Current through Register Vol. 46, No. 19, March 20, 2024
The program's policies and procedures shall address each
standard.
(1)
Hours of
operation. Inpatient and residential programs shall operate seven days
per week, 24 hours per day.
(2)
Meals. Inpatient and residential programs shall provide a
minimum of three meals per day to each patient. A program where patients are
not present during mealtime shall make provisions to make available the
necessary meals. Menus shall be prepared in consultation with a dietitian. If
patients are allowed to prepare meals, the program shall document conformity
with all commonly accepted policies and procedures of state health rules and
regulations and food hygiene.
(3)
Consultation with counsel. Patients shall have opportunity for
and access to consultation with legal counsel at any reasonable time.
(4)
Visitation with family and
friends.
a. Each patient shall have
opportunities for continuing contact with family and friends. If such contact
is clinically contraindicated, it may be restricted. Any restriction shall be
approved by the treatment supervisor and the executive director. Justification
for the restriction shall be documented in the patient record. Any restriction
shall be reviewed within three calendar days by the treatment supervisor, who
may continue or end the restriction. Continuation of a restriction shall be
documented in the patient record and shall be reviewed by the treatment
supervisor every three calendar days.
b. The program shall establish visiting
hours, which shall be conspicuously displayed at the facility and in such a
manner to be visible to those entering the facility.
(5)
Telephone use.
a. Each patient shall have opportunities to
conduct private telephone conversations. If such conversations are clinically
contraindicated, they may be restricted. Any restriction shall be approved by
the treatment supervisor and the executive director. Justification for the
restriction shall be documented in the patient record. Any restriction shall be
reviewed within three calendar days by the treatment supervisor, who may
continue or end the restriction. Continuation of a restriction shall be
documented in the patient record and shall be reviewed by the treatment
supervisor every three calendar days.
b. The program shall establish telephone
hours. Emergency telephone conversations may be received at the time of the
call or made when necessary.
(6)
Written communication.
a. Each patient shall have opportunities to
conduct private written communications. If such communications are clinically
contraindicated, they may be restricted. Any restriction shall be approved by
the treatment supervisor and the executive director. Justification for the
restriction shall be documented in the patient record. Any restriction shall be
reviewed within three calendar days by the treatment supervisor, who may
continue or end the restriction. Continuation of a restriction shall be
documented in the patient record and shall be reviewed by the treatment
supervisor every three calendar days.
b. The program shall establish access to
written communications. The program shall not intercept, read, or censor the
U.S. mail.
(7)
Facility. Inpatient and residential program facilities shall
be appropriate for 24-hour occupancy.
a.
Patient bedrooms shall include:
(1) A
sturdily constructed bed;
(2) A
clean mattress protected with a clean mattress pad;
(3) A designated space for personal
possessions and for hanging clothing in proximity to the sleeping area;
and
(4) Curtains or window blinds
on any windows.
b.
Sleeping areas.
(1) Sleeping areas shall
include doors for privacy.
(2)
Sleeping areas shall include partitioning or placement of furniture to provide
privacy for all patients.
(3) The
number of patients in a room shall be appropriate to the goals of the facility
and to the ages, developmental levels, and clinical needs of the
patients.
(4) Patients will be
allowed to keep and display personal belongings and add personal touches to the
decoration of their rooms in accordance with program policy.
(5) Staff shall respect the patient's right
to privacy by knocking on the door of the patient's room before
entering.
c. Clean
linen, towels and washcloths shall be available minimally on a weekly basis and
more often as needed.
d. Bathrooms.
(1) Bathrooms shall provide the facilities
necessary for patients' personal hygiene and personal privacy, including:
1. A safe supply of hot and cold running
potable water;
2. Clean towels,
electric hand dryers or paper towel dispensers, toilet paper and
soap;
3. Natural or mechanical
ventilation capable of removing odors;
4. Tubs or showers that have slip-proof
surfaces;
5. Partitions with doors
which provide privacy if a bathroom has multiple toilet stools; and
6. Toilets, wash basins, and other plumbing
or sanitary facilities that shall at all times be maintained in good operating
condition.
(2) The ratio
of bathroom facilities to inpatient and residential patients shall be one tub
or shower head per 12 patients, one wash basin per 12 patients and one toilet
per 8 patients.
(3) If the facility
is coeducational, the program shall designate and so identify separate
bathrooms for male and female patients.
e. The written plan to be followed in the
event of fire or tornado shall be conspicuously displayed on each floor or in
each area that patients, concerned persons, staff or visitors occupy at the
facility and shall be explained to all inpatient and residential patients as a
part of their orientation to the program. Fire drills shall be conducted at
least monthly, and tornado drills shall be conducted monthly from April through
October.
f. Written reports of
annual inspections by state or local fire safety officials or private fire
protection companies approved by the department shall be maintained with
records of corrective action taken by the program based on recommendations
articulated in such reports.
g.
Every facility shall have an adequate water supply from an approved source. A
municipal water system shall meet this requirement. Private water sources shall
be tested annually.
h. The facility
shall allow for the following:
(1) Areas in
which a patient may be alone when appropriate; and
(2) Areas for private conversations with
others.
i. Articles of
grooming and personal hygiene that are appropriate to the patient's age,
developmental level, and clinical state shall be readily available in a space
reserved near the patient's sleeping area. If access to such articles is
clinically contraindicated as approved by the treatment supervisor, a patient's
personal articles may be kept under lock and key by staff. Staff shall explain
to the patient the conditions under which the articles may be used.
Justification for this restriction shall be documented in the patient
record.
j. If patients maintain
their own living quarters or perform day-to-day housekeeping activities, these
responsibilities shall be clearly defined in writing and be a part of the
patient orientation program. Staff assistance and equipment shall be provided
as needed.
k. Patients shall be
allowed to wear their own clothing in accordance with program rules. If
clothing is provided by programs, it shall be suited to the climate and
appropriate. A laundry room shall be accessible so patients may wash their
clothing.
l. The program shall
ensure that the use and location of noise-producing equipment and appliances,
such as television sets, radios, computers, and CD players, do not interfere
with clinical and therapeutic activities.
m. The program shall provide recreation and
outdoor activities unless clinically contraindicated.
(8)
Religion-culture.
Program policies and procedures shall include a written description of any
religious orientation, religious practice, or religious restrictions. For
juvenile patients, this description shall be provided to the patient, parent(s)
or guardian, and placing agency at the time of admission in compliance with
HIPAA and DHHS, 42 CFR Part 2, regulations on the confidentiality of alcohol
and drug abuse patient records. For adult patients, this information shall be
available during orientation. The patient shall have the opportunity to
participate in religious activities and services in accordance with the
patient's faith or that of a patient's parent(s) or guardian if the patient is
a minor. The program shall, when necessary and reasonable, arrange
transportation to religious activities.
