902 KAR 20:320. Psychiatric
residential treatment facility operation and services.
RELATES TO: KRS 216B.010-216B.130, KRS 216B.010-216B.130, 216B.990, 42 C.F.R.
441.156, 42 C.F.R. 483
STATUTORY AUTHORITY: KRS 216B.042, 216B.105, KRS 216B.010-216B.130, 314.011(8), 314.042(8), 320.240(14),
NECESSITY, FUNCTION, AND CONFORMITY: KRS 216B.042, 216B.105 and KRS 216B.010-216B.130 mandate
that the Kentucky Cabinet for Health Services regulate health facilities and
services. This administrative regulation provides minimum licensure
requirements regarding the operation of and services provided in psychiatric
residential treatment facilities.
Section 1. Definitions.
(1)
"Chemical restraint" means
the use of a drug that:
(a) Is administered
to manage a resident's behavior in a way that reduces the safety risk to the
resident or others;
(b) Has the
temporary effect of restricting the resident's freedom of movement; and
(c) 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)
"Direct-care staff" means
residential or child-care workers who directly supervise residents.
(4)
"Freestanding" is defined
in KRS 216B.450(3).
(5)
"Governing body" means the
individual, agency, partnership, or corporation in which the ultimate
responsibility and authority for the conduct of the facility is vested.
(6)
"Licensure agency" means
the Cabinet for Health and Family Services, Office of Inspector General.
(7)
"Living unit" means the
area within a single building that is supplied by the facility for daily living
and therapeutic interaction of no more than nine (9) residents.
(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)
"Mental health associate"
means:
(a) An individual
with a minimum of a bachelor's degree in a mental health related field; a
registered nurse; or a licensed practical nurse with at least one (1) year's
experience in a psychiatric inpatient or residential treatment setting for
children; or
(b) An individual
with a high school diploma or an equivalence certificate and at least two (2)
years work experience in a psychiatric inpatient or residential treatment
setting for children.
(10)
"Mental health professional"
is defined in KRS 645.020.
(11)
"Personal restraint" means
the application of physical force without the use of any device for the purpose
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)
"Psychiatric residential treatment facility" or "
(13)
"Seclusion" means the
involuntary confinement of a resident alone in a room or in an area from which
the resident is physically prevented from leaving.
(14)
"Special treatment procedures" means any procedure such as chemical restraint, mechanical restraint,
personal restraint, or seclusion which may have abuse potential or be life
threatening.
(15)
"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.
(2) In accordance with KRS 216B.455(5)
multiple
(3) If a psychiatric residential treatment
facility is located on grounds shared by another licensed facility other than a
(a) The residents
of the
(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
(4)
Section 3. Licensure. A psychiatric
residential treatment facility shall comply with all the conditions for
licensure contained in 902
KAR 20:008.
Section 4. Governing Body.
A
(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 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 those 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) If 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 program director shall be responsible for
the administrative management of the facility.
(2) A program director:
(a) Shall be
qualified by training and experience to direct a treatment program for children
and adolescents with emotional problems;
(b) Shall have at
least minimum qualifications of 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)1. With a master's degree shall have two (2) years of prior
supervisory experience in a human services program; or
2. With a bachelor's degree shall have four (4) years of prior
supervisory experience in a human services program; and
(d)1. Shall 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 Police; and
2. Shall not have a
crime conviction, or plea of guilty, pursuant to KRS 17.165 or a Class A felony.
(3) A 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 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
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 a
written manual that defines policies and procedures and 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
(a) An
organizational chart that includes position titles and the name of the person
occupying the position, and that shows the chain of command;
(b) A service
philosophy with clearly defined assumptions and values;
(c)
Estimates of the clinical needs of the children and adolescents in the area
served by the facility;
(d) The services
provided by the facility in response to needs;
(e) The population
served, including age groups and other relevant characteristics of the resident
population;
(f) The intake or
admission process, including how the initial contact is made with the resident
and the family or significant others;
(g) The assessment
and evaluation procedures provided by the facility;
(h) The methods
used to deliver services to meet the identified clinical needs of the residents
served;
(i) 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) The methods
used to create a home-like environment for all residents;
(k) The methods,
means and linkages by which the facility involves all residents in community
activities, organizations, and events;
(l) The treatment
planning process and the periodic review of therapy;
(m) The discharge
and aftercare planning processes;
(n) The facility's
therapeutic programs;
(o) How professional
services are provided by qualified, experienced personnel;
(p) 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 the treatment;
(q) How the
facility is linked to regional interagency councils, psychiatric hospitals,
community mental health centers, Department for Community Based Services
offices and facilities, and school systems in the facility's service area;
(r) The means by
which the facility provides, or makes arrangements for the provision of:
1. Emergency
services and crisis stabilization;
2. Discharge and
aftercare planning that promotes continuity of care; and
3. Education and
vocational services; and
(s) Services the
facility provides to improve stability of care and reduce re-hospitalization
including:
1. How psychiatric
and nursing coverage is provided to assure the continuous ability to manage and
administer medications in crisis situations except for those that may only be
administered by a physician; and
2. How direct-care
staffing with supervision is 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.
Revisions in the documentation shall incorporate, as appropriate, relevant
findings from the facility's quality assurance and utilization review programs.
(3) Professional staff.
(a) A
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. Meet the
following requirements with regard to professional staffing:
a. (i) 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. A
c. A mental health
professional shall be available to assist on-site in emergencies on at least an
on-call basis at all times.
d. A psychiatrist
shall be available on at least an on-call basis at all times.
(b) 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 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 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)
(4) Direct-care staff.
(a) A
(b)1. Direct-care
staff shall have at least a high school diploma or equivalency and two (2)
years experience in a program in the mental health field serving children or
adolescents.
2. Completion of a
forty (40) hour training curriculum meeting the requirements of subsection
(5)(d) of this section within one (1) month of employment may be substituted
for experience, except that direct-care staff so qualified shall not be given
clinical privileges in their 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
2. At least one (1)
direct-care staff member shall be assigned to direct-care responsibilities for
each three (3) residents during normal waking hours when residents are not in
school;
3.a. 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; and
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. 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. 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) 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) hours per year
of in-service training
(c) Part-time staff
shall have at least twenty-four (24) hours of annual training specific to tasks
to be performed.
(d) Each staff
member working directly with residents shall receive annual training 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.
(6) Employment practices.
(a) A
(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. Are approved by
the governing body for all positions specifying the qualifications, duties, and
supervisory relationship of the position;
2. Accurately
reflect the actual job situation;
3. Are revised if
a change is made in the required qualifications, duties, supervision, or any
other major job-related factor; and
4. Provide the
salary range for each position.
(e) The
(f) 1. The personnel policies and
procedures shall be available and apply to all employees and shall be discussed
with all new employees.
2. The governing
body shall establish a mechanism for notifying employees of changes in the
personnel policies and procedures.
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. 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.
(g) 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, if required, affirmative action policies.
(h) The personnel
policies and procedures shall describe methods and procedures for supervising
all personnel, including volunteers.
(i) The personnel policies and procedures shall require a
criminal record check through the Administrative Office of the Courts or the
Kentucky State Police 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.
(j) 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.
(k) 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.
(l) The personnel
policies and procedures shall assure the confidentiality of personnel records
and specify who has access to various types of personnel information.
(m) 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
(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
(a) Each resident's
right to access 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 in planning for treatment;
(f) The nature of
care, procedures, and treatment that the resident 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 if 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 are 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, 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) A resident
shall be allowed to work for the facility only under the following conditions:
1. The work is
part of the individual treatment plan;
2. The work is
performed voluntarily;
3. The patient
receives wages commensurate with the economic value of the work; and
4. The work
project complies with applicable law and administrative regulation; and
(b) 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 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
(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) Have written
policies concerning resident records approved by the governing body; and
(b) Maintain a
written resident record on each resident, to be directly accessible to staff
members caring for the resident.
(2) 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, if 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) 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 if 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 resident.
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
(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
(2) A
(3) A
Section 10. Admission Criteria.
(1) A
(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
(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
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 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) 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) 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
at least physical, emotional, behavioral, social, recreational, educational,
legal, vocational, and nutritional needs.
(b) An initial
health screening for illness, injury, and communicable disease or other
immediate needs shall be conducted within twenty-four (24) hours after
admission by a nurse.
(c) A physician,
nurse practitioner, or physician's assistant shall conduct a physical
examination of each resident within fourteen (14) days after admission.
Communication to schedule the physical examination of each resident shall be
initiated within twenty-four (24) hours after admission. The physical
examination shall include at least 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
(d) If the resident
has had a complete physical examination by a qualified physician, nurse
practitioner, or physician's assistant within the previous three (3) months
which includes the requirements of paragraph (c) of this subsection of this
section and if the facility obtains complete copies of the record, the
physician, nurse practitioner, or physician's assistant may determine after
reviewing the records and assessing the resident's physical health that a
complete physical examination is not required. If that determination is made,
the examination performed in the previous three (3) months may be used to meet
the requirement for a physical examination in paragraph (c) of this section.
(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. If indicated,
psychological assessments, including intellectual, projective, and personality
testing;
5. If 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) If 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 the participation shall be documented in the resident's record.
6. a. 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 if 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. The treatment
plan shall be reviewed and updated through multidisciplinary team conferences
as clinically indicated and at least within, thirty (30) days following the
first ten (10) days of treatment and every sixty (60) days thereafter.
8. 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 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
(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, 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 the placement reasonably meets the needs of the resident.
(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.
Section 12. Services. A
(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
1.
a. Case coordination services to
assure the full integration of all services provided to each resident.
b. Case
coordination activities shall 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. a. Planned on-site verbal therapies
including formal individual, family, and group therapies.
b. These therapies
shall 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.
c. Verbal contacts
that are incidental to other activities are excluded from this service.
3. a. 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.
b. Task and skill
training activities shall 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
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 American Academy of Pediatrics;
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) If 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
(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
(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 if a psychiatric,
medical, or dental emergency of a resident occurs 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
(a) 1. Medications shall be administered by a
registered nurse, physician, or dentist, except if administered by 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 medicine administration course approved by the
Kentucky Board of Nursing;
(b) Medications
shall not be given without a written order signed by a physician, or dentist if
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 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 shall 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
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 shall 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. Education
services approved by the Department of Education shall be available either on
the same site or in close physical proximity to the
(b) If 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. Each resident's
master treatment plan shall include formal academic goals for remediation and
continuing education.
2. a. 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. 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
(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 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.
(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) Special treatment procedures may only
be:
(a) Ordered by a
trained, clinically-privileged staff person acting within his or her scope of
practice; and
(b) Carried out by
trained staff.
(5) A
(a) Any use of
special treatment procedures shall require 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 or her 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;