La. Admin. Code tit. 48 § IX-105

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

Section IX-105 - Administrative Standards

A. Governing Body

1. (MS) The agency shall adopt and implement a policy stating that no member of the immediate family of the governing body of the agency shall be an employee of, consultant to, independent contractor with or perform paid work for the agency. "Immediate family" means children, the spouses of his/her children, brothers, sister, parents, spouse and the parents of the spouse.

2. (MS) Members of the governing body are responsible for accessing orientation training regarding the guiding principles enumerated in §103 of this Chapter, services to persons with developmental disabilities, information about the programs being offered, and available funding sources.

3. (QI) The membership of the governing body should reflect the community in which the agency operates ethnically and geographically.

4. (QI) The membership of the governing body should be representative of the community and include persons with disabilities and/or families of persons with disabilities.

5. (QI) The governing body should include consumers of services.

6. (QI) Supports shall be offered and provided to consumers and family members on the governing body to insure their active participation during the meeting.

7. (MS) The governing body or its executive committee shall meet at least quarterly, and more often as needed.

8. (QI) The governing body is comprised of people who have been elected by the general membership and/or nominated by families of consumers or a nominating committee composed of consumers, other board members, and families of consumers.

9. (MS) The governing body shall ensure that the program has developed and implemented long-range goals consonant with the Guiding Principles enumerated in §103 of this Chapter.

10. (MS) The long-range goals and the plans for implementation shall be reviewed at least annually by the governing body.

11. (MS) The governing body shall review the outcome of the annual self-evaluation required by Department of Social Services, Bureau of Licensing and Certification, any resulting recommendations, and note such in its minutes.

12. (MS) The governing body shall consist of at least five members.

B. Community Relations

1. (MS) Each agency shall develop cooperative agreements and working relationships with vocational programs offering similar services and operating in or near the agency's service delivery area. Agreements shall identify a mutual referral process, shall address access to employment and alternatives to employment for the persons served.

2. (MS) Provider agencies shall use a variety of community-based generic resources to meet the needs of the individuals served and to avoid duplication of services.

3. (QI) In an effort to become an integral part of the local business community, provider agencies and/or staff should belong to and participate in civic organizations.

4. (MS) The agency shall develop and use resources for technical assistance and training.

5. (QI) The agency and/or key staff should belong to professional organizations related to the provision of services.

6. (QI) Agencies shall cooperate with existing consumer, family support, and advocacy organizations.

7. (MS) The agency may make use of volunteers in any area where such utilization will directly or indirectly enhance opportunities for the personal development of consumers. All volunteers shall receive appropriate training and be supervised by qualified mental retardation professionals. Interns and students assigned for formal work experience, and other volunteers, who are registered and have formal duty assignments, are encouraged to participate in the program but are not to be used as substitutes for staff.

C. Fiscal

1. (MS) The agency shall use of a variety of fiscal resources: Louisiana Rehabilitation Services (LRS) and Home and Community-Based Waiver funds shall be used for activities which can appropriately be funded by those sources.

2. (QI) The agency shall access work incentives offered through Social and/or Supplemental Security. Plan for Achieving Self-Support (PASS) and Impairment Related Work Expenses (IRWE) should be used for activities which can be funded by those sources, unless such use is not in the best financial interest of an individual consumer.

3. (QI) The agency shall apply for competitive funding, such as, public and private grants, and foundation funding.

D. Rights

1. (MS) The agency shall have policies and procedures which include statements that a participant has all rights afforded to citizens of the United States, the rights enumerated in R.S. 28:380 through 444, the MR/DD Law, as they apply, and in particular, the following rights:

a. receive services without regard to race, color, religion, sex, marital status, national origin, sexual orientation, age, or disability; (Restrictions based on OCDD's eligibility requirements are not prohibited.)

b. a program orientation;

c. privacy;

d. freely communicate choices, preferences, satisfaction;

e. protection from exploitation when engaged in training and productive work;

f. legal representative through referral to an advocacy organization or at their own expense; and

g. freedom from neglect and abuse.

2. (MS) The agency shall comply with the requirements of the Americans with Disabilities Act as they apply to the organization. (A lack of findings on the part of the OCDD with regard to this standard in no way implies that the OCDD has made a legal determination that the agency is in compliance with the provisions of the ADA.)

3. (MS) The majority of the members of the Human Rights Committee is external to the agency.

E. Confidentiality

1. (MS) The agency shall implement and have written policies and procedures regarding release of information. The policies and procedures shall require that the release form shall:

a. specify the name of the person or agency to whom the information is released;

b. describe the information to be released;

c. specify the purpose for the release of information;

d. specify the length of time for which the release is valid, not to exceed one year; and

e. include the date and signature of the consumer or his/her representative. The signature of a witness must be obtained, when such signature is required.

2. (MS) The agency shall have a policy which defines who has access to consumer records.

3. (MS) The agency shall maintain a record of all persons, including staff, who have accessed information from consumers records.

F. Informed Consent

1. (MS) The agency's policies and procedures and/or employee handbook shall include provisions pertaining to informed consent. Informed consent is the knowing consent of an individual or his/her legally authorized representative, so situated to be able to exercise free power of choice without undue inducement or any element of force, fraud, deceit, duress or other form of constraint or coercion. The basic elements of information necessary for informed consent include the following:

a. a fair explanation of the services to be provided and their purposes;

b. a description of any risks which may possibly exist;

c. a description of any benefits reasonably to be expected;

d. a disclosure of any appropriate alternative services that might be advantageous for the consumer; and

e. an offer to answer any inquiries concerning services.

2. (MS) The conditions under which a consumer must be provided informed consent must be described in the Policy Manual and must include, at a minimum, admission, discharge, Interdisciplinary Team meetings, and any other time that a significant change to the Individualized Program Plan is made.

G. Legal Status

1. (MS) The agency shall make reasonable efforts to determine the legal status of applicants as well as any changes in such status of applicants or current consumers (i.e., full interdiction, partial interdiction, continuing tutorship, competent major).

2. (MS) In the event that a restrictive legal action has been filed on behalf of an applicant or current consumer, the responsible individual shall be informed of the need to provide a copy of the legal document or an affidavit to that effect to the agency.

H. Personnel

1. (MS) The organization does not discriminate with regard to employment, promotion, pay or place of work because of race, sex, creed, national origin, disability or age.

2. (MS) The agency has an authorized procedure for suspension or dismissal of an employee for cause. This policy assures firm disciplinary action for employee behaviors which include, but are not necessarily limited to, abuse and neglect.

3. (MS) The immediate director of the employment/work program shall hold a bachelor's degree and have at least one year's experience in accessing employment opportunities for persons with developmental disabilities. This standard applies to employees hired on or after July 20, 1995.

4. (MS) Where certification or licensing standards exist for professional staff or consultants, these individuals shall possess up-to-date certifications and/or licenses.

I. Admissions

1. (MS) Within 30 days of admission, the agency will submit written information to the OCDD about each consumer to receive funding under the OCDD contract, including:

a. the OCDD Client Registration Form;

b. the proposed type of service to be delivered, i.e., mobile crew, individual job, enclave or facility-based services;

c. a statement that there is a vacancy and that with this admission the number of consumers to be served does not exceed the maximum number under the contractual agreement.

2. (MS) the agency must insure that the following criteria are met prior to admitting any consumer whose services will be funded by the OCDD:

a. the consumer must be 22 years old or older; and

b. there must be a diagnosis of mental retardation or some other developmental disability made in accordance with the MR/DD State Law.

J. Discharge

1. (QI) Involuntary discharges shall be reviewed by the human rights committee within 30 days after discharge. The agency shall respond to the recommendations of the committee by either following such recommendations or providing reason why not.

2. (MS) The provider shall inform the OCDD of any plans to discharge consumers at least 15 calendar days prior to the planned discharge.

K. Grievances

1. (MS) The agency shall develop policies and procedures which are consonant with the grievance requirements contained or referenced in the contract between the agency and the OCDD and include time lines for each step.

2. (MS) The agency shall inform consumers in writing of the reasons for actions taken and provide the opportunity to meet with staff to resolve any issues.

3. (QI) Prior to appeal to the governing body, the grievance procedure shall include a review of the issues incorporating input from an independent, nonpartisan person(s). Recommendations resulting from the review will be submitted to the governing body.

L. Behavior Modification. There is a need to differentiate between the normal, day to day consequences to behavior and the consequences dictated in behavior management programs. In the course of a day, positive, effective approaches which respect the dignity and reputation of individuals are used to address mild departures from expected behaviors. No formal behavior management plan is needed to use these approaches. Behavior management programs are necessary when the frequency and intensity of a behavior demands a more formal, systematic approach to insure that all relevant staff understand the program and are able to apply it appropriately.

1. (MS) The agency has written policies and procedures for behavior management which:

a. prohibit corporal punishment, chemical restraints, psychological abuse, verbal abuse, seclusion, forced exercise, mechanical restraints, and any procedure which denies food, drink, or use of rest room facilities. The exception is that per Department of Social Services, Bureau of Licensing and Certification mechanical restraints may be used on a temporary basis to safeguard against self-injurious behaviors when the agency's policy allows for such;

b. define the use of behavior modification programs, define mechanisms which authorize their use, and provide for the monitoring and control of their use;

c. define the use of restraint, define mechanisms which authorize their use, and provide for the monitoring and controlling of their use;

d. indicate that passive/physical restraint may be used only after other, less restrictive interventions/strategies have failed;

e. cover any behavioral emergency and provide documentation of the event in incident report format.

2. (MS) The agency shall inform the individual (and his/her legally-appointed guardian) of behavior management policy and procedures prior to the time that a behavior management plan is developed so that the individual can participate fully in the development of the plan.

3. (MS) The decision to implement a behavior management plan shall be made by an interdisciplinary team.

4. (MS) Behavior management plans must be:

a. reviewed by the agency administrator, (or her/his qualified designee); and

b. if the plan includes any form of punishment, it must be reviewed and approved by a specifically constituted Human Rights Committee.

5. (QI) To insure that individual's rights are not abridged, the Human Rights Committee shall review each behavior management plan prior to implementation and at least semi-annually.

6. (MS) The behavior management plan shall:

a. be developed by the Individualized Program Plan Committee in conjunction with a qualified professional (A "qualified professional" must have at least a bachelor's degree in psychology or a master's degree in counseling, social work, rehabilitation, special education or human relations and specific training in learning theory/techniques of behavior management.); and

b. be based on a written functional analysis of the behavior which is defined as:

i. a clear, measurable description of the behavior to include frequency, duration, intensity and severity of the behavior;

ii. a clear description of the need to alter behavior;

iii. an assessment of the meaning of the behavior, which includes the possibility that the behavior is:

(a). an effort to communicate;

(b). the result of medical conditions;

(c). the result of environmental causes; or

(d). the result of other factors; and

c. be written to address specific targeted behaviors, be time-limited, and clearly state the responses to be used by staff; and

d. emphasize the development of the functional alternative behavior and positive approaches and positive behavior intervention; and

e. use the least intervention possible; and

f. be evaluated by the service provider through review of specific data on the progress and effectiveness of the procedures on a periodic basis; and

g. be incorporated into the Individual Habilitation Plan.

7. (MS) Information regarding the behavior program shall be maintained in the Client Record and shall include the following:

a. documentation that the individual (and her/his legally-appointed guardian) and the Interdisciplinary team are informed of and consent to the program; and

b. documentation that all staff engaged in the implementation of the plan have received training pertinent to the plan; and

c. documentation that any prior behavior management plans used since admission or in the last five years, whichever is least, to develop an alternative behavior were taken into consideration in the development of a new plan (A file of these plans must be maintained in the consumer record.); and

d. a description of the conditions which precede the behavior in question; and

e. a description of what appears to reinforce and maintain the behavior; and

f. a clear, measurable and positive procedure which will be used to alter the behavior and develop the functional alternative behavior.

La. Admin. Code tit. 48, § IX-105

Promulgated by the Department of Health and Human Resources, Office of Mental Retardation/Developmental Disabilities, LR 13:246 (April 1987), amended by the Department of Health and Hospitals, Office for Citizens with Developmental Disabilities, LR 21:688(July 1995).

AUTHORITY NOTE: Promulgated in accordance with R.S. 28.380 through 444.