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New Licensing Standards - 2960 DOC to license/certify: ALL ALL Group Residential Group Residential Detention Detention Secure Secure Restrictive Techniques.

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Presentation on theme: "New Licensing Standards - 2960 DOC to license/certify: ALL ALL Group Residential Group Residential Detention Detention Secure Secure Restrictive Techniques."— Presentation transcript:

1 New Licensing Standards - 2960 DOC to license/certify: ALL ALL Group Residential Group Residential Detention Detention Secure Secure Restrictive Techniques Restrictive Techniques Corrections Corrections Shelter Shelter DHS to license/certify: ALL Group Residential Chemical Dependency Mental Health Shelter Transitional Restrictive Techniques

2 Administrative Standards ALL

3 2960.0010 Purpose And Applicability Governs the licensing of providers of residential care for children in out-of- home placement.

4 2960.0010 - Providers Unit of government Unit of government Individual Individual Corporation Corporation Limited liability corporation Limited liability corporation Partnership Partnership Voluntary association Voluntary association Other organization or entity Other organization or entity Controlling individual Controlling individual

5 2960.0010 Scope of the Rule residential care { on a 24-hour basis residential care { on a 24-hour basis treatment treatment detention detention foster foster rehabilitation service rehabilitation service Juvenile sex offender treatment programs also governed by MN Rule

6 Definitions Time out Time out Disciplinary room time Disciplinary room time

7 License Not transferable to another Not transferable to another individual/entity individual/entity location location

8 2960.0030 - Application Form provided Form provided applicant's name and address applicant's name and address name and location of the program name and location of the program geographic area to be served geographic area to be served license or certification being requested license or certification being requested requested license capacity requested license capacity age limits age limits

9 Application Organizational chart depicting organizational authority Organizational chart depicting organizational authority

10 2960.0030 Subpart 2B-4 Application The applicant must provide: description of the services description of the services program's philosophy program's philosophy target population target population program outcomes program outcomes

11 2960.0030 Subpart 2B-5 Approvals Health: Department of Health or local health inspector Health: Department of Health or local health inspector Local building code inspector Local building code inspector Local zoning authority Local zoning authority Fire: State Fire Marshal or approved local code inspector Fire: State Fire Marshal or approved local code inspector or Document waiver or Document waiver

12 2060.0030 Subpart 2B-6 Community Analysis Description of the neighborhood demographic characteristics Description of the neighborhood demographic characteristics racerace socioeconomic characteristicssocioeconomic characteristics crime statisticscrime statistics vehicle trafficvehicle traffic proximity of the proposed facility to schools, day care providersproximity of the proposed facility to schools, day care providers

13 Neighborhood Demographics public transportationpublic transportation public and private recreation facilitiespublic and private recreation facilities neighborhood religious and spiritual organizationsneighborhood religious and spiritual organizations

14 Neighborhood Demographics Information about local business groups, community groups, block clubs, and service organizations.Information about local business groups, community groups, block clubs, and service organizations.

15 2960.0030 Subpart 2B-7 County Role in Screening The license holder must discuss with the county social services agency of the county in which the facility is located, the facility's policy regarding the county's role in screening facility residents.The license holder must discuss with the county social services agency of the county in which the facility is located, the facility's policy regarding the county's role in screening facility residents.

16 County Role in Screening The facility must document the contact with the county and any agreement between the county and the facility regarding the county's role in screening facility residents.The facility must document the contact with the county and any agreement between the county and the facility regarding the county's role in screening facility residents.

17 2960.0030 Subpart 2D Fee An applicant for Department of Human Services licensure or certification must pay a licensing fee which is calculated according to parts 9545.2000 to 9545.2040.An applicant for Department of Human Services licensure or certification must pay a licensing fee which is calculated according to parts 9545.2000 to 9545.2040.

18 2960.0030 Subpart 3 DOC Criteria A.Primarily serve delinquent children who are at least ten years old, but younger than 21 years old, in a residential setting; B. Operate a detention or group residential facility for children alleged to be delinquent; C. Be certified to provide residential program services for residents who need correctional programming.

19 2960.0030 Subpart 4 DHS Criteria A.Serve children through the age of 19 B.Operate a group residential program with possible certifications in the areas of: chemical dependency treatment chemical dependency treatment treatment for severe emotional disturbance treatment for severe emotional disturbance shelter services shelter services transitional services transitional services

20 2960.0030 Subpart 5 Multiple Program Certifications The Department of Human Services and the Department of Corrections shall determine which commissioner will license or certify the applicant.

21 2060.0030 Subpart 6 Variance Request A.The part or parts of the standard B.Reason for the variance C.Period of time of the variance D.Written approval from the fire marshal, building inspector, or health authority as applicable E.Alternative equivalent measures

22 2960.0030 Subpart 6E Variance Authority Department of Human Services – Department of Human Services – M. S. 245A.04, subdivision 9. Department of Corrections – Department of Corrections – M. S. 241.021. The decision of the commissioner of human services or corrections to grant or deny a variance request is final and not subject to appeal under Minnesota Statutes, Chapter 14.

23 Denial of Application compliance with laws or rules compliance with laws or rules health or safety deficiencies health or safety deficiencies hazardous condition hazardous condition fire, building, zoning, health approval fire, building, zoning, health approval

24 Denial of Application Failure to comply may be indicated by: Department of Education: lack of approval of on-site school Department of Education: lack of approval of on-site school Disqualification of the applicant/ controlling individual Disqualification of the applicant/ controlling individual Failure to submit a completed application Failure to submit a completed application DHS Denial = DOC Denial DHS Denial = DOC Denial

25 2960.0030 Subpart 9 Drug and Alcohol Use Prohibited Includes prescription drugs Includes prescription drugs Policy required Policy required Training in the drug policy Training in the drug policy

26 2960.0030 Subpart 11 Policy and Procedure Review The license holder must submit the facility's program policies and procedures to the commissioner of human services or corrections for review. The license holder must submit the facility's program policies and procedures to the commissioner of human services or corrections for review.

27 2960.0030 Subpart 11 License/Certification Terms name of the license holder name of the license holder address of the program address of the program effective date and expiration dates effective date and expiration dates type of license type of license maximum number and ages of residents maximum number and ages of residents any special conditions of licensure any special conditions of licensure certification(s) granted certification(s) granted

28 Subpart 12 Licensing Actions Department of Human Services: Minnesota Statutes, Chapter 245A. Department of Human Services: Minnesota Statutes, Chapter 245A. Department of Corrections: Department of Corrections: Minnesota Statutes, Section 241.021.

29 2060.0040 Statement of Intended Use Target population served: cultural background cultural background gender gender license holders expertise and qualifications to provide the services license holders expertise and qualifications to provide the services age age medically fragile condition medically fragile condition

30 Statement of Intended Use legal status: chips, delinquency, voluntary placement, self-referral legal status: chips, delinquency, voluntary placement, self-referral primary needs of residents met in the licensed facility primary needs of residents met in the licensed facility resident services provided by programs outside the setting resident services provided by programs outside the setting

31 Statement of Intended Use Specific extent and limitations of the program Specific extent and limitations of the program Restrictive procedures-extent and limitations Restrictive procedures-extent and limitations Involvement of the resident's cultural or ethnic community to ensure culturally appropriate care Involvement of the resident's cultural or ethnic community to ensure culturally appropriate care

32 2960.0500 - Basic Rights reasonable observance of cultural and ethnic practice and religion reasonable observance of cultural and ethnic practice and religion reasonable degree of privacy reasonable degree of privacy participate in development of the resident's treatment and case plan participate in development of the resident's treatment and case plan positive and proactive adult guidance, support, and supervision positive and proactive adult guidance, support, and supervision

33 2960.0500 - Basic Rights free from abuse, neglect, inhumane treatment, and sexual exploitation free from abuse, neglect, inhumane treatment, and sexual exploitation adequate medical care adequate medical care nutritious and sufficient meals and sufficient clothing and housing nutritious and sufficient meals and sufficient clothing and housing clean, safe surroundings clean, safe surroundings public education public education

34 2960.0500 - Basic Rights Reasonable communication and visitation, which may include: Reasonable communication and visitation, which may include: Attorney Attorney Therapist Therapist Physician Physician Religious- Spiritual advisor Religious- Spiritual advisor Case manager Case manager Parent Parent Extended family members Extended family members Siblings Siblings Legal guardian Legal guardian Caseworker Caseworker

35 2960.0500 - Basic Rights access to protection and advocacy services access to protection and advocacy services state-appointed ombudsman state-appointed ombudsman personal property personal property courteous and respectful treatment courteous and respectful treatment Minnesota Statutes, Sections Minnesota Statutes, Sections 144.651 Patients Bill of Rights 253B.03 Rights of Patients

36 2960.0500 - Basic Rights grievance procedure grievance procedure free from restraint or seclusion used for a purpose other than to protect the resident from imminent danger to self or others; except for the use of disciplinary room time as it is allowed in the correctional facility's discipline plan free from restraint or seclusion used for a purpose other than to protect the resident from imminent danger to self or others; except for the use of disciplinary room time as it is allowed in the correctional facility's discipline plan free from bias and harassment regarding race, gender, age, disability, spirituality, and sexual orientation free from bias and harassment regarding race, gender, age, disability, spirituality, and sexual orientation

37 2960.0500 - Basic Rights nutritious and sufficient meals and sufficient clothing and housing nutritious and sufficient meals and sufficient clothing and housing clean, safe surroundings clean, safe surroundings public education public education

38 2960.0500 License Holder Duties provide basic services provide basic services develop operational policies and procedures which correspond to the basic rights develop operational policies and procedures which correspond to the basic rights give the resident a written copy of the resident's basic rights give the resident a written copy of the resident's basic rights

39 2960.0500 Basic Rights Information explain to the resident in a language that the resident can understand explain to the resident in a language that the resident can understand rights related to the resident's care explained within 24 hours of admission rights related to the resident's care explained within 24 hours of admission procedures which correspond to the basic rights procedures which correspond to the basic rights

40 2960.0500 Basic Rights Information tell the resident's parent, guardian, or custodian within a reasonable time that the information regarding rules is available tell the resident's parent, guardian, or custodian within a reasonable time that the information regarding rules is available Post resident rights in the: Post resident rights in the: Residents and staff area Residents and staff area Staff station Staff station how to contact the appropriate state- appointed ombudsman: name, address, and telephone number how to contact the appropriate state- appointed ombudsman: name, address, and telephone number

41 2960.0060 Statement of Program Outcomes written policies that identify program outcomes and promote the resident's development as a physically and mentally healthy person written policies that identify program outcomes and promote the resident's development as a physically and mentally healthy person the program services offered by the license holder must be consistent with the resident's case plan the program services offered by the license holder must be consistent with the resident's case plan

42 2960.0060 Outcome Measures the measurement must document the degree to which the license holder's services provided to the resident, or the resident's family, have been successful in achieving the intended outcome of the services offered to the resident and the resident's family the measurement must document the degree to which the license holder's services provided to the resident, or the resident's family, have been successful in achieving the intended outcome of the services offered to the resident and the resident's family measure the success in achieving statement outcomes measure the success in achieving statement outcomes specific factors as required by DHS/DOC specific factors as required by DHS/DOC

43 2960.0060 Outcome Measures specific factors as required by DHS/DOC specific factors as required by DHS/DOC the program services offered by the license holder must be consistent with the resident's case plan the program services offered by the license holder must be consistent with the resident's case plan

44 2960.0060 Program Evaluation annually evaluate strengths and weaknesses of the program using at least the following performance indicators: annually evaluate strengths and weaknesses of the program using at least the following performance indicators: accidents accidents use of restrictive procedures use of restrictive procedures grievances grievances adverse maltreatment findings and legal actions against the license holder adverse maltreatment findings and legal actions against the license holder

45 2960.0060 Program Evaluation satisfaction survey results satisfaction survey results critical incidents critical incidents Must be kept for two licensing periods Must be kept for two licensing periods Must use the program evaluation findings to make program improvement Must use the program evaluation findings to make program improvement

46 Independent Program Audit comply and cooperate with independent program audits DHS/DOC comply and cooperate with independent program audits DHS/DOC comply with the findings comply with the findings document with operational policies and procedures document with operational policies and procedures retain demographic information on a resident retain demographic information on a resident document the extent of the resident's program completion on designated form document the extent of the resident's program completion on designated form

47 Community Involvement Board of directors or advisory committee that represents the interests, concerns, and needs of the residents and community served and comply with the findings Board of directors or advisory committee that represents the interests, concerns, and needs of the residents and community served and comply with the findings The Board or advisory committee must meet at least annually The Board or advisory committee must meet at least annually

48 Community Involvement The license holder meet at least annually with community regarding: The license holder meet at least annually with community regarding: the nature of the program the nature of the program types of residents served types of residents served results of the services the program provided to residents results of the services the program provided to residents number of residents served in the past 12 months number of residents served in the past 12 months the number of residents likely to be served in the next 12 months. the number of residents likely to be served in the next 12 months.

49 2960.0070 Admission Process The license holder must have written specific identifiable admission criteria consistent with the statement of intended use. The license holder must have written specific identifiable admission criteria consistent with the statement of intended use. The License holder must: The License holder must: Have resources and qualified staff to respond to residents with disabilities Have resources and qualified staff to respond to residents with disabilities

50 Admission Process The license holder must:

51 Admission Process Consider placing a female resident when there are few other female residents in the facility Consider placing a female resident when there are few other female residents in the facility Whether the facility could offer gender-specific services for female residents Whether the facility could offer gender-specific services for female residents

52 Admission Process Consider placing a male resident when there are few other male residents in the facility Consider placing a male resident when there are few other male residents in the facility Whether the facility could offer gender-specific services for male residents Whether the facility could offer gender-specific services for male residents Seek approval of the commissioner of corrections to serve those over age 19 Seek approval of the commissioner of corrections to serve those over age 19

53 2960.0070 Subpart 3 Admission Documentation Within 5 working days after admission Within 5 working days after admission legal authority for resident placement legal authority for resident placement date and time of admission date and time of admission name and nicknames name and nicknames last known address and permanent address last known address and permanent address name, address, and telephone number of parents, guardian, and advocate name, address, and telephone number of parents, guardian, and advocate

54 Admission Documentation date and place of birth date and place of birth race or cultural heritage race or cultural heritage languages the resident speaks and writes languages the resident speaks and writes tribal affiliation tribal affiliation

55 Admission Documentation description of presenting problem description of presenting problem medical problems medical problems circumstances leading to admission circumstances leading to admission mental health concerns mental health concerns safety concerns: assaultive behavior, victimization concerns safety concerns: assaultive behavior, victimization concerns

56 Admission Documentation resident assets and strengths and related information from the resident, family, and concerned persons resident assets and strengths and related information from the resident, family, and concerned persons name, address, and telephone number for the last educational program contact person name, address, and telephone number for the last educational program contact person spiritual or religious affiliation spiritual or religious affiliation placing agency's case plan goals for the resident placing agency's case plan goals for the resident

57 2960.0070 Subpart 4 Resident Property inventory the resident's personal property (including clothing) inventory the resident's personal property (including clothing) resident and the license holder sign the inventory upon admission resident and the license holder sign the inventory upon admission (resident refusal: two staff sign) (resident refusal: two staff sign) ensure resident use and availability of personal funds/property unless restrictions justified in treatment plan ensure resident use and availability of personal funds/property unless restrictions justified in treatment plan

58 2960.0070 Subpart 4 Resident Funds Whenever the license holder assists with residents funds they must: Whenever the license holder assists with residents funds they must: Keep separate facility and resident funds Keep separate facility and resident funds When safekeeping funds/property When safekeeping funds/property Document receipt and disbursement Document receipt and disbursement Must have signatures of resident/ conservator/payee Must have signatures of resident/ conservator/payee Return to the resident funds/property within 3 working days request. Return to the resident funds/property within 3 working days request.

59 Funds-Must Nots borrow money from a resident borrow money from a resident purchase personal items from a resident purchase personal items from a resident sell merchandise, except canteen-type service sell merchandise, except canteen-type service sell personal services to a resident sell personal services to a resident require a resident to buy items for which the facility is reimbursed require a resident to buy items for which the facility is reimbursed use of funds that would violate part 9505.0425, subpart 3. use of funds that would violate part 9505.0425, subpart 3.

60 2960.0070 - Screenings Required health screening health screening history of abuse history of abuse vulnerability to abuse vulnerability to abuse potential for self-injury potential for self-injury current medications current medications most recent physician's/clinic's most recent physician's/clinic's name name address address number number

61 Screenings Required mental health screening mental health screening education screening Minnesota Statutes, section 125A.52 education screening Minnesota Statutes, section 125A.52 chemical abuse or chemical dependency screening chemical abuse or chemical dependency screening (The license holder will provide or contact the resident's case manager, if applicable, to arrange a screening to determine if the resident is chemically dependent) (The license holder will provide or contact the resident's case manager, if applicable, to arrange a screening to determine if the resident is chemically dependent)

62 Screenings Required screening for sexually abusive behavior; screening for sexually abusive behavior; written risk management plans (resident, other residents, staff, community) written risk management plans (resident, other residents, staff, community) vulnerability assessment vulnerability assessment culture culture gender-specific needs screening gender-specific needs screening psychosocial needs of the resident psychosocial needs of the resident needs regarding the gender of the staff needs regarding the gender of the staff

63 2960.0070 Subpart 5C Screening Time Lines other screenings: begin - 3 working days, completed - 6 working days other screenings: begin - 3 working days, completed - 6 working days health screening - within 24 hours of admission health screening - within 24 hours of admission May substitute screening or assessment completed within the last 6 months May substitute screening or assessment completed within the last 6 months if on file if on file no reason to believe condition has changed no reason to believe condition has changed

64 Screening Time Lines If a resident is transferred from another facility - Request of sending facility records needs to be immediate* If a resident is transferred from another facility - Request of sending facility records needs to be immediate* Screenings must include documented inquiries regarding the degree to which the family desires to be involved during the residents stay Screenings must include documented inquiries regarding the degree to which the family desires to be involved during the residents stay *(N/A to residents on detention status for less than 6 working days) *(N/A to residents on detention status for less than 6 working days)

65 2960.0080 - Basic Services Must provide services that fulfill the basic rights of the resident Must provide services that fulfill the basic rights of the resident Must have stated objectives and measurable outcomes Must have stated objectives and measurable outcomes Must coordinate and ensure off-campus program services if applicable Must coordinate and ensure off-campus program services if applicable Must meet the basic needs of the residents served by the facility. Must meet the basic needs of the residents served by the facility.

66 2960.0080 Subpart 3 Cooperation Cooperate with case manager/other appropriate parties in creating and delivering basic services Cooperate with case manager/other appropriate parties in creating and delivering basic services resident resident parent parent legal representative legal representative case manager case manager treatment team treatment team

67 2960.0080 Subpart 3A Implementation of Case Plan coordinate facility plan with placing agency's case plan coordinate facility plan with placing agency's case plan work with the placing agency to identify: work with the placing agency to identify: projected length of stay projected length of stay conditions for family reunification or permanency plan conditions for family reunification or permanency plan license holder actions to help carry out the plan license holder actions to help carry out the plan

68 B - Identify and Share Information (Per case plan) about the resident's treatment about the resident's treatment about major treatment outcome plans about major treatment outcome plans including attaining developmentally necessary/appropriate life skills including attaining developmentally necessary/appropriate life skills communicate as necessary with previous school and current school communicate as necessary with previous school and current school

69 D - Identify and Share Information report the resident's behaviors and other important information to the placing agency report the resident's behaviors and other important information to the placing agency recommend case plan changes to the placing agency; recommend case plan changes to the placing agency;

70 F - Identify and Share Information Share information (as allowed by law) Share information (as allowed by law) resident's therapist resident's therapist physician physician professional treating the resident professional treating the resident agencies providing discharge services agencies providing discharge services

71 Identify and Share Information Provide records to parent/guardian Provide records to parent/guardian Respond to court orders and authorized information release requests in 3 business days Respond to court orders and authorized information release requests in 3 business days

72 2960.0080 Subpart 4 Facility Rules/Due Process communicate verbally to the resident and in writing facility's rules and due process system communicate verbally to the resident and in writing facility's rules and due process system acceptable and unacceptable behaviors and the reasons why acceptable and unacceptable behaviors and the reasons why consequences applied in recognizing and rewarding acceptable behavior and modifying unacceptable behavior consequences applied in recognizing and rewarding acceptable behavior and modifying unacceptable behavior

73 2960.0080 Facility Rules/Due Process circumstances, if any, that will result in time-out or restrictive procedure use circumstances, if any, that will result in time-out or restrictive procedure use due process system for disciplinary consequences due process system for disciplinary consequences relationship of IEP discipline recommendations to the facilities relationship of IEP discipline recommendations to the facilities

74 2960.0080 Subpart 5 Discipline Policy/Procedures Policies and procedure must consider: Policies and procedure must consider: Abuse history Abuse history Developmental needs Developmental needs Culture needs Culture needs Disability needs Disability needs Gender needs Gender needs

75 2960.0080 Subpart 5 Prohibition of Corporal Punishment Rough handling Rough handling Shoving Shoving Ear or hair pulling Ear or hair pulling Shaking Shaking Slapping Slapping Kicking Kicking Biting Biting Pinching Pinching Hitting Hitting Throwing Objects Throwing Objects Spanking Spanking

76 2960.0080 Prohibition of Verbal Abuse name calling name calling derogatory statements about the resident/ family derogatory statements about the resident/ family race race gender gender disability disability sexual orientation sexual orientation religion religion culture culture

77 2960.0080 Prohibition of Verbal Abuse statements intended to statements intended to shame shame threaten threaten humiliate humiliate frighten frighten

78 2960.0080 Discipline Prohibited punishment for lapses in toilet habits, bed wetting and soiling punishment for lapses in toilet habits, bed wetting and soiling withholding of: withholding of: drinking water drinking water clothing clothing hygiene facilities hygiene facilities normal sleeping conditions normal sleeping conditions nutritious diet nutritious diet

79 2960.0080 Subpart 5A-4 Discipline Prohibited Withholding of: Withholding of: proper lighting proper lighting educational services educational services exercise activities exercise activities ventilation and proper temperature ventilation and proper temperature mail mail family visits family visits positive reinforcement positive reinforcement medical care medical care nurturing nurturing

80 2960.0080 Discipline However, a resident who destroys bedding or clothing or uses these or other items to harm self or others, may be deprived according to the residents case plan However, a resident who destroys bedding or clothing or uses these or other items to harm self or others, may be deprived according to the residents case plan

81 2960.0080 Discipline Prohibited assigning work that is dangerous or not consistent with the residents case plan assigning work that is dangerous or not consistent with the residents case plan disciplining one resident for the unrelated behavior or action of another, except recognized treatment program peer group restrictions disciplining one resident for the unrelated behavior or action of another, except recognized treatment program peer group restrictions

82 2960.0080 Discipline Prohibited Inappropriate use of restrictive techniques or procedures Inappropriate use of restrictive techniques or procedures as punishment as punishment for the convenience of staff for the convenience of staff as compensation for in adequate staffing as compensation for in adequate staffing as a substitute for program services as a substitute for program services

83 2960.0080 Subpart 5A-9 Discipline Prohibited communication restrictions beyond treatment/case plan communication restrictions beyond treatment/case plan prohibited punishments such as: prohibited punishments such as: extended time in uncomfortable or fixed positionsextended time in uncomfortable or fixed positions marchmarch standstand kneelkneel delegation of authority to punish another resident delegation of authority to punish another resident

84 2960.0080 Discipline License holder must comply with 9525.2700, subpart 2, item G, regarding the use of aversive or deprivation procedures with a resident who has mental retardation or a related condition License holder must comply with 9525.2700, subpart 2, item G, regarding the use of aversive or deprivation procedures with a resident who has mental retardation or a related condition

85 2960.0080 Subpart 5D Time-out Requirements time-out must be used as a non- emergency behavior management technique which is used to intervene in a resident's undesirable behavior and to allow the resident to reflect and become calm before returning to ongoing activities at the facility time-out must be used as a non- emergency behavior management technique which is used to intervene in a resident's undesirable behavior and to allow the resident to reflect and become calm before returning to ongoing activities at the facility

86 2960.0080 Time-out Requirements Must be used under the direction of: Must be used under the direction of: mental health professional mental health professional facility director facility director program manager program manager Must be consistent with treatment plan Must be consistent with treatment plan A staff must escort a resident to safe unlocked room or other separate living space A staff must escort a resident to safe unlocked room or other separate living space Staff must assess at least every 30 minutes Staff must assess at least every 30 minutes

87 2960.0080 Training Requirement Time-Out Staff must be trained in the following: the needs and behaviors of residents the needs and behaviors of residents building relationships with residents building relationships with residents alternatives to time-out alternatives to time-out de-escalation methods de-escalation methods avoiding power struggles with residents avoiding power struggles with residents documentation standards for the use of time-out documentation standards for the use of time-out

88 2960.0080 Time-out Requirements Treatment team review of time-out use for each resident during the treatment plan review Treatment team review of time-out use for each resident during the treatment plan review Document use of time-out in record Document use of time-out in record cause factorscause factors circumstancescircumstances resident's responseresident's response resident's ability to de-escalateresident's ability to de-escalate acceptable behavior after time-outacceptable behavior after time-out

89 2960.0080 Subpart 5E Certification Required Staff must have restrictive procedures certification (2960.0710) prior to the use of restrictive procedures with a resident Staff must have restrictive procedures certification (2960.0710) prior to the use of restrictive procedures with a resident

90 2960.0080 Subpart 6 Daily Resident Activities written schedule of daily activities written schedule of daily activities know the whereabouts of each resident know the whereabouts of each resident immediately notify the referring or placing agency of runaway / missing resident immediately notify the referring or placing agency of runaway / missing resident

91 2960.0080 Subpart 7 Culturally Appropriate Care document culturally appropriate care provided document culturally appropriate care provided opportunities to associate with culturally and racially similar adults, peers, and role models opportunities to associate with culturally and racially similar adults, peers, and role models opportunities to participate in positive experiences related to the resident's cultural and racial group opportunities to participate in positive experiences related to the resident's cultural and racial group

92 2960.0080 Culturally Appropriate Care culturally appropriate program services that address the needs of all residents in care culturally appropriate program services that address the needs of all residents in care cultural sensitivity, including the provision of interpreters and English language skill development* cultural sensitivity, including the provision of interpreters and English language skill development* * ( Laws 1995, Chapter 226, article 3, section 60, subdivision 2, paragraph (2), clause (v).)

93 2960.0080 Subpart 8 Spirituality Opportunity for voluntary participation in spirituality services, activities, and counseling Opportunity for voluntary participation in spirituality services, activities, and counseling A resident must not be required to attend the services or activities A resident must not be required to attend the services or activities Service/activities must be held in a location which allows choice Service/activities must be held in a location which allows choice Attendance or lack of attendance cannot affect rights/privilege Attendance or lack of attendance cannot affect rights/privilege Must arrange spiritual counseling if requested by a resident. Must arrange spiritual counseling if requested by a resident.

94 2960.0080 Subpart 8 Spirituality Accommodate a resident or a resident's family's request regarding spiritual needs, Accommodate a resident or a resident's family's request regarding spiritual needs, If unable: document the reason. Within reasonable safety and security rules Within reasonable safety and security rules Allow private interviews or counseling regarding spiritual, personal, or family problems Allow private interviews or counseling regarding spiritual, personal, or family problems Opportunity to meet with a spiritual or religious person of their choice. Opportunity to meet with a spiritual or religious person of their choice.

95 2960.0080 Subpart 9 Educational Services Facilitate the resident's admission to an accredited public school or other lawful school Facilitate the resident's admission to an accredited public school or other lawful school Facility- on grounds school Facility- on grounds school Year-round basis, if required by law Year-round basis, if required by law Approval of the education services from the Department of Education Approval of the education services from the Department of Education Cooperate with the school district. Cooperate with the school district.

96 Educational Services Facilitate the resident's school attendance and homework activities Facilitate the resident's school attendance and homework activities Inquire at least every 90 days Inquire at least every 90 days Report educational problems to the case manager or placing agency Report educational problems to the case manager or placing agency Chemical health education to the resident with inappropriate chemical use problem Chemical health education to the resident with inappropriate chemical use problem

97 2960.0080 Subpart 11 Health and Hygiene Services Timely access to: Timely access to: qualified persons that meet the resident's needs qualified persons that meet the resident's needs basic basic emergency emergency specialized medical specialized medical mental health mental health dental care dental care treatment services treatment services

98 Health and Hygiene Services: Pregnant Resident Ongoing and appropriate prenatal care from a medically licensed person Ongoing and appropriate prenatal care from a medically licensed person Prenatal, postnatal, and parenting information Prenatal, postnatal, and parenting information

99 Health and Hygiene Services Ensure provision of appropriate medical and dental services Ensure provision of appropriate medical and dental services Compliance with medical or dental insurance Compliance with medical or dental insurance

100 2960.0080 Subpart 11 Health Provider Gender Consideration of resident's request for a male or female health care provider Consideration of resident's request for a male or female health care provider If a female resident requests a female health care provider, and one is not available, the license holder must request permission from the health care provider that an adult female be allowed to be present during the health care procedure If a female resident requests a female health care provider, and one is not available, the license holder must request permission from the health care provider that an adult female be allowed to be present during the health care procedure Likewise for male residents Likewise for male residents

101 2960.0080 Subpart 11B Health Records Illness reported by the resident Illness reported by the resident Action taken by the license holder Action taken by the license holder Date of the resident's medical, psychological, or dental care Date of the resident's medical, psychological, or dental care

102 2960.0080 Subpart 11 Medication Plan Maintaining stock supplies of prescription drugs at the facility is prohibited. Maintaining stock supplies of prescription drugs at the facility is prohibited. Medication plan (developed with medically licensed person) for the safe storage and delivery of medicine. Medication plan (developed with medically licensed person) for the safe storage and delivery of medicine.

103 2960.0080 Subpart 11D-1 Medication Plan Contact a newly admitted residents prescribing medically licensed person to verify: Contact a newly admitted residents prescribing medically licensed person to verify: instructions about how to administer the medication instructions about how to administer the medication symptoms that the medication will alleviate symptoms that the medication will alleviate the symptoms that would warrant consultation with the physician the symptoms that would warrant consultation with the physician

104 2960.0080 Subpart 11D-2 Medication Plan Documentation of attempts to contact the child's parent or guardian to seek permission for the facility to administer the medication. Documentation of attempts to contact the child's parent or guardian to seek permission for the facility to administer the medication. If permission is denied and the parent has the legal right to deny permission, then the medication will be discontinued under the supervision of a physician unless a court order to administer the medication is obtained. If permission is denied and the parent has the legal right to deny permission, then the medication will be discontinued under the supervision of a physician unless a court order to administer the medication is obtained.

105 Medication Plan List of the side effects of medication List of the side effects of medication Document and follow the prescribing physician's directions for monitoring medications used by the resident Document and follow the prescribing physician's directions for monitoring medications used by the resident

106 2960.0080 Subpart 11-5 Medication Training Medication assistance training (non medically licensed person) Medication assistance training (non medically licensed person) Medication aide program completion Medication aide program completion Postsecondary institution Postsecondary institution Formalized training program Formalized training program Offered by the license holderOffered by the license holder Taught by a registered nurseTaught by a registered nurse Documented in staff personnel records Documented in staff personnel records

107 Medication Review Monthly medication administration review by medically licensed person Monthly medication administration review by medically licensed person Resident prescription drug record Resident prescription drug record quantity initially received from the pharmacy quantity initially received from the pharmacy amount of medication given amount of medication given dosage dosage time taken time taken refusal to take prescription medication refusal to take prescription medication

108 Medication Prescription medicine belonging to a resident must be given to the resident's parent or legal guardian upon the resident's release or must be disposed of according to a pharmacy-approved plan. Prescription medicine belonging to a resident must be given to the resident's parent or legal guardian upon the resident's release or must be disposed of according to a pharmacy-approved plan. The license holder must note the disposition of the resident's medicine in the resident's file. The license holder must note the disposition of the resident's medicine in the resident's file.

109 Medication Upon release, the license holder must give a resident who is 18 years of age or older the prescription medication prescribed for the resident. Upon release, the license holder must give a resident who is 18 years of age or older the prescription medication prescribed for the resident.

110 2960.0080 Subpart 12 Food and Nutrition Balanced diet consisting of foods and beverages: Balanced diet consisting of foods and beverages: palatable palatable adequate quantity and variety adequate quantity and variety prepared and served at appropriate temperatures prepared and served at appropriate temperatures prevent food-borne illnessprevent food-borne illness conserve nutritional valueconserve nutritional value

111 Food and Nutrition Provide a medically prescribed diet, if ordered Provide a medically prescribed diet, if ordered Offer a diet that does not conflict with the resident's religious or cultural dietary regimen. Offer a diet that does not conflict with the resident's religious or cultural dietary regimen.

112 2960.0080 Subpart 13 Clothing, Bedding, and Laundry adequate amount of clean clothing appropriate for the season adequate amount of clean clothing appropriate for the season appropriate sized, clean, fire- retardant mattress* appropriate sized, clean, fire- retardant mattress* two sheets or one sheet and clean mattress cover two sheets or one sheet and clean mattress cover sufficient clean blankets to provide appropriate warmth for the season sufficient clean blankets to provide appropriate warmth for the season

113 Clothing, Bedding, and Laundry One pillow and one pillowcase that is antiallergenic One pillow and one pillowcase that is antiallergenic Adequate bath towels and washcloths Adequate bath towels and washcloths Bedding and linens furnished upon admission Bedding and linens furnished upon admission Bedding and linens cleaned once a week or more Bedding and linens cleaned once a week or more No worn out/unfit bedding and linens No worn out/unfit bedding and linens

114 2960.0080 Subpart 14 Emergency Plan Develop a written emergency plan: Develop a written emergency plan: fire fire natural disaster natural disaster serious illness serious illness severe weather severe weather disappearance of a resident disappearance of a resident law enforcement/emergency response situation. law enforcement/emergency response situation.

115 2960.0080 Subpart 14 Emergency Plan Developed with the advice of local fire and emergency response authorities. Including emergency care/Special assistance if needed by a resident. Developed with the advice of local fire and emergency response authorities. Including emergency care/Special assistance if needed by a resident. Staff and residents plan review every six months. Staff and residents plan review every six months. Compliance documentation of the plan and the review. Compliance documentation of the plan and the review.

116 Subpart 15 Communication and Visitation Written communications and visiting policy Written communications and visiting policy Use of the telephone Use of the telephone Mail Mail Adaptive communications devices Adaptive communications devices Other means of communication, compatible with needs/case plan Other means of communication, compatible with needs/case plan

117 Subpart 16 Communication and Visitation No restriction of the parents visiting rights beyond case plan/court order limitations(M.S.260C.201) No restriction of the parents visiting rights beyond case plan/court order limitations(M.S.260C.201) Accommodation of parent's schedule Accommodation of parent's schedule

118 Subpart 17 Critical Incident/Maltreatment Reports Report critical incidents to licensing within 10 days on approved forms Report critical incidents to licensing within 10 days on approved forms Maintain records of all critical incidents on file in the facility Maintain records of all critical incidents on file in the facility Comply with mandatory maltreatment reporting* Comply with mandatory maltreatment reporting* * (Minnesota Statutes, sections 626.556 and 626.557)

119 Maltreatment Policy Policies and procedures to follow if maltreatment is suspected Policies and procedures to follow if maltreatment is suspected Annual review of maltreatment policies Annual review of maltreatment policies Policy revision: Policy revision: comply with changes in law comply with changes in law meet identified needs meet identified needs review of incident & quality assurance reports indicate a change is warranted review of incident & quality assurance reports indicate a change is warranted

120 2060.0080 Subpart 18 Resident & Family Grievance Procedures Develop & follow written grievance policy Develop & follow written grievance policy Allow others in residents life to make a formal complaint or suggestion or express concern about any aspect of the residents care Allow others in residents life to make a formal complaint or suggestion or express concern about any aspect of the residents care Staff may not influence a residents statement about the facility in a grievance Staff may not influence a residents statement about the facility in a grievance

121 Resident & Family Grievance Procedures The written grievance procedure must require: The written grievance procedure must require: Must give resident forms and assistance to file the grievance Must give resident forms and assistance to file the grievance Identify the person authorized to resolve the complaint & appeal information Identify the person authorized to resolve the complaint & appeal information Upon request, the grievance must be carried to the highest administration or placing agency Upon request, the grievance must be carried to the highest administration or placing agency

122 Subpart 19 Family Involvement If family involvement is a goal in a resident's case plan, the license holder must: If family involvement is a goal in a resident's case plan, the license holder must: list procedures and program plans which are in accordance with a resident's case plan, list procedures and program plans which are in accordance with a resident's case plan, facilitate the involvement of the resident's family or other concerned adult, in the resident's treatment or program activities. facilitate the involvement of the resident's family or other concerned adult, in the resident's treatment or program activities.

123 2960.0090 Subpart 2 No Eject Policy Written no eject policy Written no eject policy Confer with other interested persons to review the issues Confer with other interested persons to review the issues Review process must not exceed five working days Review process must not exceed five working days Any additional strategies to resolve the issues and prevent discharge Any additional strategies to resolve the issues and prevent discharge

124 No Eject Policy If discharge is warranted the reasons for it and the alternatives considered or attempted must be documented If discharge is warranted the reasons for it and the alternatives considered or attempted must be documented A resident may be temporarily removed from the facility during the five-day review period A resident may be temporarily removed from the facility during the five-day review period This subpart does not apply to a resident removed by the placing authority or a parent or guardian This subpart does not apply to a resident removed by the placing authority or a parent or guardian

125 Subpart 3 Property Return The license holder must return all of the resident's personal property to the resident The license holder must return all of the resident's personal property to the resident Signed receipt upon discharge, unless prohibited to do so by law or case plan Signed receipt upon discharge, unless prohibited to do so by law or case plan Discrepancies between the resident's inventoried property turned over to the facility at admission and the property returned to the resident at discharge, and the resolution of the discrepancy, must be documented by facility staff Discrepancies between the resident's inventoried property turned over to the facility at admission and the property returned to the resident at discharge, and the resolution of the discrepancy, must be documented by facility staff

126 2960.0100 Staffing Plan Approved by the Commissioner of Human Services or Corrections Approved by the Commissioner of Human Services or Corrections Identifies the assignments of facility staff Identifies the assignments of facility staff Meets the cultural and ethnic needs of the facility residents to the extent permitted by law Meets the cultural and ethnic needs of the facility residents to the extent permitted by law

127 2960.0100 Subpart 2 Recruitment of Culturally Balanced Staff To the extent permitted by law, it is the license holder's responsibility to actively recruit, hire, and retain full-time staff who are responsive to the diversity of the population served To the extent permitted by law, it is the license holder's responsibility to actively recruit, hire, and retain full-time staff who are responsive to the diversity of the population served If the facility staffing plan does not meet the cultural and racial needs of facility residents the license holder must document the reasons If the facility staffing plan does not meet the cultural and racial needs of facility residents the license holder must document the reasons

128 Recruitment of Culturally Balanced Staff Work with cultural or racial communities to meet the needs of residents. Work with cultural or racial communities to meet the needs of residents. In addition, the license holder must contact a cultural or racial community group related to the resident's cultural or racial minority background and seek information about how to provide opportunities for the resident to associate with adult and peer role models with similar cultural and racial backgrounds on a regular basis. In addition, the license holder must contact a cultural or racial community group related to the resident's cultural or racial minority background and seek information about how to provide opportunities for the resident to associate with adult and peer role models with similar cultural and racial backgrounds on a regular basis.

129 2960.0100 Subpart 3 Orientation The license holder must provide training for staff that is modified annually to meet the current needs of individual staff persons. The license holder must provide training for staff that is modified annually to meet the current needs of individual staff persons. The training must be directly related to serving the program's target population and to achieving the program's outcomes. The training must be directly related to serving the program's target population and to achieving the program's outcomes.

130 Orientation The license holder must ensure that staff who will have direct contact with residents attend and successfully complete orientation training before having unsupervised contact with residents. The license holder must ensure that staff who will have direct contact with residents attend and successfully complete orientation training before having unsupervised contact with residents.

131 Orientation Training Emergency Procedures evacuation routes evacuation routes emergency telephone numbers emergency telephone numbers severe storm and tornado procedures severe storm and tornado procedures location of facility alarms and equipment location of facility alarms and equipment

132 Orientation Training Statutes, Rules Relevant statutes and administrative rules and legal issues Relevant statutes and administrative rules and legal issues Reporting requirements for abuse and neglect specified in Minnesota Statutes, sections 626.556 and 626.557 Reporting requirements for abuse and neglect specified in Minnesota Statutes, sections 626.556 and 626.557 Other reporting requirements based on the ages of the residents Other reporting requirements based on the ages of the residents

133 Orientation Training Diversity Cultural diversity Cultural diversity Gender sensitivity Gender sensitivity Culturally specific services Culturally specific services Information about discrimination and racial bias issues to ensure that caregivers have cultural sensitivity and will be culturally competent to care for residents Information about discrimination and racial bias issues to ensure that caregivers have cultural sensitivity and will be culturally competent to care for residents

134 Orientation Training Diversity General and special needs, including disability needs, of residents and families served General and special needs, including disability needs, of residents and families served Operational policies and procedures of the license holder Operational policies and procedures of the license holder

135 Orientation Data practices regulations and issues. Data practices regulations and issues. The license holder must ensure that staff who have direct contact with residents receive ongoing training. Training must help staff meet the needs of residents and must include skills development. The license holder must ensure that staff who have direct contact with residents receive ongoing training. Training must help staff meet the needs of residents and must include skills development.

136 2960.0100 Subpart 3B Ongoing Training The license holder must ensure that staff who have direct contact with residents receive ongoing training. The license holder must ensure that staff who have direct contact with residents receive ongoing training. Training must help staff meet the needs of residents and must include skills development. Training must help staff meet the needs of residents and must include skills development.

137 Subpart 4 Specialized Training If needed, license holders and staff must have specialized training to develop skills to care for residents If needed, license holders and staff must have specialized training to develop skills to care for residents Specialized training must be directly related to serving the program's target population and to meeting the program's certification requirements Specialized training must be directly related to serving the program's target population and to meeting the program's certification requirements

138 2960.0100 Subpart 5 Personnel Policies Documentation of training. The license holder must document the date and number of hours of orientation and in-service training completed by each staff person in each topic area and the name of the entity that provided the training. Documentation of training. The license holder must document the date and number of hours of orientation and in-service training completed by each staff person in each topic area and the name of the entity that provided the training.

139 Subpart 6 Qualifications The license holder and staff must have the education and experience required to meet the functions and program activities that the license holder declared in the facility statement of intended use according to part 2960.0040. The license holder and staff must have the education and experience required to meet the functions and program activities that the license holder declared in the facility statement of intended use according to part 2960.0040.

140 Staff Qualifications Responsible, mature, healthy adult who is able to carry out the license holder's duties. Responsible, mature, healthy adult who is able to carry out the license holder's duties. Able to accomplish the license holder's duties to the resident's case plan and treatment plan and meet the resident's needs. Able to accomplish the license holder's duties to the resident's case plan and treatment plan and meet the resident's needs. Trained in gender-based needs and issues. Trained in gender-based needs and issues. At least 21 years old. At least 21 years old.

141 Subpart 7 Background Study A license holder and individuals identified in Minnesota Statutes, A license holder and individuals identified in Minnesota Statutes, DHS: Minnesota Statutes, section 245A.04, subdivision 3. DHS: Minnesota Statutes, section 245A.04, subdivision 3. DOC: Minnesota Statutes, section 241.021, subdivision 6. DOC: Minnesota Statutes, section 241.021, subdivision 6. must submit to a background study.

142 2960.0110 PHYSICAL ENVIRONMENT / EQUIPMENT The facility must be equipped and maintained in a manner that conforms to its statement of intended use. The facility must be equipped and maintained in a manner that conforms to its statement of intended use. The physical environment must provide for the comfort, privacy, and dignity of residents. The physical environment must provide for the comfort, privacy, and dignity of residents.

143 2960.0110 Subpart 3 Facilities The license holder must ensure that food services, storage, housekeeping, laundry, and maintenance are operated on a consistent, healthy basis. The license holder must ensure that food services, storage, housekeeping, laundry, and maintenance are operated on a consistent, healthy basis. If food service is contracted to a food service vendor, the food service vendor must meet health code requirements. If food service is contracted to a food service vendor, the food service vendor must meet health code requirements.

144 Facilities If the license holder provides educational services on site, the classrooms must provide an atmosphere that is conducive to learning and meets the resident's special physical, sensory, and emotional needs. If the license holder provides educational services on site, the classrooms must provide an atmosphere that is conducive to learning and meets the resident's special physical, sensory, and emotional needs. The license holder must provide adaptive equipment and furnishings to meet the resident's special needs. The license holder must provide adaptive equipment and furnishings to meet the resident's special needs.

145 Subpart 4 First Aid Kits A facility must have first aid kits readily available for use by residents and staff. The kits must be sufficient to meet the needs of residents and staff. A facility must have first aid kits readily available for use by residents and staff. The kits must be sufficient to meet the needs of residents and staff.

146 2960.0120 Physical Plant Standards Fire, health, zoning, and building code Fire, health, zoning, and building code Sleeping rooms for 4 or less Sleeping rooms for 4 or less Multi-bed bedrooms: ambulatory residents Multi-bed bedrooms: ambulatory residents 60 square feet per resident of useable flood space 60 square feet per resident of useable flood space three feet between beds placed side by side three feet between beds placed side by side one foot between beds placed end to end one foot between beds placed end to end

147 Subpart 2 Code Compliance Multi-bed bedrooms: non-ambulatory residents Multi-bed bedrooms: non-ambulatory residents 80 square feet per resident of useable floor space 80 square feet per resident of useable floor space adequate space for clothing and personal possessions adequate space for clothing and personal possessions appropriate furnishings to accommodate these items. appropriate furnishings to accommodate these items.

148 Code Compliance Outdoor recreational space Outdoor recreational space One shower or bathtub/sink/toilet per 8 residents One shower or bathtub/sink/toilet per 8 residents Hot and cold water Hot and cold water Heating plant providing comfortable temperature in all resident areas Heating plant providing comfortable temperature in all resident areas Lighting appropriate to function of area Lighting appropriate to function of area

149 Code Compliance Sufficient indoor space Sufficient indoor space For quiet group program activities For quiet group program activities On site education: Facility must meet the DOE provisions of educational services On site education: Facility must meet the DOE provisions of educational services Private intake admission area Private intake admission area


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