Minn. R. agency 121, ch. 2960, CERTIFICATION STANDARDS; RESTRICTIVE PROCEDURES, pt. 2960.0730

Current through Register Vol. 49, No. 24, December 9, 2024

Part 2960.0730 - [Effective 1/11/2025] SAFETY-STABILIZATION PERIOD (SSP)

Subpart 1.When used; definition.

A. Staff must place a resident in SSP when:

(1) a resident exhibits unsafe or unstable behavior; and

(2) staff cannot address the behavior with less-restrictive behavioral interventions.

B. A resident cannot remain in SSP for more than 24 hours.

C. For purposes of this part, "hours" means awake hours.

Subp. 2.Initial placement in SSP; well-being checks and reintegration.

A. When a resident is placed in SSP, staff must notify a staff supervisor or lead staff member as soon as possible but no later than 30 minutes after placement. Staff must document when SSP began and whether the supervisor or lead staff member was notified.

B. While a resident is in SSP, staff must, every 30 minutes and including sleeping hours, conduct a well-being check and assess the resident for reintegration.

Subp. 3.Documentation.

All documentation must be signed by all staff overseeing SSP, including staff conducting the well-being checks and reintegration assessments, and by all staff whose notification and approval are needed under this part. Staff must document the following information at the following intervals:

A. at one hour in SSP:

(1) the reason for SSP, including the behavior that led to SSP;

(2) how the behavior threatened the safety of the resident, other residents, or facility staff;

(3) why continued SSP is needed to alleviate the ongoing safety risk;

(4) why reintegration is not possible; and

(5) the behavioral interventions that were tried but did not alleviate the continued need for SSP;

B. at two hours and three hours in SSP:

(1) why continued SSP is needed to alleviate the ongoing safety risk;

(2) why reintegration is not possible; and

(3) the behavioral interventions that were tried but did not alleviate the continued need for SSP;

C. each hour, at four hours through 15 hours in SSP:

(1) why continued SSP is needed to alleviate the ongoing safety risk;

(2) why reintegration is not possible;

(3) the behavioral interventions that were tried but did not alleviate the continued need for SSP; and

(4) a reintegration plan, created with resident input if the resident was willing to participate, that:

(a) lists which behaviors the resident must demonstrate to transition from SSP;

(b) identifies any necessary restorative activities; and

(c) corresponds with the resident's behavior and the resident's cognitive and developmental ability; and

D. each hour, at 16 hours through 24 hours:

(1) why continued SSP is needed to alleviate the ongoing safety risk;

(2) why reintegration is not possible;

(3) the behavioral interventions that were tried but did not alleviate the continued need for SSP; and

(4) any updates to the reintegration plan.

Subp. 4.Notification.

In addition to the initial SSP notification under subpart 2, staff must notify the following individuals at the following intervals:

A. each hour, at four hours through 15 hours in SSP, the staff supervisor or a higher-level supervisor;

B. each hour, at 16 hours through 23 hours, a higher-level supervisor not involved in the resident's behavioral incident that resulted in SSP and the facility's chief administrator; and

C. at 24 hours, the higher-level supervisor; the facility's chief administrator; the resident's case manager or treatment team, placing agency, legal guardian, and family; and, as provided under subpart 6, the commissioner.

Subp. 5.Review and approval.

Except as provided under subpart 8, staff must receive approval to continue a resident's placement in SSP from the following individuals at the following intervals:

A. at one hour in SSP, a staff supervisor or lead staff member not involved in the resident's behavioral incident that resulted in SSP; and

B. each hour, at four hours through 23 hours, a staff supervisor or higher-level supervisor not involved in the resident's behavioral incident that resulted in SSP.

Subp. 6.Notification to commissioner required.

Once a resident has been in SSP for 24 hours:

A. the facility's chief administrator must notify the commissioner according to part 2960.0270, subpart 12;

B. staff must attempt reintegration; and

C. if reintegration is unsuccessful, staff must:

(1) transition the resident to administrative separation; or

(2) place the resident in administrative separation while waiting for the resident to be placed in another facility.

Subp. 7.Evaluation referral.

A resident who has been in SSP for 24 hours must be immediately referred to a mental health professional or, if a mental health professional is unavailable, a medically licensed person. The mental health professional or medically licensed person must determine whether the resident needs additional treatment services.

Subp. 8.Staffing limitations; documentation required.

Staff must document if a facility's staffing limitations do not allow for the review and approval under subpart 5.

Subp. 9.Reporting.

A. Each quarter and annually at the end of the calendar year, a license holder must report to the commissioner the following data:

(1) every SSP incident, including:

(a) the length of each incident, excluding sleeping hours; and

(b) the cumulative time that all residents were removed from their units and programming; and

(2) the number of residents who were placed in SSP, including demographic data disaggregated by age, race, and gender.

B. For each SSP incident, staff must document how many hours that a resident spends in a locked space, excluding sleeping hours and when the resident may leave without staff approval. This data must be provided in the facility's quarterly and annual reporting under item A.

Minn. R. agency 121, ch. 2960, CERTIFICATION STANDARDS; RESTRICTIVE PROCEDURES, pt. 2960.0730

49 SR 499, eff. 1/11/2025