Current through Register Vol. 30, No. 38, September 20, 2024
A. An
administrator shall ensure that the premises and equipment are sufficient to
accommodate:
1. The services stated in the
behavioral health inpatient facility's scope of services, and
2. An individual accepted as a patient by the
behavioral health inpatient facility.
B. An administrator shall ensure that:
1. A behavioral health inpatient facility has
a:
a. Waiting area with seating for patients
and visitors;
b. Room that provides
privacy for a patient to receive treatment or visitors; and
c. Common area and a dining area that:
i. Are not converted, partitioned, or
otherwise used as a sleeping area; and
ii. Contain furniture and materials to
accommodate the recreational and socialization needs of the patients and other
individuals in the behavioral health inpatient facility;
2. A bathroom is available for use
by visitors during the behavioral health inpatient facility's hours of
operation and:
a. Provides privacy;
and
b. Contains:
i. A working sink with running
water,
ii. A working toilet that
flushes and has a seat,
iii. Toilet
tissue,
iv. Soap for hand
washing,
v. Paper towels or a
mechanical air hand dryer,
vi.
Lighting, and
vii. A window that
opens or another means of ventilation;
3. For every six patients, there is at least
one working toilet that flushes and has a seat and one sink with running
water;
4. For every eight patients,
there is at least one working bathtub or shower with a slip-resistant
surface;
5. A patient bathroom
complies with the following:
a. Provides
privacy when in use;
b. Contains:
i. A shatterproof mirror, unless the
patient's treatment plan requires otherwise;
ii. A window that opens or another means of
ventilation; and
iii. Nonporous
surfaces for shower enclosures and slip-resistant surfaces in tubs and
showers;
c. Has
plumbing, piping, ductwork, or other potentially hazardous elements concealed
above a ceiling;
d. If the bathroom
or shower area has a door, the door swings outward to allow for staff emergency
access;
e. If grab bars for the
toilet and tub or shower or other assistive devices are identified in the
patient's treatment plan, has grab bars or other assistive devices to provide
for patient safety;
f. If a grab
bar is provided, has the space between the grab bar and the wall filled to
prevent a cord being tied around the grab bar;
g. Does not contain a towel bar, a shower
curtain rod, or a lever handle that is not a specifically designed
anti-ligature lever handle;
h. Has
tamper-resistant lighting fixtures, sprinkler heads, and electrical outlets;
and
i. For a bathroom with a
sprinkler head where a patient is not supervised while the patient is in the
bathroom, has a sprinkler head that is recessed or designed to minimize patient
access;
6. If a patient
bathroom door locks from the inside, an employee has a key and access to the
bathroom;
7. Each patient is
provided a bedroom for sleeping;
8.
A patient bedroom complies with the following:
a. Is not used as a common area;
b. Is not used as a passageway to another
bedroom or bathroom unless the bathroom is for the exclusive use of a patient
occupying the bedroom;
c. Contains
a door that opens into a hallway, common area, or outdoors and, except as
provided in subsection (E), another means of egress;
d. Is constructed and furnished to provide
unimpeded access to the door;
e.
Has window or door covers that provide patient privacy;
f. Has floor to ceiling walls:
g. Is a:
i.
Private bedroom that contains at least 60 square feet of floor space, not
including the closet; or
ii. Shared
bedroom that:
(1) Is shared by no more than
four patients;
(2) Contains, except
as provided in subsection (B)(9), at least 60 square feet of floor space, not
including a closet, for each patient occupying the bedroom; and
(3) Provides sufficient space between beds to
ensure that a patient has unobstructed access to the bedroom door;
h. Contains for each
patient occupying the bedroom:
i. A bed that
is: at least 36 inches wide and at least 72 inches long, and consists of at
least a frame and mattress and linens that is not a threat to health and
safety; and
ii. Individual storage
space for personnel effects and clothing such as shelves, a dresser, or chest
of drawers;
i. Has clean
linen for each bed including mattress pad, sheets large enough to tuck under
the mattress, pillows, pillow cases, bedspread, waterproof mattress covers as
needed, and blankets to ensure warmth and comfort for each patient;
j. Has sufficient lighting for a patient
occupying the bedroom to read; and
k. If applicable, has a drawer pull that is
recessed to eliminate the possibility of use as a tie-off point;
9. If a behavioral health
inpatient facility licensed before November 1, 2003 was approved for 50 square
feet of floor space for each patient in a bedroom, ensure that the bedroom
contains at least 50 square feet for each patient not including the
closet;
10. In a patient bathroom
or a patient bedroom:
a. The ceiling is
secured from access or at least 9 feet in height; and
b. A ventilation grille is:
i. Secured and has perforations that are too
small to use as a tie-off point, or
ii. Of sufficient height to prevent patient
access;
11.
For a door located in an area of the behavioral health inpatient facility that
is accessible to patients:
a. A door closing
device, if used on a patient bedroom door, is mounted on the public side of the
door;
b. A door's hinges are
designed to minimize points for hanging;
c. Except for a door lever handle that
contains specifically designed anti-ligature hardware, a door lever handle
points downward when in the latched or unlatched position; and
d. Hardware has tamper-resistant fasteners;
and
12. A window located
in an area of the behavioral health inpatient facility that is accessible to
patients is fabricated with laminated safety glass or protected by
polycarbonate, laminate, or safety screens.
C. An administrator of a licensed behavioral
health inpatient facility may submit a request, in a Department-provided
format, for additional time to comply with a physical plant requirement in
subsection (B)(5)(c) through (B)(5)(i), (B)(10), (B)(11), or (B)(12) that
includes:
1. The rule citation for the
specific plant requirement,
2. The
current physical plant condition that does not comply with the physical plant
requirement,
3. How the current
physical plant condition will be changed to comply with the physical plant
requirement,
4. Estimated
completion date of the identified physical plant change, and
5. Specific actions taken to ensure the
health and safety of a patient until the physical plant requirement is
met.
D. When the
Department receives a request for additional time to comply with a physical
plant requirement in subsection (B)(5)(c) through (B)(5)(i), (B)(10), (B)(11),
or (B)(12) submitted according to subsection (C), the Department may approve
the request for up to 24 months after the effective date of these rules based
on:
1. The behavioral health inpatient
facility's scope of services,
2.
The expected patient acuity based on the behavioral health inpatient facility's
scope of services,
3. The specific
physical plant requirement in the request, and
4. The threat to patients' health and
safety.
E. A bedroom in
a behavioral health inpatient facility is not required to have a second means
of egress if:
1. An administrator ensures that
policies and procedures are established, documented, and implemented that
provide for the safe evacuation of a patient in the bedroom based on the
patient's physical and mental limitations and the location of the bedroom;
or
2. The building where the
bedroom is located has a fire alarm system and a sprinkler system required in
R9-10-322(A)(1).
F. If a
swimming pool is located on the premises, an administrator shall ensure that:
1. The swimming pool is enclosed by a wall or
fence that:
a. Is at least five feet in height
as measured on the exterior of the wall or fence;
b. Has no vertical openings greater that four
inches across;
c. Has no horizontal
openings, except as described in subsection (F)(1)(e);
d. Is not chain-link;
e. Does not have a space between the ground
and the bottom fence rail that exceeds four inches in height; and
f. Has a self-closing, self-latching gate
that:
i. Opens away from the swimming
pool,
ii. Has a latch located at
least 54 inches from the ground, and iii. Is locked when the swimming pool is
not in use; and
2. A life preserver or shepherd's crook is
available and accessible in the pool area.
G. An administrator shall ensure that a spa
that is not enclosed by a wall or fence as described in subsection (F)(1) is
covered and locked when not in use.