2 Colo. Code Regs. § 502-1-2.5

Current through Register Vol. 47, No. 10, May 30, 2024

Section 2 CCR 502-1-2.5 - Personnel and Contracted Services

A. The BHE shall ensure administrative and/or clinical oversight of endorsement(s), service(s), and physical location(s), in accordance with policies and procedures adopted by the governing body under part 2.4.D of these rules, including, as required by those policies:

1. An administrator responsible for implementing endorsement and service policies and procedures adopted by the governing body, as well as the day-to-day operation of the endorsement, services, or location, including, but not limited to:

a. Management of business and financial operations.

b. Ensuring standards in part 2 of this Chapter are met in the endorsement, services, and location, including, but not limited to the standards in part 2.15 of these rules, medication administration.

c. Ensuring buildings are properly maintained and building safety/security needs are met.

d. Implementing infection control and emergency preparedness policies and procedures, in accordance with governing body policies.

e. Establishing and maintaining relationships with agencies, services, and behavioral health resources within the community.

f. Identifying personnel to whom administrator responsibilities are delegated during periods when the administrator is neither on-site nor available through interactive means within thirty (30) minutes.

g. A BHE may have a single administrator, or multiple administrators for the combination of endorsements, services, and locations included in the BHE license.

2. For BHEs providing clinical services, a clinical director, responsible for the overall clinical services provided to individuals, including, but not limited to:

a. Ensuring training and continuing education for all BHE personnel, relevant to the services provided by the personnel.

b. Ensuring supervision and clinical oversight of BHE personnel in accordance with part 2.5.1 of these rules.

c. Including a method to provide clinical supervision and oversight during periods when the clinical director is unable to fulfill their duties within thirty (30) minutes.

d. Ensuring services provided are appropriate as indicated in screenings and assessments.

3. A BHE may have a single clinical director, or multiple clinical directors, as appropriate for the combination of endorsements, services, and locations included in the BHE license.

4. The minimum qualifications for the administrator and clinical director are set by the BHE's policies and procedures.

5. An administrator or clinical director may be specific to a physical location or may be shared among locations, as appropriate for the services, size, and geographic dispersion of the services.

6. A single person may serve as both the administrator and the clinical director, if that person meets qualifications for both, and it is consistent with policies adopted by the governing body.

B. The BHE shall maintain a sufficient number of qualified personnel for each endorsement and at each physical location to provide the endorsed services, meet the clinical needs of the individuals, and comply with state and federal requirements. The BHE shall ensure personnel are only assigned duties they are competent to perform adequately and safely.

C. All personnel assigned to direct individual care must be qualified through either professional credentials, education, training, and/or experience in the principles, policies, procedures, and appropriate techniques for providing individual services.

1. Personnel providing individual services must be legally authorized to provide the service in accordance with applicable federal, state, and local laws.

2. Licensed, certified, and/or registered personnel must have an active license, certification, or registration in the state of Colorado and may only provide services within their scope of practice.

3. The BHE shall verify the license, certification, or registration, and check for any disciplinary action against personnel providing individual services, through the Colorado department of regulatory agencies or other state or federal agency not more than thirty (30) days before official hire date prior to hire.

4. The BHE shall create policies and procedures regarding supervision of all personnel pursuant to part 2.5.1 of this Chapter.

D. The BHE shall obtain, prior to hire or contract of new personnel or acceptance of persons for volunteer service if that volunteer service involves unsupervised direct contact with individuals receiving services, a name-based criminal history record check for each prospective personnel or volunteer.

1. If the prospective personnel has lived in Colorado for more than three (3) years at the time of application, the BHE shall obtain a name-based criminal history report conducted by the Colorado Bureau of Investigation (CBI).

2. If the prospective personnel has lived in Colorado for three (3) years or less at the time of application, the BHE shall obtain a name-based criminal history report for each state in which the prospective personnel has lived during the past three (3) years, conducted by the respective states' bureaus of investigation or equivalent state-level law enforcement agency, or a national criminal history report conducted by the federal bureau of investigation.

3. The BHE shall bear the cost of obtaining such information.

4. If a BHE contracts with a staffing agency for the provision of services, it shall require that the staffing agency meet the requirements of this part 2.5.D.

5. When determining whether a prospective personnel is eligible for hire or contract, if the criminal history record check reveals the person has a conviction or plea of guilty, active deferred judgment, or nolo contendere, the BHE shall follow its policy developed in accordance with part 2.5.E.3.a of this Chapter.

E. The BHE shall have written personnel policies developed in accordance with part 2.5.C of this Chapter, including, but not limited to:

1. Line of authority/management hierarchy of personnel.

2. Job descriptions/responsibilities.

3. Written criteria and procedures for evaluating which convictions or complaints make prospective personnel unacceptable for hire, or for existing personnel unacceptable for retention, including:

a. Factors to be considered when determining whether prospective personnel are eligible for hire when their criminal history record check reveals a conviction or plea of guilty, active deferred judgment, or nolo contendere, including, but not limited to:

(1) The nature and seriousness of the offense;

(2) The nature of the position and how the offense relates to or may impact the duties of the position. Experience in the criminal justice system is not necessarily a disqualifier and, in certain circumstances, a BHE may determine that some lived experiences would benefit a particular position;

(3) The length of time since the conviction or plea;

(4) Whether such conviction is isolated or part of a pattern; and

(5) Whether there are mitigating or aggravating circumstances involved.

4. Conditions of employment, including but not limited to:

a. That personnel refrain from sexual or romantic relationships between supervisors and supervisees and sexual or romantic relationships with individuals served.

5. Position qualifications and required credentials.

6. Orientation, training, and continuing education requirements, for the populations served and services provided.

7. Routine monitoring of personnel credentials and disciplinary actions.

8. Requirements for self-reporting of new or current investigations, criminal charges, indictments, or convictions that may affect the personnel's ability to carry out their duties or functions of the job.

9. Policies requiring all personnel to be free of communicable disease that can be readily transmitted in the BHE.

a. All personnel that have direct contact with individuals must be required to have a tuberculin skin test prior to direct contact with individuals. In the event of a positive reaction to the skin test, evidence of a chest x-ray and other appropriate follow-up may be required in accordance with community standards of practice.

F. The BHE shall ensure that all personnel have access to and know about the BHE's policies, procedures, and state and federal laws and regulations relevant to their respective duties.

G. The BHE must maintain records on all personnel, including, but not limited to:

1. Date of hire;

2. Job description;

3. Results of criminal history record checks;

4. Documentation of professional credentials, education, and training;

5. Documentation of any disciplinary action taken against the person by a credentialing body;

6. Documentation of orientation and training;

7. Evidence of review of the BHE's policies, procedures, and state and federal laws and regulations relevant to their respective duties; and

8. Documentation of tuberculosis testing and results, for personnel who have direct contact with individuals.

H. The BHE must ensure that all personnel complete an initial orientation on basic infection prevention and control, safety, and emergency preparedness procedures.

I. The BHE must ensure that all personnel receive the following training prior to working independently with individuals, and on a periodic basis consistent with policies developed in accordance with part 2.5.E of this Chapter, above

1. Training specific to the particular needs of the populations served, including the provision of person-centered, trauma-informed, harm reduction-focused, physically and programmatically accessible, and culturally and linguistically responsive services;

2. Infection control;

3. Emergency preparedness, including de-escalation of potentially dangerous situations, including but not limited to threats of violence, acts of violence, and abuse/mistreatment of an individual;

4. Critical incident reporting;

5. Suicide prevention;

6. Individual rights of the population served;

7. Confidentiality, including individual privacy and records privacy and security;

8. BHE policies and procedures;

9. Mandatory reporting requirements for suspected abuse or neglect in accordance with part 2.8.A.9.a of this Chapter; and

10. Understanding of basic pharmacology and medications that are relevant to the treatment type and population served by the agency, including but not limited to medication-assisted treatment (MAT) services and medications for opioid use disorders (MOUD).

a. This training requirement may not be used as reason to hold unqualified personnel out as experts in pharmacology. BHEs must not encourage personnel to hold themselves out as able to make recommendations that are outside of their scope of practice to individuals receiving services. Rather, this training requirement is meant to ensure that personnel receive a base knowledge for the behavioral health community they service and allow for meaningful, timely, and supportive recovery-focused interactions with individuals receiving services.

2.5.1Clinical Supervision

A. The BHE must ensure that all personnel providing behavioral health services, with the exception of peer support professionals, receive clinical supervision, as defined in part 1.3 of these rules.

B. The BHE will develop policies and procedures for supervision that address the following:

1. Supervisee's mandatory disclosure statement that clearly states they are under supervision and by whom;

2. Requirements for regular evaluation of the supervisee's progress with a rubric that is tied to the responsibilities assigned;

3. Documentation and frequency of supervisor reviews and feedback provided;

4. Maximum number of supervisees a supervisor oversees; and

5. How supervision/consultation is covered by personnel with comparable credentials when the usual supervisor is not available.

C. Clinical supervisors must at minimum:

1. Meet the standard qualifications for clinical supervision as defined by the supervisor's professional practice board.

2. Deliver clinical supervision within the supervisor's professional practice license and ethical standards for:

a. Those that are licensed or seeking professional licensure; or

b. When supervising personnel that are not seeking or not eligible for professional licensure, such as group living workers, the supervisor must follow standards in the Colorado Mental Health Practice Act, as defined in Article 245 of Title 12, C.R.S.

3. Dedicate time between the supervisor and supervisee to instruct, model, and encourage self-reflection regarding acquisition of clinical and administrative skills by the supervisees. Clinical supervisor will determine skills through observation, evaluation, feedback, and mutual problem-solving.

4. Address ethics and ethical dilemmas as aligned with the appropriate professional practice board.

5. Provide professional direction based on experience, expertise, and/or for ethical or safety concerns.

6. Ensure that safety and crisis management plans are followed and that clinical supervisors are available to personnel for assistance in crisis situations and processing of the crisis event afterwards.

7. Document the date, duration, and the content of supervision session for their supervisee(s), which may include a professional development plan. All documents pertaining to clinical supervision must be provided to the supervisee and the BHA upon request.

D. Personnel-specific clinical supervision requirements

1. Licensees will be provided with clinical supervision and/or consultation at minimum upon request by the licensee or during times of individual emergency.

2. Candidates will be provided with clinical supervision at a rate that will meet their licensing requirements for the license they are pursuing or at a minimum of one (1) hour every two weeks, whichever provides a higher level of clinical supervision.

3. All clinical documentation completed by a counselor-in-training and/or intern still in pursuit of their clinical degree must be reviewed and co-signed by a clinical supervisor able to supervise pursuant to their scope of practice.

4. Personnel not seeking or not eligible for licensure, but that are providing clinical services, will be provided clinical supervision at a frequency that ensures treatment to individuals is appropriate, safe, and in line with assessment treatment needs and the individual's treatment goals.

2 CCR 502-1-2.5

46 CR 23, December 10, 2023, effective 1/1/2024