6 Colo. Code Regs. § 1011-1-4.1

Current through Register Vol. 47, No. 11, June 10, 2024

Section 6 CCR 1011-1-4.1 - ENDORSEMENT STANDARDS FOR ALL 24-HOUR/OVERNIGHT SERVICES

4.1.1 All BHEs providing 24-hour/Overnight services shall meet the standards in this Part 4.1, and shall meet the standards in Parts 4.2, Crisis Stabilization Services, and/or 4.3, Acute Treatment Services, as applicable to the services provided by the BHE.

4.1.2 The BHE shall complete a comprehensive assessment for each new client within twenty-four (24) hours of admission.

4.1.3 Each physical location in which 24-hour/Overnight services are provided shall meet the personnel requirements in Part 2.4, with the following additions:

(A) Each location shall have appropriate oversight personnel, such as an Administrator and/or Clinical Director, or individuals delegated those same responsibilities, twenty-four (24) hours per day, seven (7) days per week.

(1) Oversight personnel when such individuals are not physically on-site shall be in accordance with policies as required at Part 2.3.4(A)(6).

(B) Each location shall have at least one person on duty trained in basic life support and first aid on-site and on-duty at all times when clients are present.

(C) There shall be at least one awake person on duty on-site twenty-four (24) hours per day, seven (7) days per week.

(D) The BHE shall have appropriate staffing to ensure the ability to administer medications at all times.

4.1.4 Personnel providing services under the 24-hour/Overnight endorsement shall meet the training requirements at Part 2.4.9, with the following additions:

(A) The recognition and response to common side effects of medications used for behavioral health disorders, and response to emergency drug reactions;

(B) Assessment skills;

(C) Behavior management and de-escalation techniques, including incidents involving harm to self or others, and elopement; and

(D) Behavioral health and medical emergency response training, consistent with emergency services policies required in Parts 2.8.4 and 2.8.5.

4.1.5 The BHE shall have policies and procedures specific to the 24-hour/overnight endorsement, services, or physical location, as appropriate, including, but not limited to:

(A) Policies and procedures to be followed in the event of serious illness, injury, or death of a client during their stay, including, but not limited to:

(1) Criteria for when a client's injury or illness warrants medical treatment or an in-person medical evaluation.

(2) Requirements for notifying the client's emergency contact, including immediate notification in the case of an emergency room visit or unscheduled hospitalization.

(3) Reporting procedures within the BHE.

(B) Written policies and procedures for the management of clients' personal funds and property, including, but not limited to:

(1) An inventory of all of the client's personal belongings shall be conducted upon admission, and documented by at least two (2) individuals, one of which shall be the client when the client is capable and willing to document the inventory. Such inventory shall be maintained in the client record.

(2) All inventoried items shall be stored in a secure location during the client's stay.

(3) All inventoried property shall be returned to the client upon discharge, and such return shall be documented by at least two (2) individuals, one of which shall be the client when the client is capable and willing to document the inventory. Such documentation shall be included in the client record.

(C) Infection control policies to address risks associated with housekeeping, dietary services, and linen and laundry services, in addition to the requirements at Part 2.3.6.

(1) Linen and laundry services shall be conducted in a manner designed to prevent contamination of clients and staff.

(a) Staff shall prevent contamination between handling soiled linen and clean linen through either the use of gloves or handwashing.

(b) Soiled linen shall be stored separately from clean linen, in separate enclosed areas.

(2) Dietary services shall be provided using methods that conform to state or local food safety standards, including, at a minimum:

(a) The individual overseeing dietary services, as required at Part 4.1.5(E)(1) shall have knowledge of foodborne disease prevention, including, but not limited to, hygienic practices and food safety techniques pertaining to preparation, food storage, and dishwashing.

(b) Food shall be prepared, handled, and stored in a sanitary manner, so that it is free from spoilage and/or contamination, and shall be safe for human consumption.

(c) Reusable equipment, dishes, cutlery, and other wares used for the preparation, serving, or storage of food shall be washed in a safe and sanitary manner, and, in the case of dishwashing machines, in accordance with manufacturer's instructions.

(D) The provision of linen and laundry services, including, but not limited to:

(1) Clients shall have access to laundry services for personal clothing, which may be provided through the use of personal laundry facilities, a centralized laundry service, or may be contracted for with an outside provider.

(2) A requirement to maintain a sufficient supply of clean linen, including sheets and towels.

(E) The provision of dietary services. Policies and procedures regarding dietary services may vary depending on the population served, the services provided, and the anticipated length of stay, but shall include, at a minimum:

(1) The governing body or Administrator shall appoint an individual to be in charge of dietary services.

(2) At least three nutritionally balanced meals in adequate portions shall be made available at regular times daily. In the event the meal provided is unpalatable, a nutritionally balanced substitute shall be available.

(3) Between-meal snacks of nourishing quality shall be available, to the extent that such availability does not conflict with a client's service plan.

(4) If the BHE admits clients who require a therapeutic diet, the following requirements shall apply:

(a) The BHE shall ensure such diet is prescribed by a physician or registered dietician.

(b) The BHE shall ensure the proper diet is provided.

(5) The BHE shall ensure enough food and water on hand to provide all clients with three (3) nutritionally balanced meals for four (4) days.

(F) If the population served includes clients at risk of harm to self or others, the BHE shall require safety checks be conducted every shift to identify and remedy hazards, and shall maintain documentation of such checks.

(G) A requirement that medication counts, as required in Part 2.9, be performed when transitioning staff responsibility for medication oversight, but no less frequently than twice daily.

(H) Standards for maintaining the client record in accordance with Part 2.7 of these rules, with the following additions:

(1) A progress note shall be recorded for each client at least daily, or more often as appropriate.

(2) Progress notes shall include any significant change in physical, behavioral, cognitive, and functional condition and action taken by staff to address the individual's changing needs.

(3) Progress notes shall be signed and dated or electronically approved by the author at the time they are written, with at least first initial, last name, and degree and/or professional credentials.

(4) Telephone orders, when given, shall be recorded at the time they are given and authenticated as soon as practical.

(I) The type of first aid equipment maintained by the BHE, including a requirement that such equipment be maintained in a readily accessible location, at each physical location providing services under the 24-hour/overnight endorsement.

(J) Smoking policies applicable to clients, including, but not limited to any prohibitions on smoking, designated areas for smoking, and methods/substances allowed under any smoking policy, such as tobacco, electronic cigarettes, vaporizers, etc.

4.1.6 The BHE shall ensure the physical locations in which client services are provided under the 24-hour/Overnight Endorsement meet the building standards in Part 2.2 of this Chapter, and Chapter 4.3 of Guidelines for Design and Construction of Residential Health, Care and Support Facilities, Facilities Guidelines Institute, with the following additions or exceptions:

(A) In addition to the FGI standard at 4.3-2.2, regarding the resident unit, the BHE shall ensure no client is assigned to any room other than a regularly designated bedroom.

(1) Temporary occupancy of a room not designated as a bedroom is permissible on a limited basis when the use of the assigned bedroom is contraindicated due to circumstances related to client safety or emergent issues. Justification for such placement, and the length of placement, shall be documented in the client record.

(B) In addition to the FGI standard at 4.3-2.2.2.7, regarding resident bathrooms, the BHE shall ensure there is a minimum of one (1) full bathroom for every six (6) clients, including a toilet, sink, toilet paper dispenser, mirror, tub and/or shower, and towel rack.

(C) Bathrooms shall be equipped with soap dispensers or the BHE shall have a procedure in place that prevents clients from sharing soap.

(D) The BHE is exempt from the FGI requirement to provide private individual storage inside the bathroom for the personal effects of each client. Such storage may be provided near the bathroom.

4.1.7 BHEs with one or more seclusion rooms shall ensure each seclusion room complies with the standards in Section 2.11 -3.2 .7, Chapter 2.11 of Guidelines for Design and Construction of Outpatient Facilities, Facilities Guidelines Institute, with the following additions:

(A) The observation of the client may be through a view panel located in the door or in close proximity to the door.

(B) The seclusion room must be at least 100 square feet in size.

6 CCR 1011-1-4.1