Current through Bulletin 2024-06, March 15, 2024
(1) The licensee shall submit to the office,
before program implementation, policies and procedures that include:
(a) a description of what constitutes sex and
gender abuse, discrimination, and harassment;
(b) procedures for preventing and reporting
abuse, discrimination, and harassment; and
(c) procedures for teaching effective and
professional communication with individuals of any sexual orientations and
genders.
(2) The
licensee shall develop, implement, and comply with safe practices that:
(a) ensure client health and
safety;
(b) ensure the needs of the
client population served are met;
(c) ensure that none of the program practices
conflict with any administrative rule or statute before implementation;
and
(d) inform staff of how to
manage any unique circumstances regarding the specific site's physical
facility, supervision, community safety, and mixing populations.
(3) The licensee shall submit any
change to an office-approved policy or curriculum to the office for approval
before implementing the proposed change.
(4) A congregate care program licensee shall
submit to the office any policies and procedures that describe behavior
management, suicide prevention, restraint, or seclusion used in the program as
described in Section
26B-2-123, before
implementation.
(5) In addition to
complying with Section
26B-2-123, a congregate care
program licensee shall ensure that the congregate care behavior management
policy and practices reflect the following:
(a) a congregate care program licensee uses
behavior management techniques that are trauma-informed and appropriate for the
client's age, behavior, needs, developmental level, and past experiences and
defer to the least restrictive method of behavior management available to
control a situation;
(b) a
congregate care program licensee only uses behavior management techniques that
emphasize de-escalation and promote self-control, self-esteem, and
independence;
(c) a congregate care
program licensee identifies a behavior management curriculum that emphasizes
de-escalation and is compliant with Section 26B-2-123;
(d) only direct care staff familiar with the
child and the child's needs conduct passive physical restraint;
(e) restraint is only used if it does not
cause undue physical discomfort, harm, or pain to the client;
(f) interventions that use painful stimuli
are prohibited as a general practice;
(g) passive physical restraint is used only
as an emergency, temporary means of physical containment to protect the
consumer, other persons, or property from immediate harm;
(h) restraint only continues as long as the
client presents an immediate danger to self or others;
(i) passive physical restraint is not used as
a convenience to staff, a substitute for programming or associated with
punishment in any way;
(j) a
client, non-direct care staff member, or other unauthorized individual does not
use any form of restraint;
(k)
staff do not use physical work assignments or activities that inflict pain as
behavior management techniques; and
(l) staff are trained to ensure the following
safe practices:
(i) appropriate de-escalation
techniques and alternatives to restraint or seclusion;
(ii) thresholds for restraints;
(iii) the physiological and psychological
impact of restraint;
(iv)
appropriate monitoring of restraint episodes;
(v) how to recognize the physical signs of
distress, positional asphyxia, and obtaining medical assistance;
(vi) how to intervene if another staff member
fails to follow correct procedures when using a restraint;
(vii) time limits for restraints;
(viii) the process for obtaining clinical
approval for continued restraints;
(ix) the procedure for documenting and
reporting restraints;
(x) the
procedure for processing restraints with clients;
(xi) the procedure for following up with
staff after a restraint;
(xii) how
staff address injuries and complaints;
(xiii) department code of conduct;
and
(xiv) client rights.
(6) A congregate care
program licensee shall ensure that congregate care seclusion policy and
practices reflect the following:
(a) seclusion
is only used to ensure the immediate safety of the child or others and is
terminated as soon as the risks have been mitigated, not to exceed four hours
without clinical justification;
(b)
staff who are familiar to the child directly supervise the child during the
seclusion;
(c) staff supervising
seclusion ensure that any potentially harmful items or objects are removed from
the seclusion environment;
(d)
seclusion rooms measure a minimum of 75 square feet and have a minimum ceiling
height of seven feet with no equipment, hardware or furnishings that obstruct
staff's view of the client or present a hazard;
(e) seclusion rooms have either natural or
mechanical ventilation with break resistant windows and either a break
resistant two-way mirror or camera that allows for observation of the entire
room;
(f) seclusion rooms do not
have locking capability and are not located in closets, bathrooms, unfurnished
areas or other areas not designated as part of residential living
space;
(g) bedrooms are not
utilized as a seclusion room and seclusion rooms may not be utilized as
bedrooms;
(h) seclusion episodes
are documented in detail by the staff involved in initiating and supervising
the seclusion episode;
(i)
seclusion episodes of more than two in a 24-hour period are supported by
clinical review and documentation regarding client suitability for remaining in
the program; and
(j) client
time-out is used when addressing behavioral issues only if:
(i) a client in time-out is never physically
prevented from leaving the time-out area;
(ii) it takes place away from the area of
activity or from other clients, such as in the client's bedroom;
(iii) staff monitors the client while in
time-out; and
(iv) the reason for
and duration of time-out is documented by staff on duty when it
occurs.
(7) A
congregate care program licensee shall develop and follow a suicide prevention
policy that complies with Subsection
26B-2-123(5).
(8) A congregate care program licensee shall
ensure that the program's licensed clinical professional conducts regular
reviews of client restraints, seclusions, behavioral interventions, and time
outs to inform processing discussions with clients and training for direct care
staff.
(9)
(a) Before a congregate care program licensee
may accept a client or send a discharging client who is transported by a youth
transportation company as defined in Section
26B-2-101, the licensee shall
ensure that the transport company is registered with the office.
(b) A congregate care program licensee shall
report private placements to the office as described in Section
26B-2-124 by completing the
congregate care out of state placement survey on the office website no later
than the fifth business day of each month.