Section 3.04 - Administration of the Program(1)Statement of Purpose. Each licensee shall maintain a written statement of purpose identifying the program's philosophy, goals and objectives and the characteristics of the residents served, intake procedures and services. The statement shall make clear which services are provided directly by the program and which will be provided in cooperation with community resources. If the licensee administers several programs at different sites, appropriate resources shall be identified for each site. The statement shall be kept current and shall be available. (a) The licensee shall identify goals and objectives of the program and shall include generally and specifically, both short term and long term aims; provided, however, that the primary purpose of each program shall be to provide children with services to meet their immediate and basic needs and to foster the optimal growth and individual development of the residents in its care. Each program shall wherever possible work towards reintegration of the residents into the families or communities from which they came or into new families or communities when necessary.(b) The licensee shall identify the characteristics of residents to be served, as reflected in the program's eligibility criteria, and shall include identification where applicable, by: 4. intellectual ability or grade level;5. physical development or health;6. social behavior and clinical profile;7. custody or guardianship status;(c) The licensee shall provide evidence that it has completed its own annual written evaluation of its overall program which shall include general effectiveness in relation to stated goals and delivery of services.(2)Organization. (a) Each licensee shall have documentary evidence of its sources of authority to operate the program. 1. A program operated by the Commonwealth or any political subdivision thereof shall maintain documents that identify the statutory basis of its existence and the administrative framework of the governmental departments in which it operates.2. A private program shall maintain documents that completely identify its ownership. Corporations, partnerships, or associations or sole proprietorships shall identify their current officers and board members, if any. Where applicable, documents shall include but not be limited to copies of all papers filed with the Secretary of State of the Commonwealth and/or any political subdivision of the Commonwealth.(b) Each licensee shall designate one person who is responsible for administrative supervision and is duly authorized to act as an agent for the licensee and to oversee the operation of the program.(c) Each licensee shall maintain an organizational table showing the administrative structure of the program, including the lines of authority, responsibility, and staff assignment. Each licensee shall familiarize residents with the organization of the program whenever that may be appropriate.(d) Each program, unless directly operated by the Department of Youth Services, shall have an advisory board of at least four persons. Such board shall include at least three persons who are not employees, or family members of employees or family members of the licensee; and who are familiar with the population that the program serves and the alternatives to residential care. If the program's board of directors meets these requirements, then the board may function as the program's advisory board. 1. The advisory board shall make recommendations on the program's policy regarding program structure, program evaluation, personnel and human rights, focusing on the quality of resident life. The program shall document the reason for any differences between these recommendations and program activities.2. The advisory board shall meet at least annually or more often if necessary to meet the above purpose.3. Copies of the minutes of the advisory board meeting(s) shall be maintained.(e) Each residential program which uses restraint of residents shall participate in a restraint safety committee comprised of licensee's child care staff, clinical staff and the restraint coordinator. The restraint safety committee shall regularly review restraint data and resident and staff safety information.(3)Administration. (a) The chief administrative person or designee shall be on the premises of the program at all times while it is in operation. All employees on duty shall know who is responsible for administrative supervision of the program at any given time.(b) Each licensee shall establish a system of business management and staffing to assure that the facility maintains complete and accurate accounts, books and records, including required financial, personnel and resident's records.(c) Separate financial accounts shall be established for funds belonging to children and complete and accurate records shall be kept of all transactions regarding these funds. 1. These funds shall be used solely for the benefit of the resident to whom the funds belong. The resident, parent, representative, payee, etc., shall be provided an accounting of all expenditures from her/his own funds upon request.2. These funds shall accompany a resident when he/she is discharged or transferred to another facility.(d) In programs serving teen parents and transition to independent living programs, where residents are responsible for their own funds and accounting, the program need not maintain financial records as required by 606 CMR 3.04(3)(c).(e) The licensee shall develop and follow procedures for conducting internal investigations within the program. Such procedures are to be used for any suspected incidents of child abuse or neglect including but not limited to incidents within the program reported to the Department of Children and Families pursuant to M.G.L. c. 119, § 51A and shall be implemented upon request of the Department for any serious incident involving the health or safety of residents within the program. The procedures shall include:1. time lines for conducting and completing the investigations;2. the written format for the investigation report;3. provisions for reporting suspected child abuse and neglect to the chief administrative person and to the Department of Children and Families in accordance with M.G.L. c. 119, § 51A, and following the procedure required by 606 CMR 3.04(3)(g) regarding reporting to the Department;4. the process for designating persons responsible for implementing each step of these procedures including conducting the investigations;5. a description of the process for reviewing the investigation report and for taking corrective action if necessary.(f) The licensee shall have a written plan for staff to file a report of abuse or neglect with the Department of Children and Families, pursuant to M.G.L. c. 119, § 51A. This plan shall include the following information for staff of programs serving teen parents:1. guidelines for reporting abuse or neglect of children by their teen parents as well as abuse or neglect of teen parents younger than 18 years old by their caregivers; and2. guidelines for determining whether incidents of neglect are reportable conditions or may be resolved by program intervention.(g) The licensee shall have a written plan for notification of the Department as well as any other state agency or referral source which requires such notification immediately after learning that a M.G.L. c. 119, § 51A report has been filed alleging abuse or neglect of a child at the program or during program activities, including those alleging parental abuse or neglect of a child who resides at the program together with his or her teen parent.(h) The licensee shall implement a procedure for documenting unusual and/or serious incidents such as behavioral incidents, runaways, serious injuries or accidents, property destruction, medication errors, medical and other emergencies. The procedure for documenting these incidents shall include a review of the report by the chief administrative person or his or her designee.(i) The licensee shall ensure incident reports are completed documenting the use of any physical restraint. Such reports must include at least the following: 1. the name of the resident;2. the names and positions of staff involved in the restraint;3. the date and time of the restraint;4. the behavior of the resident which prompted the restraint;5. a description of the surrounding activities and environment at the time of the restraint;6. a description of the efforts by staff to de-escalate the situation and the alternatives to physical restraint attempted by staff;7. the justification for the physical restraint;8. a detailed description of the actual physical restraint, including starting and ending times;9. notation of what level of restrictiveness the restraint reached (standing, sitting, floor);10. documentation of the monitoring of the resident during the restraint;11. documentation of approval for continuation of the restraint longer than 20 minutes, if applicable;12. documentation of processing and review of the restraint with the resident following the restraint;13. documentation of any injury to the resident and any medical care provided;14. documentation of any consequences taken against the resident, as a result of the incident leading to the restraint;15. information regarding opportunities for the resident's parents or guardians to discuss the administration of the restraint and/or any consequences imposed on the student, if applicable;16. signatures of all staff involved in the restraint; and17. review of the incident report by the chief administrative person or his or her designee and the restraint coordinator. Each resident who has been restrained shall be offered the opportunity to comment in writing on the restraint as soon as possible within 24 hours of its occurrence. Such comment shall be attached to the restraint incident report.
(j) The licensee shall have a written procedure regarding the receipt of, consideration of, and decision on complaints and grievances from staff, parents, and residents regarding the resident's care. The procedure must include a mechanism to inform the complainant of the results of the decision.1. The licensee shall distribute this written grievance procedure to residents and parents prior to admission and to staff during initial orientation period.2. The licensee shall maintain written records of all decisions resulting from the grievance procedure.(k) The licensee shall provide a telephone number and a system of emergency assistance to parents and to residents while they are away from the program. This system shall be in place on a 24 hour per day seven day per week basis. (l) The licensee may not discriminate in providing services to children and their families on the basis of race, religion, ethnic background, cultural heritage, national origin, marital status, sexual orientation or disability, or in approving shelter home parent applicants on the basis of age, sex, race, religion, ethnic background, cultural heritage, national origin, marital status, sexual orientation or disability. (m) The licensee shall not permit more than the number of residents as specified on the license to reside in a program at any one time. (4)Finances. The applicant or licensee shall demonstrate financial capability to carry out its program for the licensing period, except that programs which have not previously operated shall demonstrate such capacity for at least a three month period.(a) The licensee shall keep and maintain an accurate record of receipts and expenditures which shall be audited annually.(b) The licensee shall keep on file an annual budget for the operation of the program.(c) An applicant for a regular two year license shall submit evidence of the rate approved by the Commonwealth for the provision of services, if applicable.(5)Required Notifications.(a) In case of fire or other emergency which requires the evacuation of the facility and results in the need to seek other shelter, the licensee shall notify the Department within 24 hours.(b) Within ten days of receipt of notice of the initiation of civil, criminal, or administrative action against the licensee or any person employed by the licensee regarding the licensee's care of children and teen parents in its program or which could affect the continued operation of the program, the licensee shall notify the Department in writing.(c) The licensee shall notify the Department as well as any other state agency or referral source which requires such notification immediately after learning that a 51A report has been filed alleging abuse or neglect of a child at the program or during program activities, including those alleging parental abuse or neglect of a child who resides at the program together with his or her teen parent. A report of abuse or neglect shall initiate an investigation by the Department and may subject the program to further legal action by the Department, Department of Children and Families and the District Attorney. If a report is filed either: 1. pursuant to M.G.L. c. 119, § 51A; or2. with the Department against a program employee, a member of the child care staff or any other person with unsupervised access to the residents, the licensee shall prohibit the allegedly abusive or neglectful person from having unsupervised contact with children until the Department of Children and Families has completed its investigation and has determined that the allegation is unsupported, and the Department has investigated the allegation and determined that the employee may resume his or her normal duties.(d) In the event of serious illness the licensee shall notify as soon as reasonably possible, the resident's parent or person other than a parent who has legal custody of the child, the referral source, and the Department of Elementary and Secondary Education, when applicable.(e) In the event of serious accident or death, the licensee shall immediately notify the resident's parent or person other than the parent who has legal custody, the referral source, the Department, and the Department of Elementary and Secondary Education, when applicable. The licensee shall cooperate in arrangements made for examination, autopsy and burial.(f) In the event of unexpected death, the licensee shall also notify the local police.(g) In the event of a serious injury to a resident resulting in hospitalization, an incident involving firearms or dangerous weapons which results in a report to law enforcement officials, an incident involving fire which results in a response by fire officials, or an incident involving an escape from a secure facility, the licensee shall notify the Department within 24 hours of the injury or incident. The licensee, if requested by the Department, shall prepare and submit to the Department a written report regarding the injury or incident.(h) If, during the period of licensure the program is unable to renew its health, building or fire inspection certificates, the licensee shall notify the Department and submit its plan for corrective action. (i) The licensee shall notify the Department prior to any substantial change in the program, physical facility, staffing, population served, policies, or services offered, and within two weeks of a change in the advanced degree person for treatment planning. (j) The licensee shall submit, on a form provided by the Department, a quarterly report of all restraints and injuries related to restraints in the program. (6)Personnel. (a) The licensee shall describe in writing the program's current personnel policies and practices and shall make them available to all employees. These personnel policies shall include a description of:1. Criteria and procedures for hiring, assignment, promotion, probation and suspension or dismissal of an employee;2. The procedure for handling staff complaints;3. Provisions for vacations, holidays, and leaves.(b) A copy of the personnel policies shall be given to each new employee or each employee shall be informed that a copy is available upon his or her request.(c) The licensee shall make available written job descriptions for all positions, including consultants, part-time employees, interns, volunteers and per diem workers.(d) The licensee shall establish a written salary range including benefits covering all positions and shall provide each employee with information regarding the salary range for his or her position or the procedure for determining his or her salary.(e) The licensee shall obtain evidence that personnel are currently certified, licensed, or registered when applicable laws require certification, licensure, or registration.(f) The licensee shall maintain a personnel record for each employee which shall include but not be limited to: 1. employee's resume or job application;2. copies of licenses or certification held;3. documentation of reference checks by telephone;4. documentation of a completed CORI evaluation as required by 102 CMR 1.05: Disqualifying Background Information and 606 CMR 14.00: Criminal Offender and Other Background Record Checks;5. documentation of participation in training, including the prevention/restraint training post-tests as required by 606 CMR 3.04(7)(a)1.b.;6. annual evaluations as required by 606 CMR 3.04(8)(a);7. documentation of any disciplinary actions or investigations.(g) If volunteers are used, the licensee shall describe in writing its plan for using volunteer services. Volunteers shall be chosen for their ability to meet the needs of the children. The licensee shall have evidence of each volunteer's compliance with 102 CMR 1.05: Disqualifying Background Information and 606 CMR 14.00: Criminal Offender and Other Background Record Checks, and at least one reference check shall be conducted and documented for each volunteer. 1. Volunteers shall possess qualifications in accordance with the services they provide.2. The licensee shall utilize volunteers only in conjunction with appropriate ongoing, scheduled supervision and training.(7)Orientation and Training. (a) The licensee shall provide orientation for all new employees to acquaint them with the program's philosophy, organization, policies and services. 1. Each licensee shall describe in writing the program's plan for staff orientation, which shall include at a minimum, but not be limited to the characteristics of children served; symptoms and behavioral signs of emotional disturbance; symptoms of drug overdose, alcohol intoxication, or possible medical emergency; the program's emergency and evacuation procedures, procedures for reporting suspected incidents of child abuse and neglect, orientation in first aid and C.P.R., training in universal precautions and infection control procedures, and the program's policies regarding medication, runaway children, and behavior support. a. Each new employee (who may work with residents) of a program which utilizes restraint shall receive a minimum of 16 hours of training in the prevention and use of restraint, which shall address the needs and behaviors of the population served, relationship building, prevention of restraint, de-escalation methods, avoiding power struggles, thresholds for restraints, the physiological impact of restraint, monitoring physical signs of distress and obtaining medical assistance, legal issues, positional asphyxia, escape and evasion techniques, time limits, the process for obtaining approval for continued restraints, procedures to address problematic restraints, documentation, processing with children, follow-up with staff, and investigation of injuries and complaints.b. Prevention/restraint training shall include role-playing in de-escalation and demonstration of proficiency with each hold taught, and written post-training tests.2. No new employee shall be solely responsible for children in care until he or she has received the minimum orientation described in 606 CMR 3.04(7)(a).3. No employee shall participate in a restraint until he or she has successfully completed the required prevention/restraint training.(b) The licensee shall train all child care staff in first aid procedures.1. The training shall include, but not be limited to, information on: bleeding, bruises, choking, falls, poisoning, objects in the eye, animal and insect bites, and convulsions.2. Such training shall occur within one month of a new employee's beginning work unless he or she can show evidence of current first aid training.3. Each staff shall be certified in CPR and First Aid within six months of hire. Such certification shall be kept current.(c) The licensee shall train all child care and clinical staff in universal precautions and infection control procedures. These procedures shall include, but not be limited to: requirements for isolation, disposal of or separate care of eating utensils and linens, and any specific precautions which may be required on a case-by-case basis.(d) Child care and clinical staff shall be instructed about the nature of the medications administered to children, documentation procedures, potential side effects, and any special precautions or requirements that may need to be observed.(e) The licensee shall provide child care staff with quarterly training on safety procedures, as provided by 606 CMR 3.08(2)(d).(f) Programs utilizing unusual and extraordinary procedures shall train staff in all aspects of the procedures.(g) The licensee shall provide on-going staff training programs appropriate to the size and nature of the program and staff involved. Each licensee shall describe in writing the program's plan for staff training, including the curriculum for prevention/restraint training and refresher training, if applicable. 1. In any program which utilizes physical restraint, the plan for staff training shall include a minimum of eight hours' annual refresher training for each staff in effective de-escalation and safe restraint methods, written post-training tests, and regular review of restraints implemented.2. Full-time child care, professional and supervisory staff shall be required to attend a minimum of 24 hours of training per calendar year.3. Part-time and weekend staff shall be required to attend a minimum of 12 hours of training per calendar year.(8)Supervision. The licensee shall make all child care and clinical staff directly responsible to a staff person who has supervisory or administrative responsibility and who has experience suitable to the goals of the program and the responsibilities of the staff supervised. The licensee shall require child care and clinical staff to have regular, scheduled conferences with the assigned supervisor regarding children's needs and methods of meeting those needs.(a) The supervisor(s) shall conduct and document evaluations at least yearly, of all child care and clinical staff.(b) Evaluations shall consider the individual's job performance, including implementation of restraints, attendance at trainings and ability to implement residents' service plans.(c) Copies of evaluations shall be maintained in a staff's personnel record and shall be available to him or her upon request.Adopted by Mass Register Issue 1303, eff. 1/1/2016.Amended by Mass Register Issue 1306, eff. 1/1/2016.Amended by Mass Register Issue 1307, eff. 1/1/2016.