Minn. R. agency 121, ch. 2960, CERTIFICATION STANDARDS; RESTRICTIVE PROCEDURES, pt. 2960.0750

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

Part 2960.0750 - [Effective 1/11/2025] MEDICAL SEPARATION

Subpart 1.When used.

A. Medical separation must be used by staff:

(1) when a resident is exhibiting self-injurious behavior; or

(2) when a resident has:

(a) a severe or persistent medical issue; or

(b) a communicable disease.

B. Medical separation may be used to manage an epidemic or pandemic.

Subp. 2.Requirements.

A. Before a resident may be placed in medical separation, the facility's chief administrator must approve the placement. Medical separation must be overseen by a mental health professional or, if a mental health professional is unavailable, a medically licensed person.

B. Once a resident is placed in medical separation, staff must conduct well-being checks, including during sleeping hours. The well-being checks must be conducted every 15 minutes unless a mental health professional or, if a mental health professional is unavailable, a medically licensed person determines that 30-minute checks would not jeopardize the resident's health or safety.

C. Staff must document daily why medical separation is necessary and describe:

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

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

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

(b) staff safety concerns, including resident self-injurious behavior; and

(c) any mental health concerns.

D. Staff, in consultation with a mental health professional or medically licensed person, must develop a medical separation plan for a resident within eight awake hours of a resident being placed in medical separation. The plan must address modifications to the resident's daily programming and resident's treatment plan.

E. The medical separation plan must be documented. Staff, a mental health professional or medically licensed person, 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 medical separation; and

(3) after reviewing the plan, either transition the resident out of medical separation or approve and document continued placement in medical 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 medical separation for more than 48 awake hours.

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

C. Every seven calendar days that a resident remains in medical 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 medical separation plan;

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

(3) why the resident requires continued placement in medical 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 medical separation, staff 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 medical separations, including:

(a) the reason for each medical separation;

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

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

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

Minn. R. agency 121, ch. 2960, CERTIFICATION STANDARDS; RESTRICTIVE PROCEDURES, pt. 2960.0750

49 SR 499, eff. 1/11/2025