Utah Admin. Code 501-1-4

Current through Bulletin No. 2024-21, November 1, 2024

Section R501-1-4 - Program Policies, Procedures, and Safe Practices

(1) The licensee shall submit to the office, before program implementation, policies and procedures that include:

(a) a description of what constitutes sex and gender abuse, discrimination, and harassment;

(b) procedures for preventing and reporting abuse, discrimination, and harassment; and

(c) procedures for teaching effective and professional communication with individuals of any sexual orientations and genders.

(2) The licensee shall develop, implement, and comply with safe practices that:

(a) ensure client health and safety;

(b) ensure the needs of the client population served are met;

(c) ensure that none of the program practices conflict with any administrative rule or statute before implementation; and

(d) inform staff of how to manage any unique circumstances regarding the specific site's physical facility, supervision, community safety, and mixing populations.

(3) The licensee shall submit any change to an office-approved policy or curriculum to the office for approval before implementing the proposed change.

(4) A congregate care program licensee shall submit to the office any policies and procedures that describe behavior management, suicide prevention, restraint, or seclusion used in the program as described in Section 26B-2-123, before implementation.

(5) In addition to complying with Section 26B-2-123, a congregate care program licensee shall ensure that the congregate care behavior management policy and practices reflect the following:

(a) a congregate care program licensee uses behavior management techniques that are trauma-informed and appropriate for the client's age, behavior, needs, developmental level, and past experiences and defer to the least restrictive method of behavior management available to control a situation;

(b) a congregate care program licensee only uses behavior management techniques that emphasize de-escalation and promote self-control, self-esteem, and independence;

(c) a congregate care program licensee identifies a behavior management curriculum that emphasizes de-escalation and is compliant with Section 26B-2-123;

(d) only direct care staff familiar with the child and the child's needs conduct passive physical restraint;

(e) restraint is only used if it does not cause undue physical discomfort, harm, or pain to the client;

(f) interventions that use painful stimuli are prohibited as a general practice;

(g) passive physical restraint is used only as an emergency, temporary means of physical containment to protect the consumer, other persons, or property from immediate harm;

(h) restraint only continues as long as the client presents an immediate danger to self or others;

(i) passive physical restraint is not used as a convenience to staff, a substitute for programming or associated with punishment in any way;

(j) a client, non-direct care staff member, or other unauthorized individual does not use any form of restraint;

(k) staff do not use physical work assignments or activities that inflict pain as behavior management techniques; and

(l) staff are trained to ensure the following safe practices:

(i) appropriate de-escalation techniques and alternatives to restraint or seclusion;

(ii) thresholds for restraints;

(iii) the physiological and psychological impact of restraint;

(iv) appropriate monitoring of restraint episodes;

(v) how to recognize the physical signs of distress, positional asphyxia, and obtaining medical assistance;

(vi) how to intervene if another staff member fails to follow correct procedures when using a restraint;

(vii) time limits for restraints;

(viii) the process for obtaining clinical approval for continued restraints;

(ix) the procedure for documenting and reporting restraints;

(x) the procedure for processing restraints with clients;

(xi) the procedure for following up with staff after a restraint;

(xii) how staff address injuries and complaints;

(xiii) department code of conduct; and

(xiv) client rights.

(6) A congregate care program licensee shall ensure that congregate care seclusion policy and practices reflect the following:

(a) seclusion is only used to ensure the immediate safety of the child or others and is terminated as soon as the risks have been mitigated, not to exceed four hours without clinical justification;

(b) staff who are familiar to the child directly supervise the child during the seclusion;

(c) staff supervising seclusion ensure that any potentially harmful items or objects are removed from the seclusion environment;

(d) seclusion rooms measure a minimum of 75 square feet and have a minimum ceiling height of seven feet with no equipment, hardware or furnishings that obstruct staff's view of the client or present a hazard;

(e) seclusion rooms have either natural or mechanical ventilation with break resistant windows and either a break resistant two-way mirror or camera that allows for observation of the entire room;

(f) seclusion rooms do not have locking capability and are not located in closets, bathrooms, unfurnished areas or other areas not designated as part of residential living space;

(g) bedrooms are not utilized as a seclusion room and seclusion rooms may not be utilized as bedrooms;

(h) seclusion episodes are documented in detail by the staff involved in initiating and supervising the seclusion episode;

(i) seclusion episodes of more than two in a 24-hour period are supported by clinical review and documentation regarding client suitability for remaining in the program; and

(j) client time-out is used when addressing behavioral issues only if:

(i) a client in time-out is never physically prevented from leaving the time-out area;

(ii) it takes place away from the area of activity or from other clients, such as in the client's bedroom;

(iii) staff monitors the client while in time-out; and

(iv) the reason for and duration of time-out is documented by staff on duty when it occurs.

(7) A congregate care program licensee shall develop and follow a suicide prevention policy that complies with Subsection 26B-2-123(5).

(8) A congregate care program licensee shall ensure that the program's licensed clinical professional conducts regular reviews of client restraints, seclusions, behavioral interventions, and time outs to inform processing discussions with clients and training for direct care staff.

(9)

(a) Before a congregate care program licensee may accept a client or send a discharging client who is transported by a youth transportation company as defined in Section 26B-2-101, the licensee shall ensure that the transport company is registered with the office.

(b) A congregate care program licensee shall report private placements to the office as described in Section 26B-2-124 by completing the congregate care out of state placement survey on the office website no later than the fifth business day of each month.

Utah Admin. Code R501-1-4

Amended by Utah State Bulletin Number 2015-14, effective 7/1/2015

Adopted by Utah State Bulletin Number 2017-3, effective 1/17/2017

Amended by Utah State Bulletin Number 2018-6, effective 2/23/2018

Amended by Utah State Bulletin Number 2019-4, effective 1/17/2019

Amended by Utah State Bulletin Number 2022-02, effective 1/6/2022

Amended by Utah State Bulletin Number 2022-08, effective 4/5/2022

Amended by Utah State Bulletin Number 2023-06, effective 3/2/2023

Adopted by Utah State Bulletin Number 2024-01, effective 12/19/2023