14 Del. Admin. Code § 935-17.0

Current through Register Vol. 28, No. 7, January 1, 2025
Section 935-17.0 - Policies and Procedures
17.1 A licensee shall have and follow written policies and procedures:
17.1.1 Governing a child's admission to a facility or program.
17.1.2 Protecting a child's rights to privacy and dignity. A photo, video, or recording that reveals a child's identity shall not be used for research, fundraising, or public relations without the written consent of the child's parent or referring agency.
17.1.3 Regarding a child's participation in research projects. The policy shall conform to the National Institute of Mental Health Standards on Protection of Human Subjects.
17.1.4 Governing the recruitment, screening, hiring, supervision, training, evaluation, promotion, and disciplining of staff and volunteers.
17.1.5 Governing the qualifications and use of volunteers, if using volunteers. The qualifications shall be appropriate to the duties performed.
17.1.6 Governing the assignment of a child to an educational program, if a licensee chooses not to provide an educational program directly.
17.1.7 For handling an incident of suspected child abuse or neglect that occurs while a child is a client of the facility or program that complies with applicable laws.
17.1.8 Governing the discipline and behavior supports for children. These policies and procedures shall include the concepts and use of the least restrictive effective treatment and positive reinforcements and shall prohibit:
17.1.8.1 Roughly handling a child or inflicting physical punishment on a child's body, including shaking, grabbing, striking, hair-pulling, biting, pinching, plucking, slapping, hitting, kicking, or spanking;
17.1.8.2 Humiliating, ridiculing, frightening, or degrading children;
17.1.8.3 Engaging in discriminatory treatment or harassment based on child's looks, race, national origin, religion, gender, gender expression, sexual orientation, disability, ethnicity, family, or other personal traits;
17.1.8.4 Encouraging or allowing children to hit, punish, or discipline each other;
17.1.8.5 Denying children food, water, toilet use, or bathing as a result of inappropriate behavior;
17.1.8.6 Using any form of forced physical exercise or activity or work assignment that produces pain or discomfort;
17.1.8.7 Punishing the group for misbehaviors of a child or a group of children unless the policies and procedures clearly list the specific circumstances and safeguards when this would be allowed;
17.1.8.8 Denying medical or dental care;
17.1.8.9 Denying visits or communications with family or others as listed in subsection 51.1;
17.1.8.10 Denying shelter, appropriate clothing, bedding, or any other essential personal items;
17.1.8.11 Denying sleep or rest;
17.1.8.12 Using mechanical restraints;
17.1.8.13 Attempting to change or discourage a child's sexual orientation, gender identity, or gender expression; or
17.1.8.14 Physically or sexually abusing a child.
17.1.9 Governing discipline and behavior supports include the model, program, or techniques used based on a child's needs, developmental level, and behavior and its use of each of the following:
17.1.9.1 Use of a de-escalation system that is a holistic system for defusing escalating behavior and safely managing aggressive behavior;
17.1.9.2 Positive supports;
17.1.9.3 Use of "time-out," to restrict a child in care to a designated area for a period of time to give the child in care an opportunity to regain self-contro,; if applicable;
17.1.9.4 Physical escort, if applicable;
17.1.9.5 Chemical restraint, if applicable;
17.1.9.6 Physical restraint, if applicable; and
17.1.9.7 Seclusion, if applicable.
17.1.10 Governing the use of appropriate "time-out" techniques. These policies and procedures shall require that appropriate "time-out" techniques may be used after first using other developmentally appropriate behavior supports and only:
17.1.10.1 When a child's behavior is judged by the staff to be disruptive or prevents others from participating in an activity;
17.1.10.2 When at least 1 staff member has been designated to be responsible for making visual contact with the child no less frequently than every 15 minutes;
17.1.10.3 When the room used for "time out" has adequate space, temperature, light, and ventilation, and is not capable of locking;
17.1.10.4 In an area that is not a closet, a bathroom, or an unfinished basement or attic;
17.1.10.5 For a duration of time that shall not exceed 1 minute per the age of the child for children under age 6 and no more than 30 minutes for children over age 6;
17.1.10.6 When the child is reintroduced to the group in a sensitive and non-punitive manner as soon as the child has regained control;
17.1.10.7 When "time-out" episodes are documented in the child's record; and
17.1.10.8 If there are more than 15 "time-outs" for an individual child within a 24-hour period, a licensee shall ensure:
17.1.10.8.1 The events and actions of the child leading up to each "time-out" are evaluated and staff responses to those events and actions are reviewed to ensure competency of staff to implement a "time-out" only when necessary;
17.1.10.8.2 The chief administrator or designee conducts a review to determine the child's suitability to remain in placement in the facility or program or whether changes to the child's service plan are necessary; and
17.1.10.8.3 The facility or program takes appropriate action in response to the findings of the review.
17.1.11 In cases of emergencies or life-threatening situations, including arrangements for emergency transport services for children. The procedures must include provisions for supervision when a staff is required to accompany a child to a hospital emergency room.
17.1.12 On a suicide prevention policy that includes the following:
17.1.12.1 How the facility will respond in the event a child in care exhibits self-injurious, self-harm, or suicidal behavior;
17.1.12.2 Warning signs of suicide;
17.1.12.3 Emergency protocol and contacts;
17.1.12.4 Training requirements for staff members, including suicide prevention training and suicide risk assessment tool training;
17.1.12.5 Procedures for determining implementation of additional supervision precautions and for determining removal of additional supervision precautions;
17.1.12.6 Procedures to conduct a suicide risk assessment on the day of intake;
17.1.12.7 Documentation requirements for suicide ideation, self-harm, and special observation precautions to ensure immediate communication to all staff;
17.1.12.8 A process for tracking suicide behavioral patterns; and
17.1.12.9 A "post-intervention" plan with identified resources.
17.1.13 Governing the handling of grievances by children. These policies and procedures shall:
17.1.13.1 Be written in clear and simple language;
17.1.13.2 Be communicated to children in an age and developmentally appropriate manner;
17.1.13.3 Be posted in an area easily accessible to children and their parent or referring agency;
17.1.13.4 Ensure that any grievance shall be investigated by a staff who is not the subject of the grievance; and
17.1.13.5 Require continuous monitoring by a licensee of any grievance to ensure there is no punitive or retaliatory action taken or threatened against a child who reported a grievance.
17.1.14 Governing medical emergencies. These policies and procedures shall require that at least 1 staff member is on duty who is qualified to administer first aid and cardiopulmonary resuscitation (CPR) and 1 fully equipped first aid kit is placed in each building used by children and in any indoor recreation area.
17.1.15 For record security, maintenance, and disposal that addresses:
17.1.15.1 Assigning the responsibility of supervising record maintenance and custody to ensure records are uniform in organization, readily identifiable, current, and complete;
17.1.15.2 Securing a record against loss, damage, tampering, accessibility, and unauthorized use;
17.1.15.3 Determining to whom a record may be released;
17.1.15.4 Determining what type of record or portion of a record may be destroyed and what must be kept permanently;
17.1.15.5 Creating a storage system for permanent records that ensures information is protected and kept indefinitely; and
17.1.15.6 Transferring and keeping records in the event the facility or program closes.

14 Del. Admin. Code § 935-17.0

27 DE Reg. 599 (2/1/2024) (Final)