clinical
director.
(b)
Appropriate time, space, and equipment shall be provided by the facility for
leisure activity and free play.
(c) The
facility shall provide the means of observing holidays and personal milestones
in keeping with the cultural and religious background of the residents.
(8)
Speech, language, and hearing services. A The facility] shall provide or arrange for speech, language, and
hearing services to meet the identified needs of residents. These services
shall be provided by the facility or through written agreement with a qualified
speech-language and hearing clinician. The written agreement shall, at a
minimum, address:
(a) Referral of residents;
(b) Qualifications of staff providing
services;
(c) Exchange of clinical information; and
(d) Financial arrangements.
Section 13. Special Treatment
Procedures.
(1)
Special treatment procedures include procedures such as restraint or seclusion
[and holding] which may have abuse potential or be life threatening.
Special treatment shall be used only as a means to prevent a resident from
injuring himself, herself, or others [or to prevent serious
disruption of the therapeutic environment].
(2) The
use of mechanical restraint shall be prohibited in a
(3) Special
treatment procedures shall not be used as punishment or as a convenience of
staff.
(4) [(3)]
Special treatment procedures may only be:
(a)
Ordered by a [be used only by] trained, clinically-privileged
staff person acting within his or her scope of practice; and
(b)
Carried out by trained staff.
(5) A (4) The facility] shall have a
written plan approved by the governing body for the use of special treatment
procedures which at a minimum meet the following requirements:
(a) Any
use of special treatment procedures requires clinical justification;
(b) A
rationale and the clinical indications for the use of special treatment
procedures shall be clearly stated in the resident's record for each
occurrence. The rationale shall address the inadequacy of less restrictive
intervention techniques;
(c) The
plan shall specify the length of time for which a specific approval remains
effective;
(d) The
plan shall specify the length of time the special treatment procedure may be
utilized; and
(e) The
plan shall specify when continued or repeated special treatment procedures
shall trigger multidisciplinary team review.
(6)
If an emergency situation requires restraint or seclusion and a practitioner
authorized to order restraint or seclusion is not available in a
(a)
The verbal order shall be given by a practitioner, as authorized by the
facility, who is acting within his or her scope of practice;
(b)
The verbal order shall be received by a practitioner, as authorized by the facility,
who is acting within his scope of practice;
(c)
The ordering practitioner shall be immediately available by telephone for
consultation during the time that restraint or seclusion is being carried out;
and
(d)
The verbal order shall be countersigned by the ordering practitioner within
seven (7) days of date that the order was given.
(7) For a
nonemergency situation, restraint or seclusion may be carried out only after
being ordered by:
(a)
A resident's treating physician; or
(b)
A practitioner acting within his or her scope of practice, if the resident's
treating physician is not available. The practitioner shall:
1.
Contact the resident's treating physician as soon as possible and inform him or
her of the order for restraint or seclusion; and
2. Annotate the resident's record with date and time of the contact with the treating physician.
(8) An order
for restraint or seclusion shall not exceed:
(a)
The duration of the emergency safety situation;
(b) Four (4) hours for a resident eighteen
(18) to twenty-one (21) years of age;
(c) Two (2) hours for a resident nine (9)
to seventeen (17) years of age; or
(d) One (1) hour for a resident under nine (9) years of age.
(9) If an emergency safety situation exists beyond the time limit for the use of restraint or seclusion, a new order for restraint or seclusion shall be obtained.
(10) A resident
that is placed in restraint or seclusion shall receive a face-to-face
evaluation to determine physical and psychological well being. The evaluation
shall be conducted:
(a)
By a practitioner authorized by the facility and acting within his or her scope
of practice; and
(b) Within one (1) hour of restraint or seclusion being initiated.
(11) Staff who implement
special treatment procedures shall:
(a) Have documented training in the proper
use of the procedure used;
(b) Be certified in physical management by
a nationally-recognized training program in which certification is obtained
through skilled-out testing; and
(c) Receive annual training and recertification in crisis intervention and behavior management.
(12) Staff
authorized by a
(a) Be constantly, physically present with
a resident being restrained;
(b) Monitor the physical and psychological
well being of a resident being restrained; and
(c) Document observations of, and actions taken for, a resident being restrained.
(13) After a
restraint is removed from a resident, a practitioner that is authorized by a
(14) Staff shall provide constant visual attention to a resident who is in seclusion, through physical presence or a window.
(15) Staff
authorized by a
(a) Monitor the physical and psychological
well being of the resident;
(b) Ensure that a resident in seclusion is
given attention in regard to:
1. Regular meals;
2. Hydration;
3. Bathing; and
4. Use of the toilet; and
(c) Document observations of, and actions taken fo, a resident in restraint every fifteen (15) minutes.
(16) At no time
may a procedure be used in a manner that causes undue physical discomfort,
harm, or pain to a resident.
(17) A
(18) Unusual
treatment shall require the informed consent of the resident and parent,
guardian, or custodian prior to the provision of unusual treatment as follows:
(a)
The proposed unusual treatment shall be reviewed and interpreted by the child's
psychiatrist addressing the rationale for use, methods to be used, specified
time to be used, who will provide the treatment, and the methods that will be
used to evaluate the efficacy of the treatment.
(b)
The potential risks, side effects, and benefits of the proposed unusual
treatment shall be explained, verbally and in writing, to the resident and the
parent, guardian, or custodian prior to their granting approval for the unusual
treatment. The approval shall be given in writing prior to implementation of
the treatment.
(19) The
clinical director or designee shall review all uses of special treatment
procedures on a daily basis. The daily review shall include an evaluation for
the possibility of unusual or unwarranted patterns of use. [(5)
Restraint or seclusion may be ordered or carried out only after the physician
who is authorizing the use of the procedure has conducted a clinical assessment
or has consulted with a mental health professional who has conducted a clinical
assessment of the resident.
(6) Each
written order for restraint or seclusion shall be time limited and shall not
exceed twenty-four (24) hours. No PRN orders for restraint or seclusion may be
written.
(7)
Restraint or seclusion may be utilized in an emergency by trained,
clinically-privileged staff. The emergency implementation of restraint or
seclusion shall not exceed thirty (30) minutes at which time a physician staff
member's oral order is required if use of the procedure is to continue. The
physician's written order to confirm restraint or seclusion shall be entered in
the resident's record as soon as possible, but not more than twenty-four (24)
hours after the implementation of the procedure.
(8) Staff
who implement special treatment procedures shall have documented training in
the proper use of the procedure used and shall be certified in physical
management by a nationally recognized training program in which certification
is obtained through skilled-out testing.
(9) A
staff member shall be constantly, physically present with a resident in
restraint; and attention shall be given in regard to regular meals, bathing and
use of The toilet. This attention shall be documented in the resident's record.
(10) A
staff member shall always be in the seclusion room with a resident twelve (12)
years of age or under so long as the staff member is not placed in undue
physical danger due to the relative size and strength of the resident who is in
seclusion. Attention shall be given in regard to regular meals, bathing and use
of the toilet. This attention shall be documented in the resident's record.
(11)
Constant visual attention through physical presence, remote video, or window
shall be paid to an adolescent who is in seclusion and over twelve (12) years
of age or a resident who is under twelve (12) years of age if the staff member
would be placed in undue physical danger due to the resident's relative size
and strength. A staff member shall check the resident's breathing and talk to
the resident every fifteen (15) minutes and shall attend to the resident's
regular meals, bathing, and use of the toilet. This attention shall be
documented in the resident's record.
(12) At no
time may a procedure be used in a manner that causes undue physical discomfort,
harm, or pain to a resident.
(13) All
uses of special treatment procedures shall be reviewed on a daily basis by the
clinical director and evaluated by him for the possibility of unusual or
unwarranted patterns of use.
(14) A facility
shall not use extraordinary risk procedures including, but not limited to
experimental treatment modalities, psychosurgery, aversive conditioning,
electroconvulsive therapies, behavior modification procedures that use painful
stimuli, unusual medications, and investigational and experimental drugs.
(15)
Unusual treatment shall require the informed consent of the resident and
parent, guardian, or custodian prior to the provision of unusual treatment as
follows:
(a) The
proposed unusual treatment shall be reviewed and interpreted by one (1) or more
persons legally qualified to prescribe treatment addressing the rationale for
use, methods to be used, specified time to be used, who will provide the
treatment, and the methods that will be used to evaluate the efficacy of the
treatment.
(b) The
potential risks, side effects, and benefits of the proposed unusual treatment
shall be explained, verbally and in writing, to the resident and the parent,
guardian, or custodian prior to their granting approval for the unusual
treatment. The approval shall be given in writing prior to implementation of
the treatment.]
Section 14. Housekeeping Services.
(1) A The facility] shall have policies
and procedures for and services which maintain a clean, safe, and hygienic
environment for residents and facility personnel. Policies and procedures shall
include guidelines for at least the following:
(a) The
use, cleaning, and care of equipment;
(b)
Assessing the proper use of housekeeping and cleaning supplies;
(c) Evaluating
the effectiveness of cleaning; and
(d) The
role of the facility staff in maintaining a clean environment.
(2) A
laundry service shall be provided by a the
facility] or through contractual agreement.
(3) the facility] or
through contractual agreement.
Section 15. Infection Control.
(1)
Because infections acquired in a facility] or brought into a facility] from the community are potential hazards for all persons having
contact with the facility, there shall be an infection control program
developed to prevent, identify, and control infections.
(2)
Written policies and procedures pertaining to the operation of the infection
control program shall be established, reviewed at least annually, and revised
as necessary.
(3) A
practical system shall be developed for reporting, evaluating, and maintaining
records of infections among residents and personnel.
(4) The system
shall include assignment of responsibility for the ongoing collection and
analysis of data, as well as for the implementation of required follow-up
actions.
(5)
Corrective actions shall be taken on the basis of records and reports of
infections and infection potentials among residents and personnel and shall be
documented.
(6) All
new employees shall be instructed in the importance of infection control and
personal hygiene and in their responsibility in the infection control program.
(7) A
The facility] shall
document that in-service education in infection prevention and control is
provided to all services and program components.
ROBERT J.
BENVENUTI, III, Esq., Inspector General
JAMES W.
HOST, Jr., M.D., Secretary
DUANE L.
KILTY, Jr., Ph.D., Undersecretary
APPROVED
BY AGENCY:
FILED WITH
LRC:
CONTACT
PERSON: Jill
Brown, Office of Legal Services, 275 East Main Street 5 W-B,
REGULATORY
IMPACT ANALYSIS AND TIERING STATEMENT
Contact person:
Steve Davis
(1) Provide a
brief summary of:
(a) What this administrative regulation does: This administrative regulation establishes the minimum state licensure requirements for psychiatric residential treatment facility operations and services.
(b) The necessity of this administrative regulation: This administrative regulation is necessary to establish the minimum licensure requirements for psychiatric residential treatment center operation and services.
(c)
How this administrative regulation conforms to the content of the authorizing
statutes: KRS 216B.042, 216B.105, and 216B.450 to 216B.459
mandate that the Kentucky Cabinet for Health Services regulate health
facilities and services. This administrative regulation provides minimum
licensure requirements regarding the operations of and services provided by
psychiatric residential treatment facilities. EO 2004-726, effective
(d) How this administrative regulation currently assists or will assist in the effective administration of the statutes: This administrative regulation allows the Office of the Inspector General the authority to ensure that psychiatric residential treatment facilities provide adequate services to meet patient need and provide for patient safety.
(2) If this is an amendment to an existing administrative regulation, provide a brief summary of:
(a) How the amendment will change this existing administrative regulation: The amendment to this administrative regulation will reflect the statutory change that will raise the bed capacity of a psychiatric residential treatment facility from 8 to 9 beds. Language is also added to implement the requirement established in KRS 216B.452 that requires a 9 bed psychiatric residential treatment facility to provide for the stability of care for patients. The restraint and seclusion requirements are amended to more closely mirror the federal requirements for restraint and seclusion in psychiatric residential treatment facilities.
(b) The necessity of the amendment to this administrative regulation: The amendments to the bed capacity and stability of care requirements of this administrative regulation are necessary to reflect the amendments to KRS 216B.450 and 216B.455 enacted by the 2004 GA. The amendment to the restraint and seclusion requirements is necessary to comply with the federal requirements for restraint and seclusion because compliance with the federal requirements for restraint and seclusion is a standard for accreditation by all recognized accrediting bodies and KRS 216B.455was amended by the 2004 GA to require that all psychiatric residential treatment facilities be accredited by a recognized accrediting body.
(c)
How the amendment conforms to the content of the authorizing statutes: KRS 216B.042, 216B.105, and 216B.450 to 216B.459mandate
that the Kentucky Cabinet for Health Services regulate health facilities and
services. This administrative regulation provides minimum licensure
requirements regarding the operations of and services provided by psychiatric
residential treatment facilities. EO 2004-726, effective
(d) How the amendment will assist in the effective administration of the statutes: The amendment to this administrative regulation will continue to allow the Office of the Inspector General the authority to ensure that psychiatric residential treatment facilities provide adequate services to meet patient need and provide for patient safety.
(3) List the type and number of individuals, businesses, organizations, or state and local governments affected by this administrative regulation: Currently, there are 19 licensed psychiatric residential treatment facilities that are affected by this regulation.
(4) Provide an assessment of how the above group or groups will be impacted by either the implementation of this administrative regulation, if new, or by the change if it is an amendment: The psychiatric residential treatment facilities that previously had a bed capacity of 8 beds will have the opportunity to add a ninth bed. The additional language establishing the requirement for stability of care will be beneficial to the facilities by more clearly defining methods needed to achieve stable care for psychiatric residential treatment facility patients. The restraint and seclusion amendment will benefit the psychiatric residential treatment facilities by eliminating inconsistencies between federal restraint and seclusion requirements and state licensure restraint and seclusion requirements.
(5) Provide an estimate of how much it will cost to implement this administrative regulation:
(a) Initially: There are no costs associated with the amendment to this regulation on an initial basis.
(b) On a continuing basis: There are no costs associated with the amendment to this regulation on a continuing basis.
(6) What is the source of the funding to be used for the implementation and enforcement of this administrative regulation: General Funds.
(7) Provide an assessment of whether an increase in fees or funding will be necessary to implement this administrative regulation, if new, or by the change if it is an amendment: This amended regulation will not increase any fees or require any additional funding to implement.
(8) State whether or not this administrative regulation establishes any fees or directly or indirectly increases any fees: The amendment to this administrative regulation will not directly or indirectly increase any fees.
(9) TIERING: Is tiering applied? Tiering was not appropriate in this administrative regulation because the administrative regulation applies equally to all those individuals or entities regulated by it. Disparate treatment of any person or entity subject to this administrative regulation could raise questions of arbitrary action on the part of the agency. The "equal protection" and "due process" clauses of the Fourteenth Amendment of the U.S. Constitution may be implicated as well as
Sections 2 and 3
of the