La. Admin. Code tit. 67 § V-7111

Current through Register Vol. 50, No. 11, November 20, 2024

Section V-7111 - Provider Requirements

A. Provider Responsibilities

1. Enrichment Activities. Provider shall assist children of residents and residents at least twice monthly in creating and updating their lifebook. For children of residents and residents that are not developmentally able to participate in the creation and updating of their own lifebook, staff shall create and update for the children and residents.

a. Lifebooks shall be the property of children of residents and residents and shall remain with the child or resident upon discharge.

b. Lifebooks shall be available for review by DCFS.

2. Personnel Requirements

a. The provider shall employ a sufficient number of qualified staff and delegate sufficient authority to such staff to perform the following functions:

i. administrative;

ii. fiscal;

iii. clerical;

iv. housekeeping, maintenance, and food services;

v. direct resident and child of a resident services;

vi. record keeping and reporting;

vii. social service; and

viii. ancillary services.

b. Personnel can work in more than one capacity as long as they meet all of the qualifications of the position and have met the training requirements.

c. The provider that utilizes volunteers shall be responsible for the actions of the volunteers. Volunteers shall:

i. have orientation and training in the philosophy of the program and the needs of residents and children of residents and methods of meeting those needs prior to working with residents or children of residents;

ii. have documentation of a fingerprint-based satisfactory criminal background check through the FBI as noted in §7124.C or §7124 D, as applicable and required in R.S. 15:587.1 and R.S. 46:51.2.

iii. have a state central registry clearance form from Child Welfare as required in §7112;

iv. have three documented reference checks dated within three months prior to beginning volunteer services;

v. have documentation of a signed and dated job description by volunteer.

3. Personnel Qualifications

a. Program Director. The program director shall meet one of the following qualifications:

i. a doctorate degree in a human services field or in administration, business, or a related field;

ii. a masters degree in a human services field or in administration, business, or a related field and one year of work experience in a human services agency;

iii. a bachelors degree in a human services field or in administration, business, or a related field, and at least two years of work experience in a human services agency;

iv. six years of work experience in a human services field or a combination of undergraduate education and work experience in a human services field for a total of six years. Fifteen credit hours substitute for six months of work experience not to exceed 60 credit hours.

b. Service Plan Manager. The service plan manager shall have a bachelors degree in a human service field plus a minimum of one year with the relevant population.

c. Documentation of experience for program director and service plan manager shall be verified in writing by previous employer. Documentation of education shall be verified by a copy of the individuals degree or transcript.

d. Direct Care Worker. A direct care worker hired on or after August 1, 2016, shall be at least 21 years of age and have a high school diploma or equivalency and at least two years post-high school job experience.

4. Personnel Job Duties

a. The program director shall be responsible for:

i. implementing and complying with policies and procedures adopted by the governing body;

ii. adhering to all federal and state laws and standards pertaining to the operation of the agency;

iii. addressing areas of non-compliance identified by licensing inspections and complaint inspections;

iv. directing the program;

v. representing the facility in the community;

vi. delegating appropriate responsibilities to other staff including the responsibility of being in charge of the facility during their absence;

vii. recruiting qualified staff and employing, supervising, evaluating, training, and terminating employment of staff;

viii. providing leadership and carrying supervisory authority in relation to all departments of the facility;

ix. providing consultation to the governing body in carrying out their responsibilities, interpreting to them the needs of residents and children of residents, making needed policy revision recommendations, and assisting them in periodic evaluation of the facility's services;

x. supervising the facility's management including building, maintenance, and purchasing;

xi. participating with the governing body in interpreting the facility's need for financial support;

xii. establishing effective communication between staff and residents and children of residents and providing for their input into program planning and operating procedures;

xiii. reporting injuries, deaths, and critical incidents involving residents or children of residents to the appropriate authorities; and

xiv. supervising the performance of all persons involved in any service delivery/direct care to residents or children of residents.

b. The service plan manager shall be responsible for:

i. supervision of the implementation of the resident's service plan;

ii. integration of the various aspects of the resident's program;

iii. recording of the resident's progress as measured by objective indicators and making appropriate changes/modifications;

iv. reviewing quarterly service plan reviews for the successes and failures of the resident's program, including the resident's educational program, with recommendations for any modifications deemed necessary. Designated staff may prepare these reports, however, the service plan manager shall review, sign, and date the reports indicating approval;

v. signing and dating all appropriate documents;

vi. monitoring that the resident receives a review every 30 days of the need for residential placement and ensuring the timely release, whenever appropriate, of the resident to a least restrictive setting; monitoring any extraordinary restriction of the resident's freedom including use of any form of restraint, any special restriction on a resident's communication with others, and any behavior management plan;

vii. asserting and safeguarding the human and civil rights of residents, and children of residents, and their families and fostering the human dignity and personal worth of each resident;

viii. serving as liaison between the resident, provider, family, and community during the resident's admission to and residence in the facility, or while the resident is receiving services from the provider in order to:

(a). assist staff in understanding the needs of the resident and his/her family in relation to each other;

(b). assist staff in understanding social factors in the resident's day-to-day behavior, including staff/resident relationships;

(c). assist staff in preparing the resident for changes in his/her living situation;

(d). help the family to develop constructive and personally meaningful ways to support the resident's experience in the facility, through assistance with challenges associated with changes in family structure and functioning, and referral to specific services, as appropriate;

(e). help the family to participate in planning for the resident's return to home or other community placement; and

(f). supervise and implement the shared responsibility plan regarding resident and child of a resident.

c. The direct care worker shall be responsible for the daily care and supervision of the residents and children of residents in the living group to which they are assigned which includes:

i. protecting childrens and residents' rights;

ii. handling separation anxiety and alleviating the stress of a resident or child of a resident in crisis;

iii. modeling appropriate behaviors and methods of addressing stressful situations;

iv. crisis management;

v. behavior intervention and teaching of appropriate alternatives;

vi. training the resident and child of a resident in good habits of personal care, hygiene, eating, and social skills;

vii. protecting the resident and child of a resident from harm;

viii. handling routine problems arising within the living group;

ix. representing adult authority to the residents and children of residents in the living group and exercising this authority in a mature, firm, compassionate manner;

x. enabling the resident or child of a resident to meet his/her daily assignments;

xi. participating in all staff conferences regarding the resident's progress in program evaluation of service plan goals and future planning;

xii. participating in the planning of the facility's program and scheduling such program into the operation of the living group under his/her supervision;

xiii. maintaining prescribed logs of all important events that occur regarding significant information about the performance and development of each resident or child of a resident in the group;

xiv. reporting emergency medical or dental care needs to the administrative staff in a timely manner;

xv. reporting critical incidents to administrative staff in a timely manner; and

xvi. completing duties and responsibilities as assigned regarding residents and children of residents.

5. Contractors

a. Contractors hired to perform work which does not involve any contact with residents or children of residents, shall not be required to have a criminal background check if accompanied at all times by a staff person when residents or children of residents are present in the facility.

b. Contractors hired to perform work which involves contact with residents or children of residents, shall be required to have documentation of a fingerprint-based satisfactory criminal background check through the FBI as required by R.S. 15:587.1 and R.S. 46:51.2 and noted in §7124.E as applicable.

c. All contractors who are unaccompanied by staff with direct or indirect contact with children/youth shall have documentation of a state central registry clearance as required in §7112

6. Post Licensing Information

a. Providers shall advise residents of the licensing authority of DCFS and that residents may contact the Licensing Section with any unresolved complaints. Providers shall post the current telephone number, email address, and mailing address in an area regularly utilized by residents.

7. Orientation

a. All staff hired effective August 1, 2016 or after, shall complete the DCFS "mandated reporter training" available at dcfs.la.gov within five working days of the staffs date of hire and prior to having sole responsibility for residents or children of residents. Documentation of completion shall be the certificate obtained upon completion of the training.

b. The provider's orientation program shall provide training in the following topics for all staff within one week of the staffs date of hire and prior to having sole responsibility for residents or children of residents:

i. philosophy, organization, program, and practices of the provider;

ii. specific responsibilities of assigned job duties with regard to residents and children of residents;

iii. administrative procedures and programmatic goals;

iv. emergency and safety procedures including medical emergencies;

v. resident rights;

vi. detecting and reporting suspected abuse and neglect;

vii. infection control to include blood borne pathogens;

viii. confidentiality;

ix. reporting and documenting incidents;

x. LGTBQ issues;

xi. implementation of service plans to include a behavior plan, when clinically indicated;

xii. staff and resident grievance procedure;

xiii. rights and responsibilities of residents who have children residing in the facility;

xiv. responsibility of staff with regard to children of residents residing in the facility;

xv. transportation regulations, including modeling of how to properly conduct a visual check of the vehicle and demonstration by staff to program director on how to conduct a visual check;

xvi. the proper use of child safety restraints required by these regulations and state law (see reference sheet for training resources);

xvii. recognizing mental health concerns;

xviii. detecting signs of illness or dysfunction that warrant medical or nursing intervention;

xix. basic skills required to meet the dental and health needs and problems of the residents and children of residents;

xx. prohibited practices;

xxi. behavior management techniques, including acceptable and prohibited practices;

xxii. use of time-out, personal restraints, and seclusion that is to include a practice element in the chosen method performed by a certified trainer for direct care staff;

xxiii. safe self-administration and handling of all medications including psychotropic drugs, dosages, and side effects;

xxiv. working with people with disabilities, attending to the needs of such residents and children of residents in care, including interaction with family members with disabilities; and

xxv. use of specialized services identified in §7117. D 6

c. The provider shall maintain sufficient information to determine content of training noted in §7111. A.7.b i-xxv. This information shall be available for review.

d. Documentation of the orientation training shall consist of a statement/checklist in the staff record signed and dated by the staff person and program director or service plan manager, attesting to having received the applicable orientation training and the dates of the orientation training.

e. Effective August 1, 2016, staff in facilities licensed to care for children under age two years or facilities providing services for children of residents shall complete the "reducing the risk of sids in early education and child care" training available at www.pedialink.org. Documentation of completion shall be the certificate obtained upon completion of the training.

f. All direct care staff shall receive certification in adult cardiopulmonary resuscitation (CPR) and first aid within 45 days of employment. Effective August 1, 2016, if residents or children of residents under the age of 10 are accepted into the program, then staff shall also obtain a certificate in infant/child CPR. No staff member shall be left unsupervised with residents or children of residents until he/she has completed all required training. CPR and first aid shall be updated prior to the expiration of the certification as indicated by the American Red Cross, American Heart Association, or equivalent organization. Online-only training is not acceptable.

8. Annual Training

a. The provider shall ensure that all staff receive training on an annual basis in the following topics:

i. administrative procedures and programmatic goals;

ii. emergency and safety procedures including medical emergencies;

iii. resident rights;

iv. detecting and reporting suspected abuse and neglect;

v. infection control to include blood borne pathogens;

vi. confidentiality;

vii. reporting and documenting incidents;

viii. specific responsibilities of assigned job duties with regard to residents and children of residents;

ix. implementation of service plans to include a behavior plan when clinically indicated;

x. staff and resident grievance procedure;

xi. prohibited practices;

xii. recognizing mental health concerns;

xiii. detecting signs of illness or dysfunction that warrant medical or nursing intervention;

xiv. basic skills required to meet the dental and health needs and problems of the residents and children of residents;

xv. behavior management techniques including acceptable and prohibited practices;

xvi. use of time-out, personal restraints, and seclusion which is to include a practice element in the chosen method performed by a certified trainer for direct care staff;

xvii. safe self-administration and handling of all medication including psychotropic drugs, dosages, and side effects;

xviii. rights and responsibilities of residents who have children residing in the facility;

xix. responsibility of staff with regard to children of residents residing in the facility;

xx. working with people with disabilities, attending to the needs of such residents and children of residents in care, including interaction with family members with disabilities;

xxi. use of specialized services identified in §7117. D 6; and

xxii. LGBTQ issues;

xxiii. transportation regulations, including modeling of how to properly conduct a visual check of the vehicle and demonstration by staff to program director on how to conduct a visual check;

xiv. the proper use of child safety restraints required by these regulations and state law (see reference sheet for training resources).

b. Documentation of annual training shall consist of a statement/checklist in the staff record signed and dated by the staff person and program director, attesting to having received the applicable annual training and the dates of the training.

c. The provider shall maintain sufficient information available to determine content of training. This information shall be available for review.

d. All direct care staff shall have documentation of current certification in adult CPR and first aid. Effective August 1, 2016, if residents or children of residents under the age of 10 are accepted into the program, then staff shall also obtain a certificate in infant/child CPR. No staff member shall be left unsupervised with residents or children of residents until he/she has completed all required training. Online-only training is not acceptable.

e. Effective August 1, 2016, all staff currently employed shall complete the DCFS "mandated reporter training" available at dcfs.la.gov within 45 days and shall be updated annually. Documentation of completion shall be the certificate obtained upon completion of the training.

f. Staff in facilities licensed to care for children under age two years or facilities providing services for children of residents shall annually complete the "Reducing the risk of SIDS in early education and child care" training available at www.pedialink.org. Documentation of completion shall be the certificate obtained upon completion of the training.

9. Staffing and Supervision Requirements

a. The provider shall ensure that an adequate number of qualified direct care staff are present with the residents and children of residents as necessary to ensure the health, safety and well-being of residents and children of residents. Staff coverage shall be maintained in consideration of the time of day, the size and nature of the provider, the ages and needs of the residents and children of residents, and shall assure the continual safety, protection, direct care, and supervision of residents and children of residents. In addition to the required number of direct care staff, the provider shall employ a sufficient number of maintenance, housekeeping, administrative, support, and management staff to ensure that direct care staff can provide direct care services.

i. The provider shall have at least one adult staff present for every six residents when residents are present and awake. In addition, there shall be one additional staff person for every six children of residents present. There shall always be a minimum of two staff present when children of residents are on the premises.

ii. The provider shall have at least 1 adult staff present and awake for every 12 residents when residents are present and participating in rest time. Between 9 p.m. and 6 a.m., the ratio of 1 staff to every 12 residents is acceptable only if the residents are in their assigned bedrooms and participating in rest time. In addition, there shall be 1 additional staff person for every 6 children of residents present. There shall always be a minimum of 2 staff present when children of residents are on the premises, regardless of the number of children of residents present.

iii. In addition to required staff, at least one staff person shall be on call in case of emergency.

iv. Contractors (therapists, tutors, etc.) shall not be included in ratio while providing said individualized services to a specific resident(s) or child(ren) of resident(s).

v. Management or other administrative staff may be included in ratio only if they are exclusively engaged in providing supervision of the residents or direct supervision of the children of residents.

vi. Staff are allowed to sleep, during nighttime hours, only if the following are met.

(a). There is a functional security system monitored by an alarm company. Alarms shall be placed on all windows and exterior doors. The security system shall be enabled during nighttime hours and anytime that the staff/house parents are sleeping. Residents shall not be given the security system code.

(b). There shall be a functional monitoring system on all interior resident and children of resident bedroom doors.

vii. When residents or children of residents are away from the facility, staff shall be available and accessible to the residents and children of residents to handle emergencies or perform other necessary direct care functions.

viii. The provider utilizing live-in staff shall have sufficient relief staff to ensure adequate off-duty time for live-in staff.

ix. Six or more residents under two years of age shall have an additional direct care worker on duty when the residents are present to provide a staff ratio of 1 staff per every 6 residents under age two, in addition to staff noted in §7111. A.9.a i

x. The provider shall not contract with outside sources for any direct care staff, including one-on-one trainers or attendants.

xi. Staff shall be assigned to supervise residents and children of residents whose names and whereabouts that staff person shall know.

xii. When the resident is at the facility with her child, she is responsible for the care and supervision of her own child when not engaged in services or other activities. Staff shall be present and available as a resource and to lend support and guidance to the resident.

xiii. During nighttime hours, staff shall participate in the individual care of a resident and/or assisting a resident in the care of her child.

(a). In bedrooms where a child of a resident resides with their parent, an auditory device shall be required to enable staff to provide assistance to the resident in the care of her child. The monitor shall have an on/off feature which is controlled by the resident, or the devise shall be placed in the residents room during nighttime hours and removed in the morning allowing the resident privacy.

xiv. Children of residents shall be directly supervised by staff on the playground, in vehicles, and while away from the facility unless the child is accompanied by their own parent.

xv. Staff shall actively and directly supervise residents and/or children of residents engaged in water activities and shall be able to see all parts of the swimming pool, including the bottom.

10. Reasonable and Prudent Parent Standard

a. The provider shall designate in writing at least one on-site staff person as the authorized representative to apply the reasonable and prudent parent standard to decisions involving the participation of a child of a resident who is in foster care or a resident who is in foster care and placed in the facility in age or developmentally appropriate activities. The staff person(s) designated as the authorized representative shall be at the licensed location at all times during the facilitys hours of operation. The Licensing Section shall be notified in writing within five calendar days if there is a change to one of the designated representatives.

b. The authorized representative shall utilize the reasonable and prudent parent standard when making any decision involving the participation of a child of a resident who is in foster care or a resident who is in foster care and placed in the facility in age or developmentally appropriate activities.

c. The authorized representative shall receive training or training materials shall be provided on the use of the reasonable and prudent parent standard within one week of hire and prior to having responsibility for residents or children of residents and updated annually. Documentation of the reasonable and prudent parent training shall be maintained. The reasonable and prudent parent training or training materials, as developed or approved by DCFS, shall include, but is not limited to the following topic areas:

i. age- or developmentally-appropriate activities or items;

ii. reasonable and prudent parent standard;

iii. role of the provider and of DCFS; and

iv. allowing for normalcy for the resident or child of a resident while respecting the parents residual rights.

B. Record Keeping

1. Administrative File

a. The provider shall have an administrative file that shall contain, at a minimum, the following:

i. a written program plan describing the services and programs offered by the provider;

ii. organizational chart of the provider;

iii. all leases, contracts, and purchase-of-service agreements to which the provider is a party;

iv. insurance policies. Every provider shall maintain in force at all times current comprehensive general liability insurance policy, property insurance, and insurance for all vehicles used to transport residents or children of residents. This policy shall be in addition to any professional liability policies maintained by the provider and shall extend coverage to any staff member who provides transportation for any resident or child of a resident in the course and scope of his/her employment;

v. all written agreements with appropriately qualified professionals, or a state agency, for required professional services or resources not available from employees of the provider;

vi. written documentation of all residents exits and entrances from facility property. Documentation must include, at a minimum, date, time, destination, name of person with whom resident leaves premises.

2. Staff File

a. The provider shall have a personnel file for each staff that shall contain, at a minimum, the following:

i. the application for employment, including education, training, and experience;

ii. a criminal background check as noted in Section 7124.C as applicable:

(a). prior to employment, a Louisiana State Police fingerprint based criminal background check shall be conducted in the manner required by R.S. 15:587.1 and 46:51.2. Effective August 1, 2016, criminal background checks (CBC) shall be dated no earlier than 30 days of the individual being present in the facility or having access to the residents or children of residents. If an individual has previously obtained a certified copy of their criminal background check from the Louisiana Bureau of Criminal Identification and Information Section of the Louisiana State Police, such certified copy shall be acceptable as meeting the CBC requirements. This certified copy of the criminal background check shall be accepted for a period of one year from the date of issuance of the certified copy. This certified copy shall be kept on file at the facility. Prior to the one-year expiration of the certified criminal background check, a new fingerprint-based satisfactory criminal background check shall be obtained from Louisiana State Police. If the clearance is not obtained prior to the one-year expiration of the certified criminal background check, the staff is no longer allowed on the premises until a clearance is received;

(b). no person, having any supervisory or other interaction with residents or children of residents, shall be hired or on the premises of the facility until such person has submitted his or her fingerprints to the Louisiana Bureau of Criminal Identification and Information and it has been determined that such person has not been convicted of or pled nolo contendere to a crime listed in R.S. 15:587.1(C);

(c). any employee who is convicted of or has pled nolo contendere to any crime listed in R.S. 15:587.1(C) shall not continue employment after such conviction or nolo contendere plea;

iii. evidence of applicable professional or paraprofessional credentials/certifications according to state law;

iv. written job description signed and dated by individual staff;

v. documentation of three signed and dated reference checks or telephone notes dated within three months prior to hire attesting affirmatively to the individuals character, qualifications, and suitability for the position assigned. References shall be obtained from individuals not related to the staff person;

vi. staffs hire and termination dates;

vii. documentation of current driver's license for operating provider or private vehicles in transporting residents or children of residents;

viii. annual performance evaluations addressing the quality of work to include staff persons interaction with residents and children of residents, family, and other providers. The evaluations are completed by the program director and signed and dated by program director and staff;

ix. personnel action, other appropriate materials, reports, and notes relating to the staffs employment with the facility;

x. state central registry clearance forms as required in §7112

b. Staff shall have reasonable access to his/her file and shall be allowed to add any written statement he/she wishes to make to the file at any time.

3. Records

a. The provider shall ensure that all entries in records are legible, signed by the person making the entry, and accompanied by the date on which the entry was made.

b. All records shall be maintained in an accessible, standardized order and format, and shall be retained and disposed of according to state and federal law.

c. The provider shall have sufficient space, facilities, and supplies for providing effective record keeping services.

4. Resident Record

a. Active Record. The provider shall maintain a separate active record for each resident and child of a resident. The records shall be current and complete and shall be maintained in the facility in which the resident and child of a resident resides and readily available to facility staff. The provider shall have sufficient space, facilities, and supplies for providing effective storage of records. The records shall be available for inspection by the department.

b. Each residents record shall contain at least the following information:

i. resident's name, date of birth, Social Security number, previous home address, sex, religion, and birthplace of the resident;

ii. dates of admission and discharge;

iii. other identification data including documentation of court status, legal status or legal custody and who is authorized to give consents;

iv. notification signed and dated from OJJ indicating youth is appropriate for non secure placement;

v. name, address, and telephone number of the legal guardian(s), and parent(s), if appropriate;

vi. name, address, and telephone number of a physician and dentist to be called in an emergency;

vii. resident's authorization for routine and emergency medical care;

viii. the pre-admission screening and admission assessment. If the resident was admitted as an emergency admission, a copy of the emergency admission note shall be included as well;

ix. resident's history including family data, educational background, employment record, prior medical history, and prior placement history;

x. a copy of the physical assessment report;

xi. reports of assessments and of any special problems or precautions;

xii. individual service plan, updates, and quarterly reviews;

xiii. continuing record of any illness, injury, or medical or dental care when it impacts the resident's ability to function or impacts the services he or she needs;

xiv. reports of any incidents of abuse, neglect, or incidents, including use of timeout, personal restraints, or seclusion;

xv. photo of resident updated at least annually;

xvi. a summary of court visits;

xvii. a summary of all visitors and contacts including dates, name, relationship, telephone number, address, the nature of such visits/contacts, and feedback, if indicated from the family;

xviii. a record of all personal property and funds, which the resident has entrusted to the facility;

xix. reports of any resident grievances and the conclusion or disposition of these reports;

xx. written acknowledgment that the resident has received clear verbal explanation and copies of his/her rights, the house rules, written procedures for safekeeping of his/her valuable personal possessions, written statement explaining his/her rights regarding personal funds, and the right to examine his/her record;

xxi. all signed informed consents;

xxii. immunization record within 30 calendar days of admission; and

xxiii. a discharge summary.

xxiv. for residents placed from other states, proof of compliance with the Interstate Compact on Juveniles, the Interstate Compact on the Placement of Children, and the Interstate Compact on Mental Health, when indicated. Proof of compliance shall include clearance letters from the compact officers of each state involved;

c. Each child of a residents record shall contain at least the following information:

i. child's information form signed and dated by the legal guardian and updated as changes occur, listing:

(a). the child's name, date of birth, sex, date of admission;

(b). name of parent(s) and legal guardian;

(c). name and telephone number of child's physician;

(d). name and telephone number of the child's dentist (if applicable);

(e). any special concerns, including but not limited to allergies, chronic illness, and any special needs of the child (if applicable);

(f). any special dietary needs, restrictions, or food allergies/intolerances (if applicable);

(g). name and telephone number of child's caseworker (if applicable); and

(h). written authorization to care for child from legal guardian;

ii. for residents that retain custody of their children, a written authorization signed and dated by the resident to secure emergency medical treatment in the event the child of the resident is left in the care of staff;

iii. for residents that retain custody of their children, a written authorization signed and dated by the resident noting the first and last names of individuals to whom the child of the resident may be released, including child care facilities, transportation services, or any person or persons who remove the child of the resident from the facility:

(a). the provider shall verify the identity of the authorized person prior to releasing the child of a resident.

d. For residents that retain custody of their children, the provider shall obtain written, informed consent from the resident prior to releasing any information, recordings, or photographs from which the child might be identified, except for authorized state and federal agencies. This onetime written consent shall be obtained from the resident and updated as changes occur.

e. Provider shall have a signed and dated shared responsibility plan between the resident and provider detailing how they will share the responsibilities of meeting the child of the residents daily needs to include, but not limited to, who will care for the child at certain times and days of the week, who is responsible for supervising, feeding, changing, bathing, tending to the developmental needs of the child, and purchasing items for the child.

f. If the resident does not retain custody of her child, the provider shall have a written individual child care agreement for each child with the person or agency holding custody of the child.

g. If the resident retains custody of her child, the provider shall obtain written authorization signed and dated by the resident to transport her child on a regular basis. Authorization shall include (if staff transports without resident):

i. name of child;

ii. type of service (to and from home, and to and from school to include the name of the school); and

iii. names of individuals or school to whom the child may be released.

5. Staff Communication

a. The provider shall establish and follow procedures to assure adequate communication among staff to provide continuity of services to the residents and children of residents. This system of communication shall include recording and sharing of daily information noting unusual circumstances, individual and group problems of residents and children of residents, and other information requiring continued action by staff. Documentation shall be legible, signed, and dated by staff.

b. A daily log/record for all children of residents, to include first and last name and in/out times shall be maintained. This record shall accurately reflect all children of residents on the premises at any given time.

C. Confidentiality of Records

1. The provider shall have written policies and procedures for the maintenance, security and retention of records. The provider shall specify who shall supervise the maintenance of records, who shall have custody of records, to whom records may be released, and disposition or destruction of closed service record materials. Records shall be the property of the provider, and the provider, as custodian, shall secure records against loss, tampering, or unauthorized use or access.

2. The provider shall maintain the confidentiality of all records to include all court-related documents, as well as, educational and medical records. Every employee of the provider has the obligation to maintain the privacy of the resident, child of a resident, and his/her family and shall not disclose or knowingly permit the disclosure of any information concerning the resident, child of a resident or his/her family, directly or indirectly, to other residents or children of residents in the facility or any other unauthorized person.

3. When the resident is of majority age and not interdicted, a provider shall obtain the resident's written, informed permission prior to releasing any information from which the resident or his/her family might be identified, except for authorized state and federal agencies.

4. When the resident is a minor or is interdicted, the provider shall obtain written, informed consent from the legal guardian(s) prior to releasing any information from which the resident might be identified, except for accreditation teams and authorized state and federal agencies.

5. When the resident retains custody of her child, the provider shall obtain written, informed consent from the resident prior to releasing any information from which the resident might be identified, except for accreditation teams and authorized state and federal agencies.

6. When the resident does not retain custody of her child, the provider shall obtain written, informed consent from the legal guardian(s) prior to releasing any information from which the child might be identified, except for accreditation teams and authorized state and federal agencies.

7. The provider shall, upon written authorization from the resident or his/her legal guardian(s), make available information in the record to the resident, his/her counsel or the resident's legal guardian(s). If, in the professional judgment of the administration of the provider, it is felt that information contained in the record would be injurious to the health or welfare of the resident, the provider may deny access to the record. In any such case, the provider shall prepare written reasons for denial to the person requesting the record and shall maintain detailed written reasons supporting the denial in the resident's file.

8. The provider may use material from the residents or children of a residents records for teaching and research purposes, development of the governing body's understanding, and knowledge of the provider's services, or similar educational purposes, provided names are deleted, other identifying information disguised or deleted, and written authorization is obtained from the resident or his/her legal guardian(s).

D. Incidents

1. Critical and Other Incidents. The provider shall have and adhere to written policies and procedures for documenting, reporting, investigating, and analyzing all incidents and other situations or circumstances affecting the health, safety, or well-being of a resident or child of a resident.

a. The provider shall submit a written report of the following incidents to the Licensing Section within one calendar day, excluding when the incident occurs on a weekend or state holiday: (If the incident occurs on a weekend or state holiday, provider shall submit a written report on the first working day following the weekend or state holiday.)

i. elopement or unexplained absence of a resident or child of a resident;

ii. use of personal restraints with the exception of escorting;

iii. injuries of unknown origin;

iv. evacuation of residents or children of residents;

v. attempted suicide;

vi. serious threat or injury to the health, safety, or well-being of the resident or child of a resident;

vii. injury with substantial bodily harm while in seclusion or during use of personal restraint; or

viii. unplanned hospitalizations, emergency room visits, and emergency urgent care visits.

ix. any other unplanned event or series of unplanned events, accidents, incidents and other situations or circumstances affecting the health, safety, or well-being of a resident or child of a resident.

b. The program director or designee shall:

i. immediately verbally notify the legal guardian of any incident noted in §7111.D.1.a i-ix.;

ii. immediately verbally notify the appropriate law enforcement authority in accordance with state law;

iii. if requested, submit a final written report of the incident to the legal guardian as soon as possible, but no later than five working days of the incident;

iv. conduct an analysis of the incident and take appropriate corrective steps to prevent future incidents from occurring;

v. maintain copies of any written reports or notifications in the resident's or child of a residents record;

vi. ensure that a staff person accompanies residents and children of residents when emergency services are needed.

2. The provider shall verbally notify state office licensing management staff immediately in the event of a death and follow up with a written report within one calendar day of the verbal report. If the death occurs on a weekend or State holiday, provider shall verbally notify state office Licensing management staff as soon as possible on the first working day following the weekend or State holiday and follow up with a written report the same day as verbal notification. The provider shall immediately verbally notify the legal guardian and law enforcement in the event of a death.

3. When a child of a resident residing in the facility with their parent, sustains any of the following, the resident shall be immediately notified:

a. blood not contained in an adhesive strip;

b. injury of the neck and head;

c. eye injury;

d. human bite which breaks the skin;

e. any animal bite;

f. an impaled object;

g. broken or dislodged teeth;

h. allergic reaction skin changes (e.g. rash, spots, swelling, etc.);

i. unusual breathing;

j. symptoms of dehydration;

k. any temperature reading over 101 oral, 102 rectal, or 100 axillary; or

l. any injury or illness requiring professional medical attention.

4. The provider shall not delay seeking care for a resident or child of a resident while attempting to make contact with the resident or legal guardian in a situation which requires emergency medical attention.

5. At a minimum, the incident report for critical and other incidents shall contain the following:

a. date and time the incident occurred;

b. a brief description of the incident;

c. where the incident occurred;

d. names of residents, children of residents, or staff involved in the incident;

e. immediate treatment provided, if any;

f. symptoms of pain and injury discussed with the physician;

g. date and signature of the staff completing the report;

h. name and address of witnesses;

i. date and time the legal guardian, licensing, and, if applicable, law enforcement were notified;

j. any follow-up required;

k. preventive actions to be taken in the future; and

l. documentation of actions taken by the provider regarding staff involved in the incident to include corrective action.

6. A copy of all written reports shall be maintained in the residents or child of a residents record.

7. Critical incidents are noted in §7111.D.1.a iv-vi and ix, §7111.D 2, and §7111.E 2

E. Abuse and Neglect

1. The provider shall establish and follow a written, abuse/neglect policy that includes the following information:

a. describes communication strategies used by the provider to maintain staff awareness of abuse prevention, current definitions of abuse and neglect, mandated reporting requirements to the Louisiana child protection statewide centralized intake hotline and applicable laws;

b. ensures the resident and child of a resident are protected from potential harassment during the investigation;

c. ensures that the provider shall not delay reporting suspected abuse and/or neglect to the Louisiana child protection statewide centralized intake hotline in an attempt to conduct an internal investigation to verify the abuse/neglect allegations;

d. ensures that the provider shall not require any staff, including unpaid staff, to report suspected abuse/neglect to the provider or management prior to reporting to the child protection statewide hotline 1-855-4LA-KIDS (1-855-452-5437);

e. ensures the staff member involved in the incident does not work directly with the resident or child of a resident involved in the program until an internal investigation is conducted by the facility or the child protection unit staff makes an initial report;

f. ensures the staff member that may have been involved in the incident is not involved in conducting the investigation;

g. ensures that confidentiality of the incident is protected.

2. As mandated reporters, all staff and owners shall report any suspected abuse and/or neglect of a resident or child of a resident whether that abuse or neglect was perpetrated by a staff member, a family member, or any other person in accordance with R.S. 14:403 to the Louisiana child protection statewide centralized intake hotline 1-855-4LA-KIDS (1-855-452-5437). This information shall be posted in an area regularly used by residents.

3. After reporting suspected abuse and/or neglect as required by Louisiana law, provider shall submit a written report to the licensing section immediately or the next working day if the suspected abuse and/or neglect occurred on a weekend or state holiday. At a minimum the report shall contain:

a. name of suspected resident or child victim of alleged child abuse and/or neglect;

b. address and telephone number of where suspected victim may be contacted;

c. name(s) of alleged perpetrator(s);

d. alleged perpetrator(s) address;

e. nature, extent, and cause of residents or child of a residents injury, neglect or condition;

f. current circumstance of resident or child of a resident and if resident or child of a resident is currently in danger;

g. identify names of possible witnesses;

h. identify how incident came to reporters attention;

i. have other incidents of suspected abuse and/or neglect been reported regarding this resident, child of a resident, or alleged perpetrator;

j. any other pertinent information; and

k. name of person reporting to child protection and time of notification.

F. Grievance Process

1. The provider shall have and adhere to a written policy and procedure, which establishes the right of every resident and the resident's legal guardian(s) to file grievances without fear of retaliation.

2. The written grievance procedure shall include, but not be limited to:

a. a formal process for the resident and the resident's legal guardian(s) to file grievances that shall include procedures for filing verbal, written, or anonymous grievances; and

b. a formal process for the provider to communicate with the resident and/or legal guardian about the grievance within five calendar days of receipt of the grievance.

3. Each resident shall be fully informed of the grievance and complaint policy and procedure and be provided with a written copy. Each residents record shall contain written acknowledgement signed and dated by program director or designee and resident of understanding and receipt of grievance and complete policies and procedures.

4. The provider shall maintain a log documenting all verbal, written, or anonymous grievances filed.

5. Documentation of any resident's or residents legal guardian(s)' grievance and the conclusion or disposition of these grievances shall be maintained in the resident's record. This documentation shall include any action taken by the provider in response to the grievance and any follow-up action involving the resident.

G. Data Collection and Quality Improvement

1. The provider shall have and adhere to a written policy and procedure for maintaining a quality improvement program to include:

a. systematic data collection and analysis of identified areas that require improvement;

b. objective measures of performance;

c. at least monthly review of residents and children of residents records;

d. quarterly review of incidents and the use of personal restraints and seclusion to include documentation of the date, time, and identification of residents and staff involved in each incident to include a critical analysis of the incidents to note patterns of behavior by specific residents or specific staff; and

e. implementation of plans of action to improve in identified areas.

2. Documentation related to the quality improvement program shall be maintained for at least two years.

H. Family Involvement. The provider shall have and adhere to written strategies to foster ongoing positive communication and contact between children of residents, residents, and their families, their friends, and others significant in their lives.

I. Influenza Notice to Parents

1. In accordance with R.S. 46:1428 providers shall make available to each residents parent or legal guardian and to each resident aged eighteen or above information relative to the risks associated with influenza and the availability, effectiveness, known contraindications and possible side effects of the influenza immunization. This information shall include the causes and symptoms of influenza, the means by which influenza is spread, the places a parent or legal guardian may obtain additional information and where a resident or youth may be immunized against influenza. The information shall be updated annually if new information on the disease is available. The information shall be provided annually to each licensed facility by the Department of Children and Family Services and shall be made available to parents or legal guardians prior to November 1 of each year. This information shall also be provided to residents with children residing in the facility.

J. Recalled Products

1. The provider shall post the current copy of "The Safety Box" newsletter issued by the Office of the Attorney General as required by chapter 55 of title 46 of R.S. 46:2701-2711. Items listed as recalled in the newsletter shall not be used and shall be immediately removed from the premises.

La. Admin. Code tit. 67, § V-7111

Promulgated by the Department of Social Services, Office of Community Service, LR 36:811 (April 2010), amended by the Department of Children and Family Services, Division of Programs, Licensing Section, LR 38:979, 984 (April 2012), Amended by the Department of Children and Family Services, Division of Programs, Licensing Section, LR 42221 (2/1/2016), Amended by the Department of Children and Family Services, Licensing Section, LR 43261 (2/1/2017), Amended by the Department of Children and Family Services, Licensing Section, LR 431725 (9/1/2017), Amended LR 441991 (11/1/2018), effective 12/1/2018, Promulgated by the Department of Social Services, Office of Community Service, LR 36:811 (April 2010), amended by the Department of Children and Family Services, Division of Programs, Licensing Section, LR 38:979, 984 (April 2012), LR 42:221 (February 2016), amended by the Department of Children and Family Services, Licensing Section, LR 43:261 (February 2017), LR 43:1725 (September 2017), Amended by the Department of Children and Family Services, Licensing Section, LR 45521 (4/1/2019), effective 5/1/2019, Amended LR 46674 (5/1/2020), effective 6/1/2020, Amended LR 47, Amended by the Department of Children and Family Services, Licensing Section, LR 471846 (12/1/2021).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:477 and R.S. 46:1401 et seq.