Md. Code Regs. 10.01.18.07

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.01.18.07 - Additional Requirements for State Facilities

A. This regulation applies to State facilities.

B. Screening and Prevention Policies.

(1) The facility shall adopt and enforce written policies and procedures for ensuring the facility screens for, and takes reasonable steps to mitigate, an individual's risk of being subjected to, or the perpetrator of, inappropriate sexual behavior in accordance with the requirements set forth in this chapter.

(2) The facility shall provide training to staff members, upon hire and annually thereafter, regarding:

(a) The policies and procedures governing the risk screening and protection plans; and

(b) Detection and prevention of inappropriate sexual behavior in accordance with this chapter.

(3) The Department shall utilize a uniform risk assessment screening tool.

C. Required Processes Upon Admission to Facility.

(1) As soon as practicable, but no later than 3 business days after the individual's admission, the facility shall make reasonable efforts to collect the individual's medical and treatment records in accordance with §H of this regulation.

(2) The facility shall implement reasonable safety precautions upon the individual's admission.

(3) Within 48 hours of the individual's admission, clinical staff shall:

(a) Complete a risk assessment screen of the resident, in accordance with §D of this regulation;

(b) Complete a suicide risk assessment; and

(c) If necessary, modify the reasonable safety precautions to mitigate the risks identified in the risk assessment screen.

(4) Within 5 days after the individual's admission, the treatment team shall meet to:

(a) Review and, if appropriate, update the risk assessment screen;

(b) Determine if a protection plan is necessary, based upon review of the risk assessment screen and, if so, develop a protection plan, in accordance with §E of this regulation; and

(c) Develop the initial plan of care in accordance with §F of this regulation.

D. Risk Assessment Screen.

(1) To complete the risk assessment screen, clinical staff shall:

(a) Use the form required by the Department;

(b) Interview the individual; and

(c) Document the individual's responses regarding:

(i) The individual's history of trauma and other issues relevant to the individual's risk of being subjected to, or the perpetrator of, inappropriate sexual behavior in the facility;

(ii) Whether the individual feels safe in the facility, including why or why not; and

(iii) What the individual believes would make them feel safe in the facility.

(2) If the individual cannot be interviewed, the clinical staff shall document the reason on the risk assessment screen form.

E. Protection Plan.

(1) The treatment team shall develop a protection plan if the treatment team determines that it is necessary to mitigate the risk identified in the risk assessment screen.

(2) The protection plan shall be completed on the form required by the Department.

(3) If a protection plan is determined to not be necessary to mitigate the risk identified in the risk assessment screen, the rationale shall be documented in the risk assessment screen.

(4) If an individual in a State facility has a behavior plan that includes the elements required in a protection plan, the behavior plan shall satisfy the requirements of this regulation and shall be labeled as a behavior and protection plan.

F. Plan of Care.

(1) When developing the initial plan of care, the treatment team shall:

(a) Review and, if appropriate, update the risk assessment screen based upon the information available to the treatment team; and

(b) Include a protection plan, if appropriate, pursuant to §E of this regulation.

(2) The initial and all subsequent plans of care shall:

(a) Incorporate the risk assessment screen and, if applicable, the protection plan;

(b) Include consideration of the effect of trauma on the individual; and

(c) Be authorized by a physician, psychiatrist, or other appropriately qualified person under applicable legal and operational standards.

(3) The plan of care shall be reviewed at least every 3 months and whenever an individual's risk assessment screen is updated.

G. Review and Update of Risk Assessment Screens and Protection Plans.

(1) The treatment team shall review the risk assessment screen, and update if necessary, every 3 months as part of the plan of care review.

(2) The risk assessment may be reviewed more frequently if warranted by any new allegation of inappropriate sexual behavior or if additional information regarding risk factors is received by the treatment team.

(3) The plan of care shall be reviewed when the risk assessment is updated.

(4) The protection plan shall be reviewed and updated as needed or whenever the risk assessment is updated and when the plan of care is reviewed.

(5) When reviewing the protection plan, the treatment team shall consider:

(a) Effectiveness of strategies to reduce risk;

(b) Whether new or modified strategies are warranted; and

(c) The individual's desires regarding the protection plan.

H. Medical and Other Records.

(1) The facility shall designate the staff member or members responsible for collecting the individual's medical records in accordance with this subsection.

(2) The facility shall make reasonable and documented efforts to collect medical records from the individual's prior and current health care providers in accordance with this subsection, including:

(a) Discharge summaries from all hospitals where the individual received treatment in the 3 years before the individual's admission to the facility; and

(b) Somatic and other health assessments performed in the 3 years before the individual's admission to the facility.

(3) The facility shall make reasonable and documented efforts to collect any other significant records identified by the facility that the treatment team determines are clinically necessary to develop and implement the individual's plan of care.

(4) Facilities shall make reasonable and documented efforts to collect information from the following sources related to the individual's risk for being a victim or perpetrator of inappropriate sexual behavior, provision of trauma-related care or treatment, or the individual's reduced decision-making capacity, as authorized by law:

(a) Other State facilities;

(b) Local jails or detention centers and facilities operated by the Department of Public Safety and Correctional Services;

(c) The Department of Juvenile Services;

(d) Local Departments of Social Services, to identify other sources;

(e) Private hospitals and clinics; and

(f) Any persons known to the Department to have knowledge to identify other sources, including sources indicated on the responses to the risk assessment screen.

(5) Facilities shall access records in electronic databases whenever possible and as such data bases become available.

(6) The facility shall comply with applicable laws and regulations governing the confidentiality and release of medical and other personal information pursuant to applicable State and federal laws and regulations.

Md. Code Regs. 10.01.18.07

Regulation .07 adopted effective 42:23 Md. R. 1433, eff.11/23/2015; recodified to .09 effective 48:26 Md. R.1110, eff. 12/27/2021