12 Colo. Code Regs. § 2509-8-7.714

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

Section 12 CCR 2509-8-7.714 - QUALITY STANDARDS FOR TWENTY-FOUR (24)-HOUR CHILD CARE

All rules in Section 7.714 will be known and hereinafter referred to as the Quality Standards for Twenty-Four (24)-Hour Child Care and will apply to all child care applicants and licensees subject to licensing as a specialized group facility, residential child care facility, shelter residential child care facility, or psychiatric residential treatment facility. However, Section 7.714.53 , et seq., and the applicable definitions in Section 7.714.1 also apply to approved family foster care homes, see Section 7.708.36 , et seq., and day treatment centers, see Section 7.706, et seq.

7.714.1DEFINITIONS [Rev. eff. 6/1/12]

"Client Representative" means a person designated by the facility to process grievances.

"Chemical restraint" means giving an individual medication involuntarily for the purpose of restraining that individual; except that chemical restraint does not include the involuntary administration of medication pursuant to Section 27-65-111(5), C.R.S., or administration of medication for voluntary or life-saving medical procedures. A chemical restraint does not include a drug or medication that is a usual and customary part of a medical diagnostic or treatment procedure to treat the individual's medical condition or symptoms or to promote the individual's independent functioning.

"De-escalation" is the use of therapeutic interventions with a child during the escalation phase of a crisis. The interventions are designed to allow children to contain their own behavior so that acute physical behavior does not develop that would lead to the need to use a physical management.

"Emergency" means a serious, probable, imminent threat of bodily harm to self or others where there is the present ability to effect such bodily harm.

"Escalation" is an increase in intensity of a child's out-of-control behavior.

The "Family Service Plan" is a case services plan completed by a county caseworker jointly with the child, parents, and providers within sixty (60) calendar days of placement for each child receiving services from a county department of social/human services.

The "Individual Child's Plan" ("the Plan") is based upon an assessment of the child immediately following placement at the facility. It is developed by the facility for each child and must be consistent with the Family Service Plan for the child.

"Mechanical Restraint" means a physical device used to involuntarily restrict the movement of an individual or the movement or normal function of a portion of his or her body. Mechanical restraints include, but are not limited to: the use of handcuffs, shackles, straight jackets, posey vests, ankle and wrist restraints, craig beds, vail beds, and chest restraints. Mechanical restraint does not include the use of protective devices used for the purpose of providing physical support or prevention of accidental injury.

"Nationally Recognized Criteria" means a set of standards, nationally acknowledged as acceptable and appropriate for use with at-risk populations, that are incorporated into the model of physical management utilized by the facility. The Nationally Recognized Criteria shall include, at a minimum the following:

A. Annual staff training and/or certification, to include training upon hire, and ongoing (at least every six months) refresher training or practice exercises for each staff member trained or certified in restraint, to review and refresh skills involved in positive behavior intervention, prevention, de-escalation, and physical management, in accordance with the model.

B. A restraint prevention and de-escalation component, to include identifying antecedents that may cause an individual to escalate, and/or development of behavior management plans that are in alignment with individual treatment plans if necessary.

C. A physical management process that prohibits or provides alternatives to a prone position, and includes identifying primary control techniques that emphasize utilizing only the minimum amount of force necessary to gain control and keep the individual safe.

D. A debriefing process which includes a review of physical management, to determine the appropriateness and effectiveness of preventive/de-escalation techniques used, the appropriateness of physical management, and how, or if, physical managements are preventable.

"Physical Management" means the physical action of placing one's hands on an individual. Physical management may be used to gain physical control in order to protect the individual or others from harm after all attempts to verbally direct or deescalate the individual have failed. Physical management may be utilized when an emergency situation exists. The physical management continuum may include:

A. Utilizing transitional measures.

B. Placing one's hands on an individual to physically guide and/or physically control the individual.

C. Use of an approved restraint method to control or contain the individual.

D. Placing of an individual into an approved prolonged restraint method.

E. Physical management may be used to move or escort an individual into seclusion. Seclusion, in itself, is not a form of physical management.

"Physical Restraint" means the use of bodily, physical force to involuntarily limit an individual's freedom of movement.

"Prone Position" means placing an individual in a face down position.

"Prone Restraint" means a restraint in which the individual being restrained is secured for a period of time in a prone position for a period of time exceeding five (5) minutes.

"Reasonable" as used in these rules means appropriate and suitable, or not excessive or extreme.

"Religion" where used in these regulations includes traditional religious beliefs and spiritual beliefs such as those of Native Americans.

"Restraint" means any method or device used to involuntarily limit freedom of movement, including, but not limited to, bodily physical force, mechanical devices, or chemicals. Restraint includes a chemical restraint, a mechanical restraint, a physical restraint, and seclusion. Restraint does not include:

A. The use of any form of restraint in a licensed or certified hospital when such use is in the context of providing medical or dental services that are provided with the consent of the individual or the individual's guardian;

B. The use of protective devices or adaptive devices for providing physical support, prevention of injury, or voluntary or life-saving medical procedures;

C. The initial temporary holding or positioning of an individual, for less than five minutes, by a staff person appropriately trained and/or certified for protection of the individual or other persons;

D. The holding of a child by one adult for the purpose of calming or comforting the child;

E. Placement of an individual in his or her sleeping room for the night; or,

F. The use of time-out, in an unlocked setting where voluntary egress is not prevented, and as may be defined by written policies, rules, or procedures.

A "Residential Facility" ("the facility") provides 24-hour child care and includes residential child care facilities and specialized group facilities.

A "staff member" of the facility as used in these rules includes a specialized group home parent or a specialized group center or residential child care facility.

"Seclusion" means the placement of an individual, six (6) years old or older, alone in a room from which egress is involuntarily prevented.

"Transitional measure" means physical guidance, prompting techniques of short duration, or an initial temporary approved physical positioning of an individual at the onset or in response to a re-escalation during a physical management, for the purpose of quickly and effectively gaining physical control of that individual in order to prevent harm to self or others. Momentary utilization of a short term (as quickly as possible, but not to exceed five (5) minutes) prone position is only permissible during a transitional measure.

7.714.2ADMISSION POLICY AND PROCEDURES [Rev. eff. 6/1/12]

A. Admission of a child shall be in keeping with the stated purpose of the child care facility and shall be limited to those children for whom the facility is qualified by staff, program, equipment, and needs of children already in residence to provide care deemed necessary. Care must be provided in the least restrictive, most appropriate setting in order to meet the child's needs.

B. Each facility shall have a written admission policy which at a minimum must include:

1. The policies and procedures related to intake.

2. The age range and sex of children accepted for care.

3. The needs, problems, situations or patterns best addressed by the facility's program.

4. Any pre-placement requirements for the child, the parent(s) or guardian, and/or the placing agency.

5. The anticipated criteria, problems, situations, and patterns that would result in the facility requesting removal of a child from placement prior to the planned discharge.

6. The facility's policy concerning self-admission of children, if appropriate, and the application of Section 27-10-103,C.R.S. (Voluntary Application for Mental Health Services) when a child is admitted for mental health treatment.

7. A statement regarding the religious orientation or affiliation of the facility, of the child care program, and of the activities at the facility, if applicable.

8. Opportunities for children's participation in recreational activities religious activities, and community life.

C. The written description of admission policies and criteria shall be provided to referring agencies and to parents or guardians of any child referred for placement.

D. The facility shall accept a child into care only after a preliminary assessment/screening of presenting problems in areas such as social, physical health, mental health, psychological concerns, previous physical or sexual abuse, and concerns about previous delinquent, assaultive, or destructive behavior, if appropriate, has been conducted.

E. The facility shall obtain a current comprehensive intake evaluation, including a social, health, and family history, developmental assessment or mental health evaluation, and a psychological evaluation, if determined to be necessary by the facility. Educational records shall be obtained it appropriate. As much of this information as possible shall be obtained prior to admission, but the total evaluation shall be completed within fourteen (14) calendar days after admission. If the facility is unable to obtain this information within these time periods or is totally unable to obtain the information, the facility must document its attempts to obtain the information and reasons for not obtaining the information.

If a child is placed at the facility as an emergency placement, the facility shall obtain at least the following information: name, birth date, if available, and physical description of the child; date and time of the admission; name, address, telephone number and authority of person bringing the child to the facility, and the reason for placement. Any other information that may be available should be recorded at the time of placement or as it becomes available. The date that placement terminates shall also be recorded.

F. Preparation of the child for admission shall be in a manner consistent with the child's age and ability to participate in the plan and to understand the reason for the placement.

G. The placement agreement shall be developed with the involvement of the child, the parent(s) or guardian(s) and the representative of the placing agency. Where the involvement of any of these is not feasible or desirable, the reasons for the exclusion shall be recorded by the facility. The placement agreement shall address by reference or attachment at a minimum the following:

1. Discussion of the child's and the parent's or guardian's expectations regarding: family contact and involvement; how family contact and involvement are to occur; the nature and goals of care, including any specialized services or specialized treatment to be provided, the religious orientation and practices of the child and/or family; the anticipated length of stay, planned discharge date, criteria for discharge, and plan for the child following discharge.

2. The policy and procedure to be followed regarding the use of physical management, restraint and seclusion in an emergency situation pursuant to 7.714.53, et seq.

3. A delineation of the respective roles and responsibilities of all agencies and persons involved with the child and his/her family.

4. Written authorization for care and treatment of the child.

5. Written authorization to obtain routine medical and dental care for the child and to obtain emergency medical and dental care.

6. The legal status or custody of the child.

7. If a child is placed by a Colorado county department of social/human services, the appropriate State form or contract shall be completed. This form or contract may provide some of the required authorizations.

H. Within twenty-four (24) hours of arrival at the facility, a child shall be given an orientation to the facility, consistent with the child's age and ability to participate, which includes at least the following:

1. Tour of the facility and instruction on fire alarm and fire evacuation procedures, escape routes and exits.

2. The rules/regulations of the facility.

3. Procedures that will affect the child's behavior, including limiting or restricting a child's rights where allowed, the type of discipline used in the facility, the consequences for certain behaviors, and the orientation, notification and consents required by Section 7.714.53, et seq.

4. The complete children's rights and children's grievance procedures as developed by the facility and the name of the client representative.

5. A form signed by the staff member and the child, if applicable, verifying that the orientation occurred.

6. Introduction to staff.

7. Discussion of tasks and behaviors the child is expected to perform.

7.714.3RELIGION, RIGHTS, AND GRIEVANCE PROCEDURES

7.714.31Children's Rights

A. The facility shall have written policies and procedures that address and ensure the availability of each of the following core rights for children in residence. These rights may not be restricted or denied by the facility.

1. Every child has the right to enjoy freedom of thought, conscience, cultural and ethnic practice, and religion.

2. Every child has the right to a reasonable degree of privacy.

3. Every child has the right to have his or her opinions heard and considered, to the greatest extent possible, when any decisions are being made affecting his/her life.

4. Every child has the right to receive appropriate and reasonable adult guidance, support and supervision.

5. Every child has the right to be free from physical abuse or neglect and inhumane treatment. Every child has the right to be protected from all forms of sexual exploitation.

6. Every child has the right to receive adequate and appropriate medical and mental health and psychiatric care in the least restrictive setting possible, suited to meet individual needs.

7. Every child has the right to receive adequate and appropriate food, clothing, and housing.

8. Every child has the right to live in clean, safe surroundings.

9. Every child has the right to participate in an educational program that will maximize his/her potential in accordance with existing law.

10. Every child has the right to communicate with "significant others" outside the facility, such as a parent or guardian, caseworker, attorney or guardian ad litem and/or counsel for youth, current therapist, physician, religious advisor, and, if appropriate, probation officer.

11. No foster child shall be fingerprinted for the purpose of a criminal background check unless required by law enforcement.

12. A child may be photographed upon admission for identification and administrative purposes of the facility pursuant to Section 19-3-306, C.R.S. Such photographs shall be confidential and shall not be released by the facility except pursuant to court order. No other non-medical photographs or videotaping shall be taken or used without the written consent of the child's parent or legal guardian except in the case of a child abuse or police investigation

13. Every child has the right to the same consideration for care and treatment as anyone else regardless of race, color, national origin, religion, age, sex, political affiliation, sexual orientation, financial status or disability.

14. Every child has the right to be given the names and professional status of the staff members responsible for his/her care.

15. Every child has the right to receive assistance from the resident representative in filing a grievance and to receive copies of the grievance procedure.

16. Every child fifteen (15) years of age and older has the right to request his or her own medical records, to see the records at reasonable times, and to be given written reasons if the request is denied.

17. Every child fifteen (15) years of age and older, who is not in the custody of human services, has the right to accept treatment of his/her own free will and may sign in as a voluntary resident. The child has the right to refuse to sign the consent for voluntary treatment at the time of admission or may take back the consent at a later date pursuant to Section 27-65-104, C.R.S.

B. The following children's rights may be limited to reasonable periods during the day or restricted according to written policies of the facility to ensure the protection of the children, staff, and program from unreasonable and unnecessary intrusions and disruptions and from health and safety hazards.

1. Every child has the right to have access to letter-writing materials, including postage, and to have staff members of the facility assist him/her if unable to write, prepare, and mail correspondence.

2. Every child has the right to have access to telephones to both make and receive calls in privacy.

3. Every child has the right to have convenient opportunities to meet with visitors.

4. Every child has the right to wear his/her own clothes, keep and use his/her own personal possessions, and keep and be allowed to spend a reasonable sum of his/her own money.

5. Every child has the right to receive and send sealed correspondence. No incoming or outgoing correspondence shall be opened, delayed, held, or censored by the personnel of the child care facility.

C. Written policies that restrict or limit a child's rights as listed at 7.714.31, B, must include at a minimum:

1. Plans for how and when telephone and written communications will take place.

2. Plans for regular visits of the child with relatives, friends, or others interested in his/her welfare, both within and outside of the facility, unless in the judgment of treatment staff and the placement agency visits would be detrimental to the child and/or his/her family.

3. Plans for extenuating circumstances and emergency situations affecting the child and his/her family.

4. The requirement that the facility notify the child, if appropriate to the age of the child, and his/her parent(s) or guardian(s) at the time of admission of any policy that would limit or restrict a child's rights. The notification must be communicated in a language or mode of communication the child can understand and, if possible, be signed by the child and his/her parent(s) or guardian(s).

D. If the facility enforces any restrictions upon the child's rights as listed at 7.714.31, B, the facility must, in compliance with the written policy and procedure of the facility:

1. Inform the child and the child's family and custodian or legal guardian, in a language or mode of communication the child can understand, of the conditions of and reasons for restriction or termination, of his/her rights.

2. Place a written report summarizing the conditions of and reasons for restriction, denial, or termination of the child's rights in that child's case record or treatment record. Information pertaining to a restriction, denial, or termination of a child's rights contained in the child's treatment or case record must be made available, upon request, to the child or the child's guardian ad litem (gal) and/or counsel for YOUTH.

3. When a restriction of a child's rights affects another individual, the individual shall be informed, in a language or mode of communication the individual can understand, of the conditions of and reasons for the action.

7.714.32Children's Grievance Procedure [Rev. eff. 7/2/06]

A. The facility must designate a client representative and establish a written grievance procedure that provides adequate due process safeguards, spells out the appeal process and assures that children and parent(s) or guardian(s) are entitled to report any grievance and shall not be subject to any adverse action as a result of filing the grievance.

1. The facility must follow grievance procedures without alteration or interference and must respond to any grievance filed within 72 hours.

2. This grievance procedure shall be made available to all children as provided for in the resident rights.

3. If a grievance is filed with the facility, the grievance shall be recorded in the child's record along with the investigation findings and resulting action taken by the facility. Information regarding the grievance must be sent to the individual or agency holding legal custody of the child. A copy of the child's grievance may be sent to the parent with the child's permission.

4. A list of the resident rights shall be prominently posted in all facilities in areas frequented by children and legal guardians. These rights shall include the grievance procedure, the name, address, and telephone number of their resident representative, as well as a list of agencies where complaints may be filed.

B. A list of the children's rights and the grievance procedures must be provided and explained to the child and the parent or guardian in a language or manner of communication that they can understand.

7.714.33Religion [Rev. eff. 7/2/06]

The facility shall demonstrate consideration for, and sensitivity to, the religious backgrounds of children in care. The facility shall assist a child's involvement in religious activities appropriate to the child's religious background, based upon the needs and interests of the child.

A. A child in care at the facility shall be allowed and encouraged to celebrate his/her religious holidays.

B. Opportunity and assistance shall be provided for each child to practice the chosen/preferred religious beliefs and faith of his/her family. If the family has no preference, the individual preference of the child shall be respected. This includes, but is not limited to, making necessary arrangements for attendance of children at the appropriate religious institution or at a study group for religious instruction.

C. A child may be invited to participate in the religious activities of the facility.

D. A child shall not be coerced or forced to participate in the religious activities of the facility or to attend religious services.

E. Prior to placement of the child at the facility, the parent(s), guardian(s), and/or placing agencies must be notified of the practices, philosophy, and religious affiliation of the facility.

F. Any form of religious intervention used by the facility to control or change a child's behavior, or treat or heal a medical condition, must be approved, in writing, by the legal guardian(s) of the child prior to the use of the intervention.

G. A facility cannot deny medical care to a child because of the religious beliefs of the facility.

H. The child's family and/or guardian must be consulted prior to any planned change in religious affiliation made by the child while he/she is in care at the facility.

7.714.4PROGRAM DESCRIPTION AND INDIVIDUAL CHILD'S PLAN [Rev. eff. 6/1/12]

A. The facility shall have a written overall program description for the facility. The written description shall include the following:

1. The title of the person who has overall responsibility for the development, implementation, and coordination of the treatment program.

2. Staff responsibility for planning and implementation of the treatment procedures and techniques.

3. The range of procedures and techniques to be used and the anticipated range or types of behavior or conditions for which such procedures and techniques are to be used, including philosophy of treatment, modes of therapy, treatment modalities, positive behavior intervention, problem management, discipline, physical management, restraint, and seclusion where allowed and approved by the department.

4. The facility's responsibility for monitoring the safety of children during treatment.

5. Review procedures for ensuring the appropriateness of the ongoing treatment and placement for each child.

6. Policies and procedures encouraging termination of the treatment procedures at the earliest opportunity in the event of achievement of goals, or when the procedures are proving to be ineffective or detrimental for a particular child.

7. Policies and procedures on how the facility involves the child and the parent(s) or guardian(s) in the plan for care and treatment of the child and obtains their consent of the plan and any subsequent revisions to the plan.

8. Policies and procedures on how the facility monitors the ongoing physical safety of a child during treatment or therapy which involves face to face interaction with the child.

9. Requirements, where appropriate, for medical examination of a child prior to implementation of a treatment strategy on a regular basis.

10. Provisions for regular and thorough review and analysis of the individualized treatment strategies and the overall treatment orientation of the facility, including provisions for making appropriate adjustments in the treatment strategies and orientation, the recording practices and procedures, and the program activities in accordance with the results of the reviews.

11. Each facility shall adopt and implement a written policy for continuity of resident care which shall include, at a minimum, the following:

a. Ease of resident movement from one element of service to another within the facility.

b. Aftercare planning, to be completed ninety (90) calendar days prior to a scheduled discharge, and included with the resident's discharge summary which describes any recommendations for the resident to follow after discharge from the facility.

c. Referrals to other agencies.

12. The placement alternative selected shall be conducive to the optimum restoration of the resident's mental and physical functioning, with due regard for the safety of the resident and those around him/her and the availability of placement alternatives.

B. A facility shall prohibit all cruel and aversive treatment or therapy including, but not limited to, the following:

1. Any intervention designed to or likely to cause a child physical pain.

2. Releasing noxious, toxic or unpleasant sprays, mists, or substances in proximity to the child's face.

3. Any intervention that denies a child sleep, food, water, shelter, access to bathroom facilities, adequate bedding, or appropriate physical comfort.

4. Any intervention or type of treatment that subjects a child to verbal abuse, ridicule, humiliation, or that can be expected to cause excessive emotional trauma.

5. Interventions that use a device, material, or object that is designed to simultaneously immobilize ail four of the child's extremities.

6. Any treatment intervention that deprives a child of the use of his/her senses, including sight, hearing, touch, taste, or smell.

7. Physical management, restraint, and seclusion except as described at Section 7.714.53.

8. Use of rebirthing therapy or any therapy technique that may be considered similar to rebirthing therapy as a therapeutic treatment, as defined by Section 12-43-222(1)(t)(IV), C.R.S.

C. Within seven (7) calendar days of admitting a child in care, a facility shall begin a comprehensive assessment/evaluation of the child.

1. The assessment/evaluation shall be conducted by a planning team This team shall include persons responsible for implementing the plan on a daily basis and persons who have had direct interaction with and observation of the child.

2. The planning team shall assess and evaluate the needs and strengths of the child in at least the following areas where information is available:

a. Medical, health and dental care, including a health history of the child and family, and if appropriate health information regarding speech therapy, occupational therapy, and physical therapy needs of the child;

b. Mental and psychological health, including treatment history;

c. Education/vocation;

d. Personal/social development;

e. Family and community relationships;

f. Vocational training, if appropriate;

g. Recreation;

h. Life skills development;

i. Emancipation skills, if appropriate;

j. Legal status and history;

k. Treatment/placement history;

l. Alcohol/substance abuse history.

3. All direct assessments/evaluations of the child shall be conducted in the child's dominant language or mode of communication, including augmented or facilitated communication, if necessary, and shall take into consideration the child's age, disability, and cultural and religious background.

D. On the basis of this assessment/evaluation, and within fourteen (14) calendar days of admission, a facility shall develop an individual child's plan that is written, time-limited, strength-focused, outcome based, and goal-oriented. The plan must support the Family Services Plan.

1. A facility must provide an opportunity for the following persons to participate in the planning/evaluation process:

a. The primary caregiver for the child;

b. The child, unless contraindicated;

c. His/her parent(s) or guardian(s), unless contraindicated;

d. Representatives of the placing agency;

e. School personnel;

f. Other persons significant in the child's life, such as a GAL, attorney, religious advisor, and therapist.

g. When any of the above persons do not participate, the facility shall have documentation of its efforts to involve the persons(s). When the involvement of parents(s) or guardian(s) of the child is deemed contraindicated by the agency or individual holding legal custody of the child, the reasons for contraindication shall be documented.

2. The individual plan shall include the following components:

a. The findings of the assessment/evaluation.

b. A statement of specific, measurable goals to be achieved or worked toward for the child and his/her family.

c. Strategy for fostering, maintaining, and enhancing positive family relationships with the child and his/her family, including siblings, or other individuals considered like family, or guardian(s), and including the development of a permanent home for the child.

d. Strategy for fostering, maintaining and enhancing active community involvement for the child.

e. Specification of the daily activities intended to achieve the stated goals including, but not limited to, educational, vocational, and recreational activities.

f. Specification of therapeutic services, specialized services, and strategies for positive behavior intervention that will be provided directly or arranged for, frequency of services, and method for ensuring their proper integration with the child's ongoing program activities.

g. Long-term and short-term goals and the method to be used for evaluating the child's progress toward meeting the goals.

h. Goals and preliminary plans for discharge, aftercare, and moving to a less restrictive setting.

i. Identification of all persons responsible for implementing or coordinating implementation of the plan.

j. Signature by a representative of the facility, a representative of the placing agency, the child, if indicated, and the child's parent(s) or guardian(s).

k. Assurance by the facility that the plan and any subsequent revisions are explained to the child in care and his/her parent(s) or guardian(s) in a language or manner of communication the child and parent(s) or guardian(s) can understand.

l. Quarterly review of each plan to evaluate the progress which the short-term and long-term goals have been achieved and not achieved. The parties listed in Section 7.714.4 , D, 1, shall have an opportunity to participate in the reviews. The plan shall support the Family Service Plan.

E. If the assessment/evaluation process or the plan requires the services of a specialist, such as a psychiatrist, psychologist, speech therapist, occupational therapist, or physical therapist, the specialist shall be currently certified or licensed according to State law.

F. In addition to A-E, the following is required for an Individual Child's Plan in a Residential Child Care Facility that provides mental health services:

1. The licensed mental health professional responsible for providing care shall develop the mental health component of the Individual Child's Plan.

2. The multidisciplinary team shall include the Individual Child's Plan within its child specific case file.

3. The multidisciplinary team shall develop and finalize a comprehensive Individual Child's Plan of care (as covered in Section 7.714.4, D, 1, a-g) within fourteen (14) calendar days after the determination that mental health services are required. The plan shall be signed and dated by the child, the referral agency, the licensed mental health professional, and the parent/guardian. If a provisionally licensed mental health professional is providing the services, that person and his/her licensed supervisor shall also sign the Individual Child's Plan of care. The plan of care shall:

a. Address all areas listed at Section 7.714.4, C, together with mental health services and other needs including the child's presenting problems, physical health, emotional status, behavior, support system in the community, available resources, and discharge plan.

b. Include specific goals and measurable objectives, expected dates of achievement, specific discharge and transitional/after-care and follow-up services criteria to be met for termination of treatment, and specific treatment goals including, but not limited to:

1) Expected resolution of the problem that necessitated mental health services and the specific functional achievement to be obtained in measurable terms.

2) Indications that planned services can reasonably be expected to improve the client's condition.

c. Specify the type, frequency, and duration of mental health services, rehabilitation services, medication management, emergency services, initial assessment, documented treatment modifications, and other services determined to be necessary to meet the child's specific mental health service goals.

d. Specify that all RCCF mental health services are necessary to meet the needs of the child and that the mental health services are necessary to treat the child's current diagnosis.

e. Identify the provision of, or the referral for, services other than RCCF mental health services and shall document any court ordered treatment including identifying the agency responsible for providing the court ordered treatment.

f. Be provided in all situations except emergency situations.

4. The RCCF shall ensure that the child and the legal guardian participate in the formulation, review, and revision of the Individual Child's Plan of care including, but not limited to, the mental health services portion of the plan. If the child or legal guardian is unable to participate or when his or her participation is clinically contraindicated, the RCCF shall document the reasons in the child's record. Any decision to not involve the family or guardian shall be approved by the referral agency. In addition, other persons selected by the child, the family or guardian, the referral agency or the multidisciplinary team may be included in the formulation, review, and revision of the plan care.

5. There shall be monthly review of each plan to evaluate whether the short-term and long-term goals have been achieved and not achieved. The plan shall be revised as appropriate.

6. There shall be documentation of the client's response to treatment approaches and changes in the Individual Child's Plan of care with the reasons for such changes.

G. The facility shall have a written plan for each individual in residence. Prior to the placement of the child in seclusion, the conditions for use of the seclusion shall be detailed and justified in the written plan, and the child shall be oriented to the room, the purpose of its use and type of behavior which might result in its use.

7.714.5SAFETY, DISCIPLINE, PHYSICAL MANAGEMENT, RESTRAINT, AND SECLUSION

7.714.51Building Safety

7.714.511Building Site [Rev. eff. 7/2/06]

A. The facility must be located in an area that is readily accessible to health resources, public and private utilities, adequate and safe water supplies, sewage disposal, and fire and police protection.

B. The facility site shall be located in accordance with local zoning department requirements.

C. The entire premises of the facility are subject to inspection for licensing purposes, including but not limited to the residence where care is to be provided, the grounds surrounding the facility, the basement, the attic (if accessible), any storage buildings, and a garage or carport, if applicable.

D. If the facility is located in the same building as, or immediately adjacent to, other facilities, or an adult treatment center, or a nursing home, it shall be so arranged that the care and activities of the children residing in the facility are completely separate and independent from the other facility. The facility may not be operated on the premises of a business that might be hazardous to the health, safety, morals, or welfare of children and the operation of the facility.

E. The facility, including indoor and outdoor space, shall be maintained in a safe condition free from hazards to health and safety.

F. There shall be outdoor space available to provide some recreation area for children. This area shall be fenced if children younger than five years old are in care, or older children with disabilities require either containment or protection from outside elements such as animals.

7.714.512Building Maintenance [Rev. eff. 7/2/06]

A. Buildings shall be kept in good repair and maintained in a safe, clean, and sanitary condition. Good housekeeping must be observed in all areas at all times. Needed repairs must be identified regularly and corrected immediately.

B. All areas of the facility available to children's activities including equipment, materials and furnishings shall be of sturdy, safe construction, and free of hazards, such as sharp points or comers, splinters, protruding nails, broken play and recreational equipment.

C. Closets, attics, basements, cellars, and furnace rooms shall be kept free from accumulation of significant amounts of extraneous materials such as furnishings, newspapers, or magazines that could pose a fire or health hazard.

7.714.513Fire Safety [Rev. eff. 7/2/06]

A. Fire hazards, such as defective electrical appliances and electric cords, dangerous or defective heating equipment or flammable material stored in such a manner as to create a risk of fire shall be corrected or eliminated.

B. The facility shall contain at least one U.L.-approved fire extinguisher on each floor of the facility that is highly visible, easily accessible, and in working condition, weighing not less than five pounds, that has a rating of 2A, 10BC. This requirement may be waived where more extensive fire-control measures are required by a local fire department.

C. A smoke detector, in working condition, must be installed on each level of the facility where child care occurs and near sleeping areas.

D. All heating units, gas or electric, shall be installed and maintained with safety devices to prevent fire, explosions, and other hazards. No gas or electric space heaters, open-flame gas or oil stoves, hot plates, or unvented heaters shall be used in the facility for heating purposes.

E. Flammables, aerosol paints, insecticides, chemicals, and other dangerous materials shall be locked or stored so they are inaccessible to children and must be stored in areas separate from sleeping or living areas. Flammables shall be stored in an OSHA approved container.

F. Heating devices such as radiators, registers, fireplaces, and steam and hot water pipes that pose a fire or burn hazard to children shall be screened or otherwise protected.

G. Flammable material must not be stored near a furnace, hot water heater, or other heating device.

H. There shall be no candles or other burnable objects permitted in sleeping areas.

I. Exit doors shall be obvious, clearly identified as an exit, and marked by an approved sign that is clearly visible from any direction of exit access. No lock or fastening to prevent free escape from the inside of any room used by the children shall be permitted except for a Department-approved locked quiet room.

J. Exit routes shall be kept free of any barriers to free escape including, but not limited to, discarded furniture, furnishings, laundry, and stacks of newspapers or magazines that could interfere with the prompt evacuation of the facility.

7.714.514Disaster Drills [Rev. eff. 7/2/06]

A. There shall be written procedures for staff and children to follow in case of emergency or disaster. These procedures shall be developed by the facility with the assistance of qualified fire and safety personnel and shall include provisions for staff roles and responsibilities during an emergency, evaluation of the facility, and the assignment of a central meeting place where each individual may be accounted for.

B. Fire exit drills must be held on each shift on a rotating basis with no less than one (1) shift per quarter so that all occupants are familiar with the drill procedure and their conduct during a drill is a matter of established routine.

C. Drills must be held at unexpected times and under varying conditions to simulate the conditions of an actual fire.

D. Drills must emphasize orderly evacuation under proper discipline rather than speed. Running or horseplay shall not be permitted.

E. Drills must include suitable procedures for ensuring that all persons in the facility actually participate.

F. A record of fire drills held over the past twelve (12) months must be maintained by the facility on a drill log, including the number of children and staff participating in the drill.

G. Fire alarm facilities shall be regularly used in the conduct of drills.

H. The facility shall make special provisions for the evacuation of any physically handicapped children in the facility.

I. The facility shall take special care to help emotionally disturbed or perceptually handicapped children understand the nature of such drills.

J. If appropriate to the location of the facility, tornado drills must be held often enough so that all occupants are familiar with the drill procedure and conduct during a drill is a matter of established routine. A record of tornado drills held over the past 12 months must be maintained by the facility.

7.714.515General Comfort and Safety [Rev. eff. 7/2/06]

A. All hazardous chemicals, tools, and other equipment, including matches, plastic bags, paints, gasoline, medicines, insecticides, and cleaning and laundry materials, shall be inventoried and stored in a secured locked area.

B. A facility shall not maintain any weapons such as firearms, air rifles, hunting bows, hunting knives, or hunting sting shots on the grounds or within the structure of the facility. A facility shall not permit any staff member or child to be in possession of any firearm on the grounds or within the structures of the facility. Chemical weapons, even when carried by staff members to and from work for protection, shall be locked when present at the facility. Weapons must not be transported in any vehicle in which children are riding. Law enforcement professionals are exempt from the requirements of this section if conditions of their employment require them to carry weapons.

C. The facility shall be equipped with adequate light, heat, ventilation, and plumbing for safe and comfortable occupancy.

D. All stairways containing more than four steps shall be equipped with a handrail.

E. The facility shall have an unblocked, non-mobile landline telephone, and emergency numbers shall be posted near the telephone, including those related to medical care, fire, law enforcement, and poison control where available. Numbers for the agency or person having legal custody of each child shall also be readily available.

7.714.516Transportation [Rev. eff. 7/2/06]

A. A facility shall ensure that each child is provided with the transportation necessary for implementing the child's individual plan.

B. A facility shall have means of transporting children in cases of emergency.

C. Any vehicle used by the facility in transporting children in care, whether such vehicle is operated by a staff member or any other person acting on behalf of the facility, shall be properly licensed, and the vehicle shall be maintained in accordance with Colorado law.

D. Any staff member or other person acting on behalf of the facility operating a vehicle for purpose of transporting children shall be properly licensed to operate the class of vehicle in accordance with Colorado law.

E. Children under 21 years of age must be properly fastened into a child restraint system that conforms to all applicable Federal Motor Vehicle Safety Standards and pursuant to Colorado law.

F. A facility shall not allow the number of persons in any vehicle used to transport children to exceed the number of available seats in the vehicle.

G. The vehicle shall be enclosed and provided with door locks, and contain a First Aid kit and fire extinguisher.

H. A facility shall ascertain the nature of any need or problem of a child which might cause difficulty during transportation, such as seizures or a tendency toward motion sickness. The facility shall communicate this information to the driver of any vehicle transporting children in care.

I. The facility shall have a written policy concerning under what circumstances a vehicle may be driven by a licensed resident alone or with one resident passenger. Such driving privileges, if granted, shall be a part of the child's individual plan.

7.714.52Discipline

A. The facility shall have written policies and procedures regarding discipline that must be explained to all children, parent(s), guardian(s), staff, and placing agencies. These policies must include positive responses to a child's appropriate behavior.

B. Discipline shall be constructive or educational in nature and may include talking with the child about the situation, praise for appropriate behavior, diversion, separation from the problem situation, and withholding privileges.

C. Basic rights shall not be denied as a disciplinary measure.

D. Separation when used as discipline must be brief and appropriate to the child's age and circumstances. The child shall always be within hearing of an adult in a safe, clean, well-lighted, well-ventilated room in the facility that contains at least 50 square feet of floor space. No child shall be isolated in a bathroom, closet, attic, pantry, or garage.

E. Children in care at the facility shall not discipline other residents. This does not prohibit a facility from operating an organized therapeutic self-government program or positive peer culture that is conducted in accordance with the written policies of the facility and these rules, and is directly supervised by a staff member

F. A facility shall prohibit all cruel and unusual discipline including, but not limited to, the following:

1. Any type of physical hitting or any type of physical punishment inflicted in any manner upon the body of the child such as spanking, striking, swatting, punching, shaking, biting, hair pulling, roughly handling a child, striking with an inanimate object, or any humiliating or frightening method of discipline to control the actions of any child or group of children.

2. Discipline that is designed to, or likely to, cause physical pain.

3. Physical exercises such as running or walking laps, push-ups, or carrying or stacking heavy rocks, bricks, or lumber when used solely as a means of punishment.

4. Assignment of physically strenuous or harsh work that could result in harm to the child

5. Requiring or forcing a child to take an uncomfortable position such as squatting or bending, or requiring a child to stay in a position for an extended length of time such as standing with nose to the wall, holding hands over head, or sitting in a cross-legged position on the floor, or requiring or forcing a child to repeat physical movements when used solely as a means of punishment.

6. Group discipline except in accordance with the facility's written policy and these rules.

7. Verbal abuse or derogatory remarks about the child, his/her family, his/her race; religion, or cultural background.

8. Denial of any essential/basic program service solely for disciplinary purposes.

9. Deprivation of meals or snacks, although scheduled meals or snacks may be provided individually.

10. Denial of visiting or communication privileges with family, clergy, attorney, guardian ad litem (gal) and/or counsel FOR YOUTH or caseworker solely as a means of punishment.

11. Releasing noxious, toxic, or otherwise unpleasant sprays, mists, or aerosol substances in proximity to the child's face.

12. Denial of sleep.

13. Requiring the child to remain silent for a period of time inconsistent with the child's age, developmental level, or medical condition.

14. Denial of shelter, clothing or bedding.

15. Withholding of emotional response or stimulation.

16. Discipline associated with toileting, toileting accidents or lapses in toilet training.

17. Sending a child to bed as punishment. This does not prohibit a facility from setting individual bed times for children.

18. Force feeding a child.

19. Use of physical management, restraint or seclusion as discipline for a child.

7.714.53PHYSICAL MANAGEMENT, RESTRAINT AND SECLUSION [Rev. eff. 6/1/12]

If a facility is authorized to use physical management, restraint or seclusion at the facility, the facility shall use physical management, restraint or seclusion only in accordance with the following rules unless the specific rules prohibit, limit or modify the requirements placed upon the facility.

7.714.531Authorization [Ref. eff. 6/1/12]

At the time of admission to the facility, the legal custodian of the individual shall be notified that physical management or seclusion may performed in certain circumstances. For a facility to perform physical management or seclusion, the legal custodian must give written consent for physical management and/or seclusion to be performed on the individual. No physical management or seclusion shall be performed on an individual without the specific written permission of the individual's legal custodian.

7.714.532Uses Of Physical Management, Restraint and Seclusion [Rev. eff. 6/1/12]

Facility staff, including pre-approved family foster care home providers, may only use:

A. Restraint or seclusion in an emergency after the failure of less restrictive alternatives or after a determination that such alternatives would be inappropriate or ineffective under the circumstances; and,

B. Restraint if prior to the use of restraint:

1. Staff have been appropriately trained or certified in accordance with a model that includes nationally recognized criteria; and,

2. The facility tried all positive and constructive methods of dealing with the individual, including, but not limited to, implementation of a structured and consistent behavior management program, physical structuring of the environment, talking with the individual, praise for appropriate behavior, skill training and development, assisting the individual with the expression of feelings, and de-escalation of the situation.

In addition to the circumstances delineated in these rules, Seclusion may be used pursuant to a valid court order that the individual is kept separate from the general population.

7.714.533Facility Policies And/Or Procedures [Rev. eff. 6/1/12]

Facility policies and/or procedures shall, at a minimum, include and comply with the following:

A. The use of prone restraint is prohibited. Momentary (as quickly as possible, but not to exceed five (5) minutes) utilization of a prone position is permissible only during the transitional measure portion of a physical management.

B. When using a physical or mechanical restraint method, in the course of a physical management, trained or certified staff shall be positioned within arm's length of the individual and continuously monitor the person to assure that the individual is properly positioned, that the individual's blood circulation is not restricted, that the individual's airway is not obstructed, and that the individual's other physical needs are met. Staff shall not place excessive pressure on the chest, abdomen or back of an individual or inhibit or impede the individual's ability to breathe. Staff shall continuously monitor to ensure that the breathing of the individual in such restraint is not compromised. If the individual is exceedingly agitated, staff may move further from the individual, but must still be able to effectively assess, and respond as necessary, to the individual's physical condition. If breathing is compromised in any way, the restraint shall be discontinued immediately and a physical assessment shall occur to determine if medical attention is needed.

1. A transitional measure may be used during an episode of physical management to effectively gain initial physical control of an individual in order to prevent harm to self or others. A transitional measure may result in a restraint to maintain prolonged physical control or containment of an individual.

2. When mechanical restraints are used, staff shall provide relief periods, except when the individual is sleeping, of at least ten minutes as often as every two hours, so long as relief from the mechanical restraint is determined to be safe. During such relief periods, the staff shall ensure proper positioning of the individual and provide movement of limbs, as necessary. In addition, during such relief periods, staff shall provide assistance with toileting, as necessary. The individual's dignity and safety shall be maintained during relief periods. Staff shall note the relief periods granted in the record of the individual being restrained.

3. An individual in physical restraint shall be released from such restraint within fifteen minutes after physical control of the individual is gained, except when precluded for safety reasons and documented accordingly.

C. Chemical restraint is prohibited.

D. When seclusion is utilized:

1. Relief periods shall be provided for reasonable access to toilet facilities. While in seclusion, staff shall be physically present and individuals shall be visually observed no less than every fifteen (15) minutes.

2. When a facility utilizes seclusion, there shall be a seclusion room supervisor who is a fulltime facility staff member, is a Colorado Licensed Clinical Social Worker (LCSW), a Licensed Professional Counselor (LPC), a Licensed Marriage and Family Therapist (LMFT), a Colorado licensed psychologist or a board-eligible psychiatrist licensed to practice medicine in Colorado, and is designated and trained to be responsible for the use of seclusion and the seclusion room. If the seclusion room supervisor is not a psychiatrist or a licensed psychologist, there shall be such a person contracted to provide consultation with the seclusion room supervisor and staff. Staff will obtain authorization from the seclusion room supervisor prior to utilizing the seclusion room.

E. Each program choosing to use physical management, restraint and/or seclusion is to have a written policy, and practices consistent with these rules and the written policy. The program's written policy must include at a minimum the following information:

1. Documentation of the physical management model used. The physical management model shall comport with the requirements provided in section 7.714.53, et seq.

2. Documentation of the type of behavior management system utilized by the program.

3. The training, which satisfies the requirements of section 7.714.53, et seq., provided to staff members approved to use physical management and seclusion, and the type and number of hours of training each staff member is required to take as required by the model.

4. Which staff members will be approved by the program to use physical management and seclusion. Staff members authorized to perform seclusion shall be from one or more of the following positions: administrator, assistant administrator, child care staff, social worker, teacher, psychologist, psychiatrist, or nurse.

5. The preventive and de-escalation techniques and positive behavioral intervention that must be attempted by staff prior to the use of physical management and seclusion.

6. How the facility continuously monitors physical management, how the facility will be physically present, such that the staff member is able to immediately respond to the needs of the individual in seclusion, and how the individual in seclusion shall be visually observed no less than every fifteen (15) minutes.

7. The philosophy and use of the seclusion room, the intake process, the evaluation of an individual while in the room, emergency procedure while an individual is in seclusion and method for a resident's grievance regarding the use of the room.

8. The type of written documentation the facility maintains of each physical management or seclusion. The record shall be prepared by each staff member involved in the physical management and/or seclusion and shall contain all of the following:

a. A description of the incident including the name of the individual, date and time of day, the name of any witnesses to the incident, staff members involved, their position at the facility and their involvement in the physical management, and how long the physical management or seclusion lasted, the person who authorized the seclusion, those that visited the individual during the seclusion, the exact time of each seclusion fifteen (15)-minute monitoring check and the behavior of the individual at each monitoring check, time and date of each seclusion counseling visit, the person who authorized the release from seclusion, and the time and date of the release.

b. The precipitating incident(s) and the individual's behavior before the restraint or seclusion.

c. What specific actions were attempted and/or taken to de-escalate the situation and control, calm, or contain the individual and the effect of these de-escalating actions upon the individual.

d. The staff's decision-making process to perform a physical management and/or seclusion, A description of the physical management and/or seclusion including the individual's physical, emotional and behavioral condition prior to, during and after the physical management, including, but not limited to, breathing, pulse, color, and signs of choking or respiratory distress, and in the case of seclusion, the time the individual was last given access to restroom facilities, the time the individual had opportunity for exercise if exercise is required under the individual child plan, when and what type of medications were given and by whom, when the individual's last staff contact occurred, and the stated reasons and/or authorization to continue any seclusion.

e. A description of the debriefing and evaluation with the individual and with the staff following the physical management to address other options that may have been successful in de-escalating the individual.

f. An indication of review by the neutral reviewer as to the appropriateness of the physical management or seclusion.

g. Verification that notification of the use of physical management or seclusion was made to the legal custodian.

9. Evaluation by an objective, internal professional of the documentation of each physical management to determine appropriateness and effectiveness of the preventive and de-escalation techniques used and the physical management performed, as well as assessing carefully any injuries, bruising, or death.

10. The requirement that staff not restrain an individual in physical areas that may pose a threat to the health and safety of the individual including, but not limited to, soft, pliable surfaces, concrete, asphalt or areas including broken glass.

11. All facilities shall ensure that staff are trained to explain, at time of admission, the use of physical management, restraint and/or seclusion to the individual, legal custodian, and if appropriate, to the individual's family. The explanation provided to the legal custodian and individual will occur in a language or communication understandable to him/her and will include the purpose of physical management, the physical management model used, and the circumstances when a physical management may occur.

12. Notification to the legal custodian of each use of physical management, restraint and/or seclusion, no later than the end of the day that the physical management, restraint or seclusion occurred with a written report completed and given to the legal custodian by the next business day.

13. Emergency procedures, including First Aid, that will be used if an individual or staff member is seriously injured during a physical management.

14. The requirement of staff to report any critical incident, or child abuse or neglect pursuant to Colorado state law and Sections 7.701.52 and 7.701.53.

15. If seclusion is performed, the purpose of the seclusion room, evaluation of the individual while in the room, the emergency procedures for an individual in seclusion, and the method for the resident's right to grieve the use of the room.

7.714.534SECLUSION [Rev. eff. 6/1/12]

A. Seclusion may only occur for the period of time necessary to accomplish its purpose. The individual shall be released from seclusion when state of emergency has ceased. Seclusion shall not exceed two (2) hours per incident unless required by the individual's treatment plan or individual child plan.

B. At the time of placement of the individual in seclusion, the neutral reviewer shall be notified in person or by telephone. Leaving a message is not notification, and if the neutral reviewer cannot be contacted in person or by telephone, the individual may not be placed in a seclusion room.

C. There must be notification of another staff member, who is currently on duty, that an individual has been placed in seclusion.

D. A staff member must be physically present, at all times when an individual is locked inside the room.

E. Physical Requirements for a Seclusion Room

1. The seclusion room shall be located in reasonable proximity to the living unit or other areas of activity.

2. The seclusion room shall be a minimum of eighty (80) square feet in size.

3. The seclusion room shall be kept in a clean and sanitary condition.

4. All switches for light, heat, and ventilation, as well as other electrical outlets, shall be outside the room. All switches shall be available only to the staff.

5. There shall be no features by which an individual might injure him or her self within the seclusion room such as utility pipes, cleaning equipment and materials, or mirrors.

6. Exterior windows are not recommended, but if there are window panes they shall be of shatter-resistant material and have psychiatric screening.

7. There shall be an observation window on the door from which all parts of the room are visible for purposes of supervision. The window shall be made of shatter-resistant materials.

8. The seclusion room shall have a lighted, soothing environment. The individual shall not be subjected to glaring lights. All lights shall be recessed into the ceiling and shall be covered with a shatter-resistant guard which is flush with the ceiling.

9. There shall be no more than one locked door between the individual and the staff member.

10. If the seclusion room is soundproof, there must be an intercom system which is activated when an individual is in the room.

F. Approvals Necessary to Operate a Seclusion Room

1. The written approval of the local fire department and the Colorado Department of Human Services must be received prior to the initial use of the seclusion room.

2. The licensee shall request such an inspection and there shall be an inspection by the fire department at least annually. The licensee shall retain a copy of the inspection report in the facility file.

3. If it is found, at the time of inspection by the State Department of Human Services, that the facility does not meet all the regulations for operation of the room, the department staff member shall give written notice of specific deficiencies which shall be corrected. The facility shall cease secluding any individual in the locked room until corrections are completed and authorization is given by the Colorado Department of Human Services.

7.714.535STAFF TRAINING [Rev. eff. 6/1/12]

A. Staff utilizing any physical management in facilities or programs shall be trained in the appropriate use and implementation of a model that includes nationally recognized criteria prior to any staff being approved to use physical management. The model shall include, at a minimum, the following:

1. Annual staff training and/or certification, to include training upon hire, and ongoing (at least every six months) refresher training or practice exercises for each staff member trained or certified in restraint, to review and refresh skills involved in positive behavior intervention, prevention, de-escalation, and physical management, in accordance with the model.

a. Staff will be periodically observed when performing a physical management by a supervisor of the facility who has been training in physical management. If a supervisor of the facility determines a staff member did not correctly perform a physical management, the staff member must be immediately retrained or be restricted from performing further physical management until retraining can occur, and;

b. If available, the staff person shall complete any competency tests offered as part of the training prior to being approved to use physical management.

2. How to assess the signs of physical distress in a person in restraint.

3. A restraint prevention and de-escalation component, to include identifying antecedents that may cause an individual to escalate, and/or development of behavior management plans that are in alignment with individual treatment plans if necessary.

4. A physical management process that prohibits or provides alternatives to a prone position, and includes identifying primary control techniques that emphasize utilizing only the minimum amount of force necessary to gain control and keep the individual safe.

5. A debriefing process which includes a review of physical management, to determine the appropriateness and effectiveness of preventive/de-escalation techniques used, the appropriateness of physical management, and how, or if, physical managements are preventable.

B. Persons specified to place an individual in the seclusion shall have ongoing training and supervision which shall include at least the following:

1. The safety of the individual and staff and emergency procedures including First Aid and fire protection;

2. The purpose and policy, legal ramifications of placing the individual in seclusion;

3. The role of the neutral reviewer;

4. The dynamics of the behavior of individuals when in seclusion;

5. Safe methods of getting the individual to the seclusion room;

6. Methods of searching an individual when placing the individual in the seclusion room; and,

7. The protection of keys for the seclusion room.

7.714.536DOCUMENTATION [Rev. eff. 6/1/12]

Each facility shall have processes in place to document the reason for the physical management and/or seclusion, alternative methods attempted, and the type and duration of physical management and/or seclusion in the record of the individual. Each physical management or seclusion shall be recorded as required by section 7.714.533, E, 7.

7.714.537REVIEW [Eff. 6/1/12]

A. Each facility shall include physical management, restraint and/or seclusion in its critical incident review process and/or quality management program.

1. Review the Use of Physical Management

a. Records of each physical management shall be reviewed by a supervisor of the facility within forty-eight (48) hours of each restraint.

b. According to the policies and procedures of the facility, the entire individual's behavior management or treatment plan must be reviewed if it appears that the individual is being physically managed an excessive number of times, frequently in a short period of time, or frequently by the same staff member.

c. If any particular de-escalation technique appears to be causing an escalation in the behavior of an individual or a group of individuals, the use of the technique shall be evaluated for its effectiveness. De-escalation techniques that are not effective or are counter-productive must be terminated at the earliest opportunity.

d. If either the individual or a staff member was seriously injured or died during a physical management, a thorough review of the physical management and injuries must be instituted immediately. Based on the findings of the review, the staff members involved in the physical management must be retrained, be restricted from performing further physical management, and/ or corrective personnel action must be taken.

e. If a staff member appears to be involved in a larger number of physical managements than other staff members and is not a part of a specially trained team, or is unsuccessful at using de-escalation effectively, the facility must conduct a thorough review of the staff member's interactions with individuals in care, prior physical management training, and need for further training or corrective personnel action as required by program's policies.

2. Review the Use of Seclusion

a. The record of use of the seclusion room shall be reviewed daily by the seclusion room supervisor and weekly by the facility administrator. If one individual is placed in the seclusion room more than three times in 72 hours or a maximum of 5 hours in 72 hours, the entire plan for the individual shall be reviewed, and a person, who meets the requirements of consultant to the seclusion room supervisor, and staff shall authorize any further use of the seclusion room or other treatment for the individual.

b. If the same staff member places an individual in the seclusion room repeatedly, this shall be investigated by the seclusion room supervisor.

c. The facility which operates a seclusion room shall appoint a neutral reviewer. The neutral reviewer shall not be the seclusion room supervisor or the person who placed the individual in the seclusion room. The reviewer shall determine if the situation resulting in the seclusion of an individual in a seclusion room merits such a decision. The reviewer may be a staff member of the facility or a professional contracted by the facility in one of the following positions: administrator, assistant administrator, social worker, psychologist, psychiatrist, nurse, lawyer.

B. All agencies shall have an administrative oversight component, to include, at a minimum, tracking and reviewing episodes of seclusion, physical management and restraint data such as through a quality assurance or performance improvement process.

C. Pursuant to Section 26-6-106(2)(k) of the Colorado Revised Statutes, a license can be suspended or revoked for failure to comply with the rules governing seclusion.

7.714.6EDUCATIONAL/VOCATIONAL PROGRAMS [Rev. eff. 7/2/06]

A. Educational/vocational programs shall be developed and provided for all school-age children who are residents of the facility in accordance with the individual child's plan, the Public School Finance Act and as required by the Exceptional Children's Educational Act and Rules and Regulations.

1. Children shall attend educational/vocational programs in the most appropriate and least restrictive educational setting for the child, including, but not limited to, attending regular classes conducted in accredited elementary, middle, and secondary schools within the community.

2. Children attending school shall be permitted to participate in school extracurricular activities to the extent of their interests and abilities and in accordance with each individual child's plan.

3. The facility shall develop assurances that the educational/vocational program is an integral part of the total plan. Such assurances shall include procedures for information sharing, joint planning, and follow-through.

B. In order to ensure that all students who may have disabilities are provided an appropriate education, the facility shall ensure that adequate "child find" procedures are utilized. Such procedures shall be developed cooperatively with local education agencies (LEA) in accordance with Exceptional Children's Educational Act rules and regulations and LEA procedures. Child find includes a process for screening, referring, assessing and staffing students suspected of having a disabling condition.

C. The facility that operates its own educational program shall provide adequate space, staff, equipment and educational materials as required in Exceptional Children's Educational Act Rules and Regulations.

D. School records shall be transmitted according to State law, pursuant to Section 24-72-204, C.R.S., and the Individuals with Disabilities Education Act (IDEA).

7.714.7COMMUNITY PARTICIPATION [Rev. eff. 7/2/06]

Participation in community activities shall be encouraged, supported, and a vital part of each child's life and choice, and shall be in accordance with each individual child's plan.

A. The facility shall reflect consideration for, and sensitivity to, the racial, cultural, ethnic and/or religious backgrounds of children in care. The facility shall involve a child in cultural and/or ethnic activities appropriate to his/her cultural and/or ethnic background.

B. The facility shall utilize available services, facilities, and activity programs of the community, and children shall be given op opportunities to participate as individuals or as a group in agency-sponsored recreational and cultural programs such as provided by YMCA, YWCA, Scouting organizations, schools, and churches or other religious institutions.

C. Children shall be provided work opportunities according to the established policy of the facility and the age of the child, and shall have opportunities to experience the use and value of money by making purchases for items according to their own choice.

1. Money earned, received as a gift, or received as allowance by a child in care shall be deemed to be that child's personal property. The facility shall maintain a written record of all monies earned or given to a child.

2. Limitations may be placed on the amount of money a child may possess or have access to when such limitations are considered to be in the child's best interests.

3. The facility may deduct reasonable sums from a child's allowance as restitution for damages done by the child. Restitution must be negotiated with the child and based on the child's ability to pay. The facility may deduct no more than half of what a child earns or was given during a week. A written record of damages and any restitution paid by a child must be maintained by the facility.

D. Chores at the facility are considered part of the participatory responsibility of living together. They shall provide constructive experiences in accordance with the age and ability of the child and shall not substitute for the work of staff.

E. All chores shall be scheduled so as not to conflict with other essential scheduled activities.

F. The facility shall comply with all child labor laws and regulations in making work assignments.

G. Paid or voluntary work assignments outside of the facility shall be approved by the administrator of the facility, a staff member, or the parent(s) or guardian(s) of the child, who shall know the employer, the specific type of work, and the conditions of employment.

H. A child shall not be exploited in any manner. A child may not participate in solicitation on behalf of the facility for a fund- raising activity without the written permission of the parent(s) or guardian(s) for each specific activity, and the child must be willing to participate in the activity.

7.714.8PERSONAL CARE OF THE CHILD

7.714.81Medical and Health Services [Rev. eff. 7/2/06]

A. The facility shall ensure the availability of a comprehensive program of preventive, routine, and emergency medical and dental care for each child in care. Every reasonable effort shall be made to obtain routine and corrective dental care. The facility shall have a written plan for providing such care. This plan shall include at a minimum:

1. Assignment of one person to be responsible for the coordination of medical care for the children residing in the facility.

2. Ongoing appraisal of the general health of each child, including immunizations, in accordance with state law and regulations.

3. Procedures for obtaining diagnostic services, emergency care, including the availability of a physician or emergency medical facility on a 24-hour, seven-day-a-week basis, corrective care, recuperative care, and immunization updates.

4. Provision of health education, which includes sex education, and birth control information and education, age appropriate to the child.

5. Provision that any medical treatment administered will be explained to the child in a language or manner of communication understandable to him/her.

6. The provision of dental care by a Colorado-licensed dentist, who is available to the facility.

7. Procedure for obtaining the written authorization from the child's legal guardian or custodian prior to any new psychotropic medication being dispensed.

8. Procedures for dispensing medication, storage of medication, documentation of administration of all medication, disposing of medications when not needed or no longer in use, and notification to a primary physician in cases of medication errors and/or drug reactions.

B. A general medical examination for each child must be completed or scheduled with a physician, physician's assistant or a nurse practitioner prior to or within fourteen (14) calendar days following admission. A statement from the examiner shall be retained in the child's file. This exam shall include the following:

1. An examination for physical injury and disease.

2. Vision and hearing screening.

3. A current assessment of the child's health, including immunizations.

C. Whenever indicated, a child shall be referred to an appropriate specialist for either further assessment or treatment.

D. Subsequent physical and other examinations shall be done annually or as directed, in writing, by the physician or other qualified health professional.

E. Dental examinations for all children three years of age or older, or at a younger age if recommended by a physician or dentist, must have been completed within four months prior to placement or within eight (8) weeks following placement. The facility or governing body shall ensure that each child receives a dental examination every six months or as required in writing by a dentist.

F. At all times there shall be first aid supplies readily available at the facility and at least one (1) person present at the facility and supervising the children for every 20 children present, who is certified in First Aid or the equivalent and CPR for all ages of children in care.

G. The facility, in conjunction with the parent(s) or guardian(s), shall make every effort to ensure that a child needing corrective devices such as glasses, hearing aids, etc., is provided with the necessary equipment.

H. The facility has the right to request a statement regarding the child's general health from a medical examiner. In a potentially life- threatening situation, the facility shall refer the child's care to the appropriate medical and legal authority. If a child wishes an exemption from a medical examination or medical treatment due to religious beliefs, the child shall submit a written statement signed by his/her parent(s) or guardian(s) which states the reasons for such an exemption. The facility has the right to refuse admission to a child whose parent(s) or guardian(s) refuses medical treatment or examination based upon religious convictions.

I. The facility shall regularly maintain and update a child's Human Services Health Passport, or a document containing all the information listed in the Health Passport, for children placed by a county department of social services. If received, the original of the document shall be given to the caseworker upon the child's discharge so that it can be given to the facility where the child is being admitted or to the child's parent(s), guardian(s), or family member(s) with whom the child is placed.

J. Medications shall be administered and stored in the following manner:

1. When a child first comes into care, the facility shall ascertain all medication the child is currently taking.

2. All medication must be kept in a clean, locked storage area inaccessible to children and stored according to pharmacy instructions.

3. All prescriptive medications shall be administered only upon the written prescription of a physician or nurse practitioner. The facility shall also obtain written authorization from the prescribing physician or nurse practitioner to administer any non-prescriptive medication, including dietary supplements.

4. The facility shall have a written medication schedule for each child to whom medication is prescribed, a copy of which shall be available to staff.

5. In an emergency situation, non-prescriptive medication may be administered on the verbal authorization of a physician. Written confirmation must then be obtained for the verbal authorization.

6. The facility shall maintain for each child a cumulative record of all medication, both prescriptive and non-prescriptive, dispensed to that child including:

a. The name of the child.

b. The name and dosage of medication.

c. The time and date the medication was dispensed.

d. The name of the person administering the medication.

7. The facility shall document the following information as it relates to handling and dispensing medication:

a. Documentation of:

1) all medication errors; and,

2) drug reactions.

b. Documentation of all discontinued medication and disposing of medications.

8. Only staff members trained and authorized by State statute shall administer medications. All direct care staff shall be trained in the recognition of common side effects of medication.

K. In all instances where a new prescription medication is to be ordered as a part of a treatment program, the following information shall be provided to the client and his/her custodian or legal guardian:

1. The name of the medication being prescribed;

2. The proper use of the medication;

3. The reasons for ordering the medication for this client;

4. A description of the benefits expected;

5. The common side effects, if any;

6. The major risks, if any;

7. The probable consequences of not taking the medication explained in a language or mode of communication that is easily understood by the child, his/her family and/or legal guardian.

L. No involuntary medications may be administered.

M. The facility shall have policy and procedures for documenting that the required information was given to the child before the child took the medication. When information is given to the child, the documentation shall include an assessment regarding whether the child understood.

N. The child may refuse to take his/her medication at any time. The facility must document the refusal in the medication log.

O. No child shall be threatened with or experience adverse behavioral consequences by staff action due to refusal to take medication.

7.714.82Food and Nutrition [Rev. eff. 7/2/06]

A. The facility shall provide nutritious foods in the variety and amounts as appropriate for the age, appetite, and activity of each child in care.

B. At least three nourishing, wholesome, well-balanced meals a day shall be offered at regular intervals except when children receive their morning and/or noon meal(s) at school. No more than fourteen (14) hours shall elapse between the evening and morning meals. Nourishing snacks shall be part of the daily food provided.

C. Children shall be encouraged to eat a variety of the food served but shall not be subjected to undue coercion, including forced feeding, or punished for refusal to eat.

D. All food shall be from sources approved or considered satisfactory by the local health department.

E. There shall be a record made of the special diets prescribed and prepared for a child.

F. Children must not be given foods that are contrary to their religious beliefs, or those of their family, or are known to cause an allergic reaction or a health hazard.

G. Water shall be readily accessible to children.

7.714.83Personal Hygiene and Daily Routine [Rev. eff. 7/2/06]

A. The facility shall establish procedures to ensure that children receive training in good habits of personal care, hygiene, and grooming appropriate to their age, gender, race and culture.

1. There shall be supervision by staff to provide for proper grooming and physical cleanliness of the children.

2. The facility shall ensure that children are provided with necessary and appropriately maintained toiletry items, individual towels and washcloths, toothbrush, toothpaste, comb, and shampoo.

B. The facility shall have a plan of basic daily routines for children in care.

1. Daily routines shall not be allowed to conflict with the implementation of a child's plan.

2. Daily routines shall be established for mealtimes, waking, and bedtimes.

3. Opportunity for physical exercise shall be planned for each child.

7.714.84Clothing and Personal Belongings [Rev. eff. 7/2/06]

A. The facility shall allow a child in care to bring his/her personal belongings to the program, as defined by the facility policy, and to acquire belongings of his/her own in accordance with 1he child's plan. However, the facility shall, as necessary, limit or supervise the use of these items while the child is in care. Where extraordinary limitations are imposed, the child shall be informed of the reasons, in a language or manner of communication the child can understand. The decision and reasons shall be recorded in the child's case record. Provisions shall be made for the protection of the child's property.

B. The facility shall ensure that each child in care has adequate clean, proper-fitting, attractive, and seasonable clothing as required for health, comfort, and physical well-being and as appropriate to age, gender, individual needs, culture, and ethnicity.

1. Each child's clothing shall be distinguished as his/her own in accordance with the facility's policies.

2. A child's clothing shall be kept clean and in good repair. The child shall be involved, as appropriate, in the care and maintenance of his/her clothing. As appropriate, laundering, ironing, and sewing facilities shall be accessible to tie child.

C. The facility shall ensure that discharge plans make provisions for clothing needs at time of discharge. The wardrobe for each child shall go with him/her at time of discharge.

7.714.9PERSONNEL/POLICY REQUIREMENTS

7.714.91General Requirements for All Staff [Rev. eff. 7/2/06]

A. The facility shall provide adequate numbers of staff to assure the health and safety and the proper care and treatment of the children in care.

B. All staff in the facility shall demonstrate an interest in, and a knowledge of, children and a concern for their proper care and well- being.

C. The facility shall have written screening procedures and make reasonable efforts to evaluate the overall emotional health and stability of each applicant and/or staff member. Procedures should include exploring for any history of child battering, child abuse, child molestation, child neglect, or previous criminal convictions.

D. A facility shall not hire or continue to employ any person whose health, educational achievement, or emotional or psychological makeup impairs his/her ability to properly protect the health and safety of the children in care, or who could endanger the physical or psychological well-being of the children.

E. A staff member who, upon examination or as a result of tests, shows indication of a physical condition which could be hazardous to a child, other staff, or self, or which would prevent performance of duties, shall not be assigned or returned to his/her position until the condition has cleared to the satisfaction of the examining physician or nurse practitioner.

7.714.92Personnel Policy, Orientation, and Training [Rev. eff. 6/1/12]

A. The facility shall have a comprehensive written plan for the recruitment, hiring or certification, orientation, ongoing training, and professional development of staff.

1. The facility shall have an introductory training and orientation program for all staff. This program shall include orientation to emergency and safety procedures and the general and specific duties and responsibilities of the job.

2. The facility shall maintain written documentation of specific in-service training held, staff participating in the training, the hours involved, and/or other on-going training activities in which staff were involved. Activities related to supervision of the staff members' routine tasks shall not be considered training activities for the purpose of this requirement.

B. The facility shall document that staff receive appropriate training in the following areas:

1. The facility's emergency and safety procedures, including but not limited to fire evacuation drills and disaster drills, on at least a semiannual basis.

2. The principles and practices of child care, including developmentally appropriate practices.

3. The facility's and, where appropriate, certifying authority's administrative procedures and overall program goals.

4. Acceptable behavior management techniques, appropriate discipline and physical management, restraint and seclusion of children in accordance with facility policies and these rules, including the ability to recognize and respond to signs of physical distress in children who are subject to a physical management.

5. Appropriate professional boundaries (both physical and emotional) between staff and children while in placement at the facility and after discharge.

6. Annual review of these regulations by all appropriate staff members of the facility.

7. All staff must have a minimum of twenty (20) clock-hours of on-going job specific training a year. Training may include areas listed above.

8. Individuals that are qualified by education, training, and experience must provide staff training.

9. Staff training must include training exercises in which staff members successfully demonstrate in practice the techniques which they have learned for managing emergency safety intervention.

10. The facility must document in the staff personnel record that the training and demonstration of competency were successfully completed. Documentation must include the date training was completed and the name of persons certifying the completion of training.

7.714.93Records and Reports

7.714.931Confidentiality [Rev. eff. 7/2/06]

A. The facility shall have a policy as to the maintenance, storage and confidentiality of records.

B. Records shall be the property of the facility and shall be protected against loss, tampering, or unauthorized use.

C. Facts learned about children and their families shall be kept confidential, with the following exceptions:

1. In medical emergencies, and then only when the assistance and/or expertise is required of that unauthorized person; or

2. To the child, his/her parent(s) or guardian(s) and their respective legal counsel(s), a court having jurisdiction over the child, or an authorized public official, or licensing representative in performance of his/her mandated duties; or,

3. If the parent(s) or guardian(s) has given voluntary, written consent.

D. School records shall be transmitted according to State law, pursuant to Section 24-72-204, C.R.S., and the Individuals with Disabilities Education Act.

E. Medical records shall be kept in a secure location at the facility and only be released in accordance with the Health Insurance Portability and Accountability Act (HIPAA).

F. Any information concerning observed behavior which reasonably appears to constitute a criminal offense committed on the premises of a facility or any criminal offense committed against any person while performing or receiving services is not considered privileged or confidential.

G. All researchers conducting clinical research must sign an oath of confidentiality. All information identifying individual children by name, address, telephone number and/or social security number collected for research purposes, shall not be disclosed.

H. When names are deleted and other identifying information is disguised or deleted, material from case records may be used for teaching purposes, development of the governing bodies' understanding and knowledge of the facilities' services or similar educational purposes.

I. Information regarding treatment for alcohol or drug abuse may be released only in compliance with the Federal Regulations on Confidentiality of Alcohol and Drug Abuse Resident Records, 42 CFR, Part 2 . No amendments or later editions incorporated.

7.714.932Records

A. The facility shall maintain an organized, legible, chronological, current record for each child in care as required for the licensing or certification of the facility in accordance with the rules regulating the facility. The record shall be separated into discrete sections addressing medical, education, clinical, milieu, and fee for service therapy.

B. Records for children shall be retained for at least three years. Retention of records for a longer period may be desirable when they reflect an accident, injury or other unusual circumstance.

C. A record of admission shall be completed for each child in care prior to or at the time of placement. The admission record shall be maintained at the facility where the child resides and shall contain:

1. Child's legal name, date and place of birth (verified by a birth certificate when possible), gender, race, religious preferences of parent(s) or child, date and reason for placement.

2. Child's address and telephone number, parent(s) or guardian(s) address and telephone number if different from the child.

3. Name, address, day and nighttime telephone number of individual or agency placing the child with the name of individual arranging the placement.

4. Any documents pertaining to the child's legal status such as court orders, including the appointment of a Guardian Ad Litem and/ or counsel for youth, legal guardianship, custody agreements, or the termination of parental rights.

5. A copy of the placement agreement pursuant to 7.714.2, G.

6. Health records including a health history, chronic medical problems of the child, illnesses the child has had during the last six months and a complete list of all medications the child is taking.

7. Current medical and dental reports, accident, injury, or illness reports, record of medication administered and necessary medical care provided to the child while in placement. Psychiatric and psychological reports, when available.

8. Copies of educational records, including the Individualized Educational Plan (IEP) where applicable, and reports of school work, including scholastic performance, certificates of achievement or award, and extracurricular interests.

9. The Individual Child's Plan (ICP) and Family Service Plan (FSP) when developed or Individualized Treatment Plan (ITP) for committed youth, a summary of the periodic evaluations of the child's progress and resultant changes in the ICP, FSP or ITP.

10. Summary recording of significant contacts with parent(s), guardian(s) and other involved agencies.

11. Documentation of all transfers and reasons for transfers within the authorized facility.

D. Clinical Record Requirements for RCCFs Providing Mental Health Services

In addition to 7.714.932, A-C, an RCCF shall maintain current organized, legible, chronological, treatment record for each client. Treatment records shall include:

1. A mental health diagnosis;

2. Copies of any CCARs pertaining to the client's current need for mental health services;

3. All plans of care and revisions for the current treatment episode;

4. Documentation of client's attendance at, participation in and outcomes of RCCF mental health services;

5. Documentation that the client and/or the legal guardian was provided a copy of the plan of care;

6. Correspondence to and from agencies and individuals involved in the client's treatment;

7. An explanation whenever any member of the multidisciplinary team, client, parent or guardian, does not sign the plan of care;

8. The name of the licensed mental health professional responsible for the formulation, implementation, review and revision of the client's plan of care;

9. Signed releases of information when necessary;

10. Documentation of any unplanned discharges without advance notice and any discharges against the agency's or licensed mental health professional's advice;

11. Treatment entries that are signed and dated by the person providing treatment/therapy, including title or position of the person providing the treatment/ therapy. If the clinical services are provided by a provisionally licensed therapist, the supervisor must also sign the entries;

12. All changes in diagnoses need to be documented with changes to the CCAR;

13. All members of the clinical staff shall be trained annually in the development and review of plans of care, and there must be documentation of such;

14. Clinical supervisors who are providing supervision to provisionally licensed therapists (P-LCWS, P-LPC, P-LMFT, psychologist) must document supervision hours provided to supervisees.

E. Within five (5) business days of when a child is removed from placement, the facility shall complete and send to the placing agency a summary of the child's discharge from the facility which includes at a minimum:

1. The date of the discharge of the child from the facility.

2. Where the child was placed following discharge.

3. A summary of the services provided to the child during care.

4. Goals met/not met during treatment.

5. The treatment goals and assessed needs which remain to be met and alternate service possibilities which might meet those goals and needs.

6. A statement of an aftercare plan and identification of who is responsible for follow-up services and aftercare.

7. If the discharge was planned or unplanned.

8. The circumstances which led to an unplanned discharge.

F. Copies of a child's file, including discharge information but excluding all medical information covered by HIPAA, shall be provided to parent(s) or guardian(s) upon request or to others by written consent pursuant to Section 7.714.931.

G. A copy of all policies and dated revisions developed by the facility shall be maintained for at least three years.

7.714.933Required Notification [Rev. eff. 6/1/12]

A. The facility shall immediately notify the child's legal custodian, and/or the responsible agency of any serious illness or serious injury resulting in medical treatment away from the facility, hospitalization or death involving a child in care.

B. The facility shall notify the legal custodian, and/or placing authority as soon as possible upon discovery that a child has run away.

C. Critical incidents shall be reported as outlined in Section 7.701.52.

D. A report about a death must include:

1. The child's name, birth date, address, and telephone number.

2. The names of the child's parent(s) or guardian(s) and their address and telephone number if different from that of the child.

3. Date of the fatality.

4. Brief description of the incident or illness leading to the death.

5. Names and addresses of witnesses or persons who were with the child at the time of death.

6. Name and address of police department or authority to whom the report was made.

E. Any change in the status of the facility that would affect care of children shall be immediately reported to the licensing agency.

F. The facility must immediately notify the Department of any court order or physician's order that violates these regulations.

G. The facility must notify the parent(s), guardian(s), or placing authority regularly of the issues related to the care of the child including use of time out rooms, discipline, treatment, behavior management, physical management, restraint and seclusion, and restriction of rights.

12 CCR 2509-8-7.714

37 CR 13, July 10, 2014, effective 8/1/2014

38 CR 04, February 25, 2015, effective 4/1/2015

38 CR 17, September 10, 2015, effective 10/1/2015

38 CR 19, October 10, 2015, effective 11/1/2015

38 CR 23, December 10, 2015, effective 1/1/2016

39 CR 01, January 10, 2016, effective 2/1/2016

39 CR 17, September 10, 2016, effective 10/1/2016

40 CR 05, March 10, 2017, effective 4/1/2017

40 CR 17, September 10, 2017, effective 10/1/2017

41 CR 01, January 10, 2018, effective 2/1/2018

41 CR 03, February 10, 2018, effective 3/2/2018

41 CR 05, March 10, 2018, effective 4/1/2018

41 CR 17, September 10, 2018, effective 9/30/2018

40 CR 23, December 10, 2017, effective 12/30/2018

41 CR 23, December 10, 2018, effective 1/1/2019

42 CR 01, January 10, 2019, effective 2/1/2019

42 CR 03, February 10, 2019, effective 3/15/2019

42 CR 09, May 10, 2019, effective 6/1/2019

43 CR 01, January 10, 2020, effective 1/30/2020

43 CR 15, August 10, 2020, effective 9/1/2020

43 CR 17, September 10, 2020, effective 9/30/2020

44 CR 01, January 10, 2021, effective 1/30/2021

44 CR 05, March 10, 2021, effective 4/1/2021

44 CR 11, June 10, 2021, effective 6/30/2021

44 CR 17, September 10, 2021, effective 10/1/2021

44 CR 21, November 10, 2021, effective 12/1/2021

45 CR 15, August 10, 2022, effective 7/8/2022

45 CR 17, September 10, 2022, effective 9/30/2022

46 CR 03, February 10, 2022, effective 3/2/2023

46 CR 05, March 10, 2023, effective 4/1/2023

46 CR 07, April 10, 2023, effective 6/1/2023