Minn. R. agency 121, ch. 2960, CERTIFICATION STANDARDS; RESTRICTIVE PROCEDURES, pt. 2960.0740

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

Part 2960.0740 - [Effective 1/11/2025] ADMINISTRATIVE SEPARATION

Subpart 1.When used.

Administrative separation must be used by staff when a resident:

A. is engaging in behavior that requires law enforcement to determine whether criminal charges or delinquency proceedings should be brought;

B. is participating in gang activity that would threaten the resident, other residents, or facility staff if the resident were not separated;

C. according to the vulnerability assessment under part 2960.0070, subpart 5, item A, is vulnerable on the basis of actions or comments and the vulnerability creates a threat to the resident's safety;

D. on the basis of actions or comments, creates a threat to another resident's safety and requires a different environment better suited to the resident's needs until staff can create a modified treatment plan; or

E. is being chronically disruptive and the disruption:

(1) presents an ongoing threat to the safety of the resident, other residents, or facility staff; and

(2) cannot be addressed with safety-stabilization period.

Subp. 2.Requirements.

A. Before a resident may be placed in administrative separation, the facility's chief administrator must approve the placement. Staff must document daily why administrative separation is necessary and why other behavioral interventions were unavailable or unsuccessful. The documentation must describe:

(1) any modifications to the resident's daily programming; and

(2) the resident's behavioral problems, including:

(a) the circumstances leading to being placed in administrative separation;

(b) staff safety concerns, including resident assaultive behavior;

(c) any mental health concerns; and

(d) any victimization concerns.

B. Once a resident is placed in administrative separation, staff must conduct well-being checks every 30 minutes, including during sleeping hours.

C. Within 12 awake hours of a resident being placed in administrative separation, staff must develop an administrative separation plan for the resident. The administrative separation plan must be developed by the resident's case manager or treatment team. The plan must:

(1) address modifications to the resident's daily programming, including identifying ways to provide the resident with more structure or support with additional program services;

(2) address modifications to the resident's treatment plan;

(3) list incentives that staff will use to promote positive behavior, including how staff will use positive behavior interventions and supports;

(4) describe how staff will attempt to deter the resident from planning and engaging in negative behaviors; and

(5) provide for the resident to self-reflect and focus on restoring any harm caused to other residents or staff.

D. The administrative separation plan must be documented. Staff and the chief administrator must:

(1) review the plan daily and modify it as needed;

(2) assess a resident's progress toward transitioning out of administrative separation; and

(3) after reviewing the plan, either transition the resident out of administrative separation or approve and document continued placement in administrative separation.

Subp. 3.Notification.

A. A facility's chief administrator must notify the commissioner according to part 2960.0270, subpart 12, if a resident is expected to be, or has been, in administrative separation for more than 48 awake hours.

B. The notification must be within ten days of the resident's placement, or expected placement, in administrative separation for more than 48 awake hours.

C. Every seven calendar days that a resident remains in administrative separation, the facility's chief administrator must notify the commissioner and the resident's case manager or treatment team, placing agency, legal guardian, and family of the following:

(1) the resident's administrative separation plan;

(2) the resident's progress toward transitioning out of administrative separation; and

(3) why the resident requires continued placement in administrative separation.

D. The facility's chief administrator must document whether they provided the notification under item C.

Subp. 4.Reintegrating the resident into facility operations.

A. When staff determine that the resident's behavior no longer requires safety-based separation and the resident can be reintegrated into facility operations:

(1) staff must follow the facility's reintegration processes under part 2960.0720, subpart 10, item A;

(2) the following individuals must approve reintegration:

(a) the resident's case manager or treatment team;

(b) if the resident's behavioral problems included mental health or victimization concerns, a mental health professional or, if a mental health professional is unavailable, a medically licensed person; and

(c) the facility's chief administrator; and

(3) staff must document the reintegration process and approval from all individuals under subitem (2).

B. Within four hours after the resident has been reintegrated into facility operations, the facility's chief administrator must notify the commissioner and the resident's case manager or treatment team, placing agency, legal guardian, and family.

C. The facility's chief administrator must document whether they provided the notification under item B.

Subp. 5.Reporting.

A. For each incident of administrative separation, a facility must document how many hours that a resident spends in a locked or unlocked space, excluding sleeping hours, when the resident cannot leave without staff approval. This data must be provided in the facility's quarterly and annual reporting under item B.

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

(1) the number of administrative separations, including:

(a) the reason for each administrative separation;

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

(c) the time that each resident was in administrative separation without other individuals in the room; and

(2) the number of residents who experienced administrative separation, including demographic data disaggregated by age, race, and gender.

Minn. R. agency 121, ch. 2960, CERTIFICATION STANDARDS; RESTRICTIVE PROCEDURES, pt. 2960.0740

49 SR 499, eff. 1/11/2025