La. Admin. Code tit. 48 § I-6239

Current through Register Vol. 50, No. 9, September 20, 2024

Section I-6239 - Policies and Procedures

A. The TGH shall have written policies and procedures approved by the owner or governing body, which shall be implemented and followed, that address at a minimum the following:

1. confidentiality and confidentiality agreements;

2. security of files;

3. publicity and marketing, including the prohibition of illegal or coercive inducement, solicitation and kickbacks;

4. personnel;

5. client rights;

6. grievance procedures;

7. client funds;

8. emergency preparedness;

9. abuse and neglect;

10. incidents and accidents, including medical emergencies;

11. universal precautions;

12. documentation;

13. admission and discharge procedures;

14. bedroom assignment for clients; and

15. behavior management.

B. A TGH shall have written personnel policies, which shall be implemented and followed, that include:

1. a plan for recruitment, screening, orientation, ongoing training, development, supervision and performance evaluation of staff members, whether directly employed, contract or volunteer;

2. written job descriptions for each staff position, including volunteers;

3. policies that shall, at a minimum, be consistent with Office of Public Health guidelines, to indicate whether, when and how staff have a health assessment;

4. an employee grievance procedure;

5. abuse reporting procedures that require all employees to report any incidents of abuse or mistreatment, whether that abuse or mistreatment is done by another staff member, a family member, a client or any other person;

6. a nondiscrimination policy;

7. a policy that requires all employees to report any signs or symptoms of a communicable disease or personal illness to their supervisor or the Clinical Director as possible to prevent the disease or illness from spreading to other clients or personnel.

C. A TGH shall maintain the requirements for financial viability under this rule at all times.

D. Behavior Management

1. The TGH shall develop and implement written policies and procedures for the management of behaviors to be used on facility-wide level, insuring that procedures begin with the least restrictive, most positive measures and follow a hierarchy of acceptable measures. The policies and procedures shall be provided to all TGH staff and shall include:

a. appropriate and inappropriate behaviors of clients;

b. consequences of inappropriate behaviors of clients;

c. the phases of behavior escalation and appropriate intervention methods to be used at each level.

d. documentation in the client's record of the use of any behavioral management measures.

E. House Rules and Regulations. A TGH shall have a clearly written list of rules and regulations governing conduct for clients in care and shall document that these rules and regulations are made available to each staff member, client and, where appropriate, the clients parent(s) or legal guardian(s). A copy of the house rules shall be given to clients and, where appropriate, the clients parent(s) or legal guardian(s) upon admission and shall be posted and accessible to all employees and clients.

F. Limitations on Potentially Harmful Responses or Punishments. A TGH shall have a written list of prohibited responses and punishments to clients by staff members and shall document that this list is made available to each staff member, client and, where appropriate, the client's parent(s) or legal guardian(s).

1. This list shall include the following prohibited responses/punishments:

a. any type of physical hitting or other painful physical contact except as required for medical, dental or first aid procedures necessary to preserve the child's life or health;

b. physical, chemical and mechanical restraints;

c. requiring a client to take an extremely uncomfortable position;

d. verbal or psychological abuse, ridicule or humiliation;

e. withholding of a meal, except under a physician's order;

f. denial of sufficient sleep, except under a physician's order;

g. requiring a child to remain silent for a long period of time;

h. denial of shelter, warmth, clothing or bedding;

i. assignment of harsh physical work.

j. physical exercise or repeated physical motions;

k. excessive denial of usual services;

l. denial of visiting or communication with family or legal guardian;

m. extensive withholding of emotional response;

n. any other cruel, severe, unusual, degrading or unnecessary discipline.

2. A TGH shall not discipline groups of clients for actions committed by an individual.

3. Children shall neither discipline nor supervise other children except as part of an organized therapeutic self-government program that is conducted in accordance with written policy and is supervised directly by staff. Such programs shall not be in conflict with regulations regarding behavior management.

4. Discipline shall not be administered by any persons who are not known to the client.

G. Restraints

1. A TGH shall develop and implement a written policy which prohibits the use of any form of mechanical, physical or chemical restraints. TGH providers may have a policy that allows passive physical restraint, but it shall be utilized only when the child's behaviors escalate to a level of possibly harming himself/herself or others.

2. The TGH's policy shall provide that passive physical restraints are only to be performed by two trained staff personnel in accordance with an approved curriculum. A single person restraint can be initiated in a life threatening crisis with support staff in close proximity to provide assistance.

H. Time-Out Procedures

1. A provider using time-out rooms for seclusion of clients for brief periods shall have a written policy governing the use of time-out procedures. This policy shall ensure that:

a. the room shall be unlocked;

b. time-out procedures are used only when less restrictive measures have been used without effect. Written documentation of less restrictive measures used shall be required;

c. emergency use of time-out shall be approved by the clinical director for a period not to exceed one hour;

d. time-out used as an individual behavior management plan shall be part of the overall plan of treatment;

e. the plan shall state the reasons for using time-out and the terms and conditions under which time-out will be terminated or extended, specifying a maximum duration of the use of the procedure that shall under no circumstances exceed eight hours;

f. when a child is in time-out, a staff member shall exercise direct physical supervision of the child at all times;

g. a child in time-out shall not be denied access to bathroom facilities, water or meals.

I. Copies of the behavior management policy, the prohibited response and punishment policy, including restraint prohibitions and time out procedures, shall be provided in triplicate upon admission. The child and parent(s) or legal guardian(s) shall sign all three copies. The child and parent(s) or legal guardian(s) shall retain one copy each and the provider shall retain the other copy in the child's record.

J. Copies of the behavior management policy, the prohibited response and discipline policy, including restraint prohibitions and time out procedures, shall be provided in duplicate to each new employee upon hiring. The employee shall sign both copies. The employee shall retain one copy and the provider shall retain the other copy in the employee's personnel record.

K. A TGH shall comply with all federal and state laws, rules and regulations in the development and implementation of its policies and procedures.

La. Admin. Code tit. 48, § I-6239

Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 38:411 (February 2012), Amended by the Department of Health, Bureau of Health Services Financing, LR 44778 (4/1/2018).

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