La. Admin. Code tit. 48 § I-9035

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

Section I-9035 - Administrative Policies and Records [Formerly Section 9031]

A. Every PRTF shall have policies that are clearly written and current. All policies shall be available for review by all staff and LDH personnel. All policies shall be available for review upon request by a resident or a residents parent or legal guardian.

B. All policies shall be reviewed annually by the governing body.

C. The PRTF shall have policies governing:

1. admission and discharge;

2. personnel;

3. volunteers;

4. grievance procedures;

5. behavior management;

6. use of restraint and seclusion;

7. mandatory reporting of abuse or neglect;

8. administering medication;

9. confidentiality of records;

10. participation of residents in activities related to fundraising and publicity;

11. participation of residents in research projects;

12. the photographing and audio or audio-visual recording of residents and clarification of the agencys prohibited use of social media to ensure that all staff, either contracted or directly employed, receive training relative to the restrictive use of social media;

13. all hazards risk assessment and emergency/disaster procedures, including the provision that when the PRTF has an interruption in services or a change in the licensed location due to an emergency situation, the PRTF shall notify the HSS no later than the next stated business day;

14. sentinel events and critical incidents; and

15. factors that determine room assignments, including, but not limited to, age and diagnoses.

D. Admission Policy

1. A PRTF shall have written admission policies and criteria which shall include the following:

a. intake policy and procedures;

b. admission criteria and procedures;

c. policy regarding the determination of legal status, according to appropriate state laws, before admission;

d. the age of the populations served;

e. the services provided by the PRTF;

f. criteria for discharge;

g. only accepting residents for placement from the parent(s), legal guardian(s) custodial agency or a court of competent jurisdiction;

h. not admitting more residents into care than the number specified on the provider's license; and

i. ensuring that the resident, the resident's parent(s) or legal guardian(s) and others, as appropriate, are provided reasonable opportunity to participate in the admission process and decisions. Proper consents shall be obtained before admission.

2. Notification of Facility Policy Regarding the Use of Restraint and Seclusion. At admission, the facility shall:

a. inform both the incoming resident and, in the case of a minor, the resident's parent(s) or legal guardian(s) of the facility's policy regarding the use of restraint or seclusion during an emergency safety situation that may occur while the resident is in the program;

b. communicate its restraint and seclusion policy in a language that the resident, or his or her parent(s) or legal guardian(s) understands (including American Sign Language, if appropriate) and when necessary, the facility shall provide interpreters or translators;

c. obtain an acknowledgment, in writing, from the resident, or in the case of a minor, from the parent(s) or legal guardian(s) that he or she has been informed of the facility's policy on the use of restraint or seclusion during an emergency safety situation. Staff shall file this acknowledgment in the resident's record; and

d. provide a copy of the facility policy to the resident and in the case of a minor, to the resident's parent(s) or legal guardian(s).

i. The facilitys policy shall provide contact information, including the phone number and mailing address, for the appropriate state protection and advocacy organization.

E. Behavior Management

1. The PRTF shall develop and maintain a written behavior management policy which includes:

a. the goals and purposes of the behavior management program;

b. the methods of behavior management;

c. a list of staff authorized to administer the behavior management policy;

d. the methods of monitoring and documenting the use of the behavior management policy; and

e. minimizing the use of restraint and seclusion and using less restrictive alternatives whenever possible.

2. The facility policy shall prohibit:

a. shaking, striking, spanking or any cruel treatment;

b. harsh, humiliating, cruel, abusive or degrading language;

c. denial of food or sleep;

d. work tasks that are degrading or unnecessary and inappropriate to the resident's age and ability;

e. denial of private familial and significant other contact, including visits, phone calls, and mail, as a means of punishment;

f. use of chemical agents, including tear gas, mace, or similar agents;

g. extreme physical exercise;

h. one resident punishing another resident;

i. group punishment;

j. violating a resident's rights; and

k. use of restraints or seclusion in non-emergency situations.

3. The PRTF shall satisfy all of the requirements contained in federal and state laws and regulations regarding the use of restraint or seclusion, including application of time out.

F. Resident Abuse or Neglect

1. The provider shall have comprehensive written procedures concerning resident abuse or neglect including:

a. a description of ongoing communication strategies used by the provider to maintain staff awareness of abuse prevention, current definitions of abuse and neglect, and mandated reporting requirements to HSS and the DCFS, Child Welfare Division;

b. a procedure for disciplining staff members who abuse or neglect a resident;

c. procedures for insuring that the staff member involved in suspected resident abuse or neglect does not work directly with the resident involved or any other resident in the program until the investigation is complete.

2. Any case of suspected resident abuse or neglect shall be reported immediately to the HSS and, unless prohibited by state law, the DCFS, Child Welfare Division.

3. Staff shall report any case of suspected resident abuse or neglect to both HSS and the DCFS, Child Welfare Division by no later than close of business the next business day after a case of suspected resident abuse or neglect. The report shall include:

a. the name of the resident involved in the suspected resident abuse or neglect;

b. a description of the suspected resident abuse or neglect;

c. the date and time the suspected abuse or neglect occurred;

d. the steps taken to investigate the abuse and/or neglect; and

e. the action taken as a result of the incident.

4. In the case of a minor, the facility shall notify the resident's parent(s) or legal guardian(s) as soon as possible, and in no case later than 24 hours after the suspected resident abuse or neglect.

5. Staff shall document in the resident's record that the suspected resident abuse or neglect was reported to both HSS and the DCFS, Child Welfare Division, including the name of the person to whom the incident was reported. A copy of the report shall be maintained in the resident's record.

G. The facility shall report each serious occurrence to both HSS and, unless prohibited by state law, the DCFS, Child Welfare Division. Serious occurrences that shall be reported include a resident's death, or a serious injury to a resident or a suicide attempt by a resident.

1. Staff shall report any serious occurrence involving a resident to both HSS and the DCFS, Child Welfare Division by no later than close of business the next business day after a serious occurrence. The report shall include the name of the resident involved in the serious occurrence, a description of the occurrence, and the name, street address, and telephone number of the facility. The facility shall conduct an investigation of the serious occurrence to include interviews of all staff involved, findings of the investigation, and actions taken as a result of the investigation.

2. In the case of a minor, the facility shall notify the resident's parent(s) or legal guardian(s) as soon as possible, and in no case later than 24 hours after the serious occurrence.

3. Staff shall document in the resident's record that the serious occurrence was reported to both HSS and the DCFS, Child Welfare Division, including the name of the person to whom the incident was reported. A copy of the report shall be maintained in the resident's record, as well as in the incident and accident report logs kept by the facility.

H. The PRTF shall have a written policy regarding participation of residents in activities related to fundraising and publicity. Consent of the resident and, where appropriate, the resident's parent(s) or legal guardian(s) shall be obtained prior to participation in such activities.

I. The PRTF shall have written policies and procedures regarding the photographing and audio or audio-visual recordings of residents.

1. The written consent of the resident and, where appropriate, the resident's parent(s) or legal guardian(s) shall be obtained before the resident is photographed or recorded for research or program publicity purposes.

2. All photographs and recordings shall be used in a manner that respects the dignity and confidentiality of the resident.

J. The PRTF shall have written policies regarding the participation of residents in research projects. No resident shall participate in any research project without the express written consent of the resident and the resident's parent(s) or legal guardian(s).

K. Administrative Records

1. The records and reports to be maintained at the facility and available for survey staff to review are:

a. residents' clinical records;

b. personnel records;

c. criminal history investigation records;

d. orientation and training hour records;

e. menus of food served to residents;

f. fire drill reports acceptable to the OFSM as defined by the most current adopted edition of the NFPA 101, Life Safety Code;

g. schedules of planned recreational, leisure or physical exercise activities;

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

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

j. written policies and procedures governing all aspects of the provider's activities to include:

i. behavior management;

ii. emergency evacuation; and

iii. smoking policy.

L. Information obtained by the department from any applicant or licensee regarding residents, their parents, or other relatives is deemed confidential and privileged communication. The names of any complainants and information regarding a resident abuse report or investigation is kept confidential.

1. The PRTF shall ensure the confidentiality and security of resident records, including information in a computerized medical record system, in accordance with the HIPAA Privacy Regulations and any Louisiana state laws and regulations which provide a more stringent standard of confidentiality than the HIPAA Privacy Regulations. Information from, or copies of records may be released only to authorized individuals, and the PRTF shall ensure that unauthorized individuals cannot gain access to or alter resident records. Original medical records shall not be released outside the PRTF unless under court order or subpoena or in order to safeguard the record in the event of a physical plant emergency or natural disaster.

a. The provider shall have written procedures for the maintenance and security of clinical records specifying who shall supervise the maintenance of records, who shall have custody of records, and to whom records may be released. Records shall be the property of the provider, and the provider as custodian shall secure records against loss, tampering or unauthorized use.

b. Employees of the PRTF shall not disclose or knowingly permit the disclosure of any information concerning the resident or his/her family, directly or indirectly, to any unauthorized person.

c. When the resident is of majority age and noninterdicted, the 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 accreditation teams and authorized state and federal agencies.

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

e. The provider shall, upon written authorization from the resident or his/her parent(s) or legal guardian(s), make available information in the case record to the resident, his counsel or the resident's parent(s) or legal guardian(s).

f. If, in the professional judgment of the clinical director, it is felt that information contained in the record is reasonably likely to endanger the life or physical safety 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.

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

2. PRTF records shall be retained by the PRTF in their original, microfilmed or similarly reproduced form for a minimum period of 10 years from the date a resident is discharged.

a. Graphic matter, images, x-ray films, nuclear medicine reports and like matter that were necessary to produce a diagnostic or therapeutic report shall be retained, preserved and properly stored by the PRTF in their original, microfilmed or similarly reproduced form for a minimum period of five years from the date a resident is discharged. Such graphic matter, images, x-ray film and like matter shall be retained for longer periods when requested in writing by any one of the following:

i. an attending or consulting physician of the resident;

ii. the resident or someone acting legally in his/her behalf; or

iii. legal counsel for a party having an interest affected by the resident's medical records.

3. The written record for each resident shall include:

a. administrative, treatment, and educational data from the time of admission until the time the resident leaves the facility, including intake evaluation notes and physician progress notes;

b. the name, home address, home telephone number, name of parent(s) or legal guardian(s), home address, and telephone number of parent(s) or legal guardian(s) (if different from resident's), sex, race, religion, birth date and birthplace of the resident;

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

d. placement agreement;

e. the resident's history including educational background, employment record, prior medical history and prior placement history;

f. a copy of the resident's individual service plan and any modifications to that plan;

g. progress reports;

h. reports of any incidents of abuse, neglect, accidents or critical incidents, including use of passive physical restraints;

i. reports of any resident's grievances and the conclusions or dispositions of these reports. If the resident's grievance was in writing, a copy of the written grievance shall be included;

j. a summary of family visits and contacts including dates, the nature of such visits/contacts and feedback from the family;

k. a summary of attendance and leaves from the facility;

l. the written notes from providers of professional or specialized services; and

m. the discharge summary at the time of discharge.

4. All of the resident's records shall be available for inspection by the department.

M. Quality Assessment and Improvement

1. The governing body shall ensure that there is an effective, written, ongoing, facility-wide program designed to assess and improve the quality of resident care.

2. There shall be a written plan for assessing and improving quality that describes the objectives, organization, scope and mechanisms for overseeing the effectiveness of monitoring, evaluation and improvement activities. All organized services related to resident care, including services furnished by a contractor, shall be evaluated. The services provided by each LMHP shall be periodically evaluated to determine whether they are of an acceptable level of quality and appropriateness.

3. Assessment of quality shall address:

a. resident care problems;

b. cause of problems;

c. documented corrective actions; and

d. monitoring or follow-up to determine effectiveness of the corrective actions taken.

La. Admin. Code tit. 48, § I-9035

Promulgated by the department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 30:60 (January 2004), amended by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 38:380 (February 2012), Amended by the Department of Health, Bureau of Health Services Financing, LR 44291 (2/1/2018).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and R.S. 40:2009.