Current through Register Vol. 50, No. 9, September 20, 2024
A. The
TGH shall have written policies and procedures approved by the owner or
governing body, which shall be implemented and followed, that address at a
minimum the following:
1. confidentiality and
confidentiality agreements;
2.
security of files;
3. publicity and
marketing, including the prohibition of illegal or coercive inducement,
solicitation and kickbacks;
4.
personnel;
5. client
rights;
6. grievance
procedures;
7. client
funds;
8. emergency
preparedness;
9. abuse and
neglect;
10. incidents and
accidents, including medical emergencies;
11. universal precautions;
12. documentation;
13. admission and discharge
procedures;
14. bedroom assignment
for clients; and
15. behavior
management.
B. A TGH
shall have written personnel policies, which shall be implemented and followed,
that include:
1. a plan for recruitment,
screening, orientation, ongoing training, development, supervision and
performance evaluation of staff members, whether directly employed, contract or
volunteer;
2. written job
descriptions for each staff position, including volunteers;
3. policies that shall, at a minimum, be
consistent with Office of Public Health guidelines, to indicate whether, when
and how staff have a health assessment;
4. an employee grievance procedure;
5. abuse reporting procedures that require
all employees to report any incidents of abuse or mistreatment, whether that
abuse or mistreatment is done by another staff member, a family member, a
client or any other person;
6. a
nondiscrimination policy;
7. a
policy that requires all employees to report any signs or symptoms of a
communicable disease or personal illness to their supervisor or the Clinical
Director as possible to prevent the disease or illness from spreading to other
clients or personnel.
C.
A TGH shall maintain the requirements for financial viability under this rule
at all times.
D. Behavior
Management
1. The TGH shall develop and
implement written policies and procedures for the management of behaviors to be
used on facility-wide level, insuring that procedures begin with the least
restrictive, most positive measures and follow a hierarchy of acceptable
measures. The policies and procedures shall be provided to all TGH staff and
shall include:
a. appropriate and
inappropriate behaviors of clients;
b. consequences of inappropriate behaviors of
clients;
c. the phases of behavior
escalation and appropriate intervention methods to be used at each
level.
d. documentation in the
client's record of the use of any behavioral management measures.
E. House Rules and
Regulations. A TGH shall have a clearly written list of rules and regulations
governing conduct for clients in care and shall document that these rules and
regulations are made available to each staff member, client and, where
appropriate, the clients parent(s) or legal guardian(s). A copy of the house
rules shall be given to clients and, where appropriate, the clients parent(s)
or legal guardian(s) upon admission and shall be posted and accessible to all
employees and clients.
F.
Limitations on Potentially Harmful Responses or Punishments. A TGH shall have a
written list of prohibited responses and punishments to clients by staff
members and shall document that this list is made available to each staff
member, client and, where appropriate, the client's parent(s) or legal
guardian(s).
1. This list shall include the
following prohibited responses/punishments:
a.
any type of physical hitting or other painful physical contact except as
required for medical, dental or first aid procedures necessary to preserve the
child's life or health;
b.
physical, chemical and mechanical restraints;
c. requiring a client to take an extremely
uncomfortable position;
d. verbal
or psychological abuse, ridicule or humiliation;
e. withholding of a meal, except under a
physician's order;
f. denial of
sufficient sleep, except under a physician's order;
g. requiring a child to remain silent for a
long period of time;
h. denial of
shelter, warmth, clothing or bedding;
i. assignment of harsh physical
work.
j. physical exercise or
repeated physical motions;
k.
excessive denial of usual services;
l. denial of visiting or communication with
family or legal guardian;
m.
extensive withholding of emotional response;
n. any other cruel, severe, unusual,
degrading or unnecessary discipline.
2. A TGH shall not discipline groups of
clients for actions committed by an individual.
3. Children shall neither discipline nor
supervise other children except as part of an organized therapeutic
self-government program that is conducted in accordance with written policy and
is supervised directly by staff. Such programs shall not be in conflict with
regulations regarding behavior management.
4. Discipline shall not be administered by
any persons who are not known to the client.
G. Restraints
1. A TGH shall develop and implement a
written policy which prohibits the use of any form of mechanical, physical or
chemical restraints. TGH providers may have a policy that allows passive
physical restraint, but it shall be utilized only when the child's behaviors
escalate to a level of possibly harming himself/herself or others.
2. The TGH's policy shall provide that
passive physical restraints are only to be performed by two trained staff
personnel in accordance with an approved curriculum. A single person restraint
can be initiated in a life threatening crisis with support staff in close
proximity to provide assistance.
H. Time-Out Procedures
1. A provider using time-out rooms for
seclusion of clients for brief periods shall have a written policy governing
the use of time-out procedures. This policy shall ensure that:
a. the room shall be unlocked;
b. time-out procedures are used only when
less restrictive measures have been used without effect. Written documentation
of less restrictive measures used shall be required;
c. emergency use of time-out shall be
approved by the clinical director for a period not to exceed one
hour;
d. time-out used as an
individual behavior management plan shall be part of the overall plan of
treatment;
e. the plan shall state
the reasons for using time-out and the terms and conditions under which
time-out will be terminated or extended, specifying a maximum duration of the
use of the procedure that shall under no circumstances exceed eight
hours;
f. when a child is in
time-out, a staff member shall exercise direct physical supervision of the
child at all times;
g. a child in
time-out shall not be denied access to bathroom facilities, water or
meals.
I.
Copies of the behavior management policy, the prohibited response and
punishment policy, including restraint prohibitions and time out procedures,
shall be provided in triplicate upon admission. The child and parent(s) or
legal guardian(s) shall sign all three copies. The child and parent(s) or legal
guardian(s) shall retain one copy each and the provider shall retain the other
copy in the child's record.
J.
Copies of the behavior management policy, the prohibited response and
discipline policy, including restraint prohibitions and time out procedures,
shall be provided in duplicate to each new employee upon hiring. The employee
shall sign both copies. The employee shall retain one copy and the provider
shall retain the other copy in the employee's personnel record.
K. A TGH shall comply with all federal and
state laws, rules and regulations in the development and implementation of its
policies and procedures.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
36:254 and
R.S.
40:2009.
