This regulation establishes licensing requirements for Child and Adolescent Crisis Stabilization Units (C & A CSUs) in Georgia, operated under the Department of Behavioral Health and Developmental Disabilities. Operators must obtain a license prior to admitting individuals, comply with detailed application, staffing, documentation, and operational standards, and designate the unit as an emergency receiving and evaluating facility. The C & A CSU provides short-term medically monitored psychiatric stabilization and detoxification services for children ages 5–12 and adolescents ages 13–17, with a maximum length of stay of 29 calendar days per episode.
View official sourceSubject 82-4-1 CHILD AND ADOLESCENT CRISIS STABILIZATION UNITS Rule 82-4-1-.01 Legal Authority These regulations have been promulgated to ensure that basic statutory licensing requirements to operate Child and Adolescent Crisis Stabilization Units (C & A CSUs) are met and to ensure that organizations providing this service promote the empowerment and resiliency of the individuals they serve. These rules are adopted and published pursuant to the Official Code of Georgia Annotated (O.C.G.A) Sec. 37-1-29 . These rules and regulations supersede any and all prior operational standards related to the designation or certification of Crisis Stabilization Units. Rule 82-4-1-.02 Title and Purpose 1. The purpose of these rules is to establish general licensing procedures, operational requirements and enforcement procedures required by the Department of Behavioral Health and Developmental Disabilities (DBHDD) for the C & A CSU. The issuance of a C & A CSU operating license requires compliance with these rules and regulations and authorizes the licensee to establish services to meet the needs of the individuals in a safe, therapeutic environment. The issuance of such license also sets forth the minimum requirements for providing medically monitored short-term residential services for the purpose of providing psychiatric stabilization for individuals who are seriously emotionally disturbed and/or detoxification services for individuals. The C & A CSU shall be designated as an emergency receiving and evaluating facility. 2. Compliance with this Chapter does not constitute release from the requirements of other applicable federal, state, or local laws, codes, rules, regulations and ordinances. This Chapter must be followed where it exceeds other codes and ordinances. 3. Licensure of the C & A CSU does not constitute an entitlement to any type or level of funding by DBHDD. Rule 82-4-1-.03 Definitions The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise: 1. Abuse means any unjustifiable intentional or grossly negligent act, exploitation or series of acts, or omission of acts which causes physical or mental injury or endangers the safety of an individual, including but not limited to, verbal abuse, assault or battery, failure to provide treatment or care, or sexual harassment of the individual; 2. Adolescent means an individual between the ages of thirteen (13) and seventeen (17) and who is not emancipated; 3. Advanced Practice Nursing means practice under a "Nurse Protocol Agreement", which is a written document, mutually agreed upon and signed by an APRN and a physician, by which the physician delegates to that APRN the authority to perform certain medical acts pursuant to O.C.G.A. Sec. 43-34-25 , which may include without being limited to, the ordering of drugs, medical devices, medical treatments, diagnostic studies, or in life-threatening situations radiographic imaging tests; 4. Advanced Practice Registered Nurse, (hereinafter referred to as APRN), means a registered professional nurse licensed under Title 43, Chapter 25 of the Official Code of Georgia Annotated, who is recognized by the Georgia Board of Nursing as having met the requirements established by the Georgia Board of Nursing to engage in advanced nursing practice and who holds a master's degree or other graduate degree approved by the Georgia Board of Nursing and national board certification in his or her area of specialty, or a person who is recognized as an advanced practice registered nurse by the Georgia Board of Nursing on or before June 30, 2006; 5. Certificate of Need (CON) as defined in O.C.G.A. Sec. 31-6-2 means an official determination by the Department of Community Health (DCH), evidenced by certification issued pursuant to an application, that the action proposed in the application satisfies and complies with the CON criteria contained in the Georgia Code and rules promulgated by DCH; 6. Certified Addiction Counselor means an individual who is certified by one of the approved certifying bodies recognized by the state of Georgia, i.e. the Alcohol and Drug Abuse Certification Board of Georgia or the Georgia Addiction Counselor's Association; 7. Charge Nurse means a registered nurse who has the responsibility for coordination and supervision of nursing services during the period of a work shift; 8. Chemical Restraint means an over-the-counter or prescribed medication or drug that is administered to manage an individual's behavior in a way that reduces the safety risk to the individual or to others that has the effect of reducing the individual's freedom of movement and that is not a standard treatment for the individual's medical or psychiatric condition; 9. Chief Executive Officer (CEO) means the person, by whatever title used, whom the governing body has delegated the responsibility for the management and operation of the facility including the implementation of the rules and policies adopted by the governing body; 10. Child means an individual between the ages of five (5) and twelve (12) years old; 11. Commissioner means the commissioner of the Department of Behavioral Health and developmental Disabilities (DBHDD); 12. Contraband means any item or article of property that poses a threat to the security and safety of the C & A CSU, individuals, employees, visitors or public, or other items prohibited by C & A CSU policy or state law; 13. Crisis Bed means any bed operated by the Crisis Stabilization Unit; 14. Crisis Stabilization Unit (CSU) means a medically monitored short-term residential program that is licensed by the Department under these rules and designated by the Department as an emergency receiving and evaluating facility to provide emergency disability services that include providing psychiatric and behavioral stabilization and detoxification services twenty-four hours a day, seven days a week; 15. Department means the Department of Behavioral Health and Developmental Disabilities (DBHDD); 16. Emancipated minor means a person who is at least sixteen (16) but less than eighteen (18) years of age where the rights of the minor's parents to the custody, control, services, and earnings of the minor have been terminated by operation of state law or pursuant to a valid emancipation order issued by a court of competent jurisdiction; 17. Emergency Disability Services provided in a C & A CSU means services provided to individuals who meet criteria for admission to an emergency receiving and evaluating facility on voluntary or involuntary status; 18. Emergency Receiving Facility means a facility designated by the Department to receive individuals under emergency conditions as provided in Part 1 of Article 3 of Chapter 3 and Part 1 of Article 3 of Chapter 7 of Title 37 of the Official Code of Georgia Annotated; 19. Evaluating Facility means a facility designated by the Department to receive individuals for evaluations provided in Part 2 of Article 3 of Chapter 3 and Part 2 of Article 3 of Chapter 7 of Title 37 of the Official Code of Georgia Annotated; 20. Governing Body means the Board of Trustees, the partnership, the corporation, the association, the person, group of persons or other legal entity that is legally responsible for operation of the C & A CSU; 21. Individual means a child or adolescent receiving services in a C & A CSU; 22. Individualized Resiliency Plan (IRP) is the document that is initiated during an individual's admission to the C & A CSU and is continued, when the individual is discharged to the next level of care. The development of an IRP proceeds from a synthesis of (a) the reason for admission, (b) the individual/family's goals and choices,(c) treatment and support needs as identified by multidisciplinary assessments, (d) interventions, and (e) discharge criteria; 23. Involuntary Status means admission of an individual who has a mental illness or an addictive disease and who meets clinical criteria for admission, and whose guardian has not admitted the individual on a voluntary status pursuant to O.C.G.A. Secs. 37-3-41 , 37-7-41 ; 24. Law Enforcement Hold means that an individual is in the custody or control of law enforcement and must be discharged only to the custody of law enforcement; 25. Legal Guardian means: a. The parent of a minor, provided that he or she has physical custody of the minor and his or her parental rights have not terminated; or b. A guardian of the minor who is duly appointed and serving pursuant to a court order. 26. License means the official authorization granted by the Department pursuant to any of the provisions of O.C.G.A. Sec. 37-1-29 and the rules to operate a C & A CSU physically located in Georgia; 27. Licensed/Certified Clinician in a CSU setting means a person who is licensed or certified as a LCSW, LMSW, LPC, APC, LMFT, AMFT, PhD, Psychologist or a CACII; 28. Licensed Practical Nurse (LPN) means any person who holds a current license to practice nursing pursuant to O.C.G.A. Sec. 43-26-32 et seq ; 29. Licensing requirements means any provisions of law, rule, regulation, or formal order of the Department which apply to the C & A CSU with respect to initial or continued authority to operate; 30. Manual Hold (also known as Manual Restraint or Personal Hold) means the application of physical force, without the use of any device, for the purpose of restricting the free movement of an individual's body regardless of duration or timeframe; 31. Medical Director means the chief medical officer who is physician with overall responsibility for treatment of individuals receiving services within the C & A CSU or a physician appointed in writing as the designee of such chief medical officer; 32. Nursing Administrator means a full time employee of the C & A CSU who: a. Is a registered professional nurse; b. Is responsible for: i. The management of the nursing staff in the C & A CSU; ii. Effective nursing care systems; and iii. Ensuring continuous quality improvement in care. 33. Nursing staff, as used in these rules, means the licensed and unlicensed assistive personnel providing direct care twenty-four hours a day, seven days a week. This includes the registered nurse in charge, other registered nurses on duty, licensed practical nurses, and unlicensed assistive personnel in the employ of the C & A CSU; 34. Physician means a person lawfully licensed in this state to practice medicine and surgery under the provisions of O.C.G.A. Sec. 43-34-20 et seq. Physician, as it is used in these rules, means physician as well as those practitioners to whom the physician may delegate authority as defined in Physician Extender below; 35. Physician's Assistant means a skilled person who is licensed to a supervising physician and who is qualified by academic and practical training to provide patients' services not necessarily within the physical presence but under the personal direction or supervision of the supervising physician pursuant to O.C.G.A. Sec. 43-34-102 et seq ; 36. Physician Extender means an advanced practice registered nurse or a physician's assistant to whom the physician may delegate authority as defined in O.C.G.A. Secs. 43-34-23 , 43-34-25 ; 37. Plan of Correction means a plan for correcting deficiencies in meeting rules and regulations of the Department; 38. Psychiatric Residential Treatment Facility (PRTF) means a facility that provides comprehensive mental health and substance abuse treatment to children, adolescents and young adults twenty-one (21) years of age or younger who, due to severe emotional disturbance, are in need of quality active treatment that can only be provided in an inpatient treatment setting and for whom alternative, less restrictive forms of treatment have been tried and found unsuccessful or are not medically indicated; 39. Psychiatrist means any physician certified as a diplomat in psychiatry by the American Board of Psychiatry and Neurology, or who has completed three (3) years of an approved residency training program in psychiatry and has had at least two (2) years of full-time practice in this specialty; 40. Registered Professional Nurse (RN) means any person who holds a current license to practice nursing under O.C.G.A. Sec 43-26-3 et seq ; 41. Restraint means any method, device, material or equipment attached or adjacent to the individual's body that the individual cannot easily remove and that restricts freedom of movement or normal access to one's body. This includes use of a manual restraint; manual hold or personal hold, a physical device, a mechanical device, use of material that is any physical matter including cloth or fabric, or use of equipment; 42. Risk Mitigation Plan is a document which addresses safety management for CSUs for which the architectural structure and/or environment of care is not consistent with the applicable provision; 43. Seclusion means the involuntary confinement of an individual alone in a room or area of a room from which the individual is physically prevented from leaving; 44. Treatment means care, diagnostic and therapeutic services, including the administration of medication, and any other service for an individual as defined in O.C.G.A. Sec. 37-3-1 ; 45. Treatment Facility means a facility designated by the Department to receive individuals for involuntary commitment for treatment provided in Part 3 of Article 3 of Chapter 3 and Part 3 of Article 3 of Chapter 7 of Title 37 of the Official Code of Georgia Annotated; 46. Treatment Team means physician, RN, licensed clinician, and related professionals such as certified peer specialists, certified addiction counselors, etc; 47. Unlicensed Assistive Personnel, as used in these rules, means individuals in the employ of the C & A CSU who provide direct care and oversight to individuals served in the C & A CSU, including, but not limited to, vital signs, activities of daily living, safety observations, and other duties as assigned. Unlicensed assistive personnel may be referred to as psychiatric assistants, certified nursing assistants, mental health assistants, healthcare technicians, or other recognized industry terms; 48. Voluntary Status means admission of an individual who has a mental illness or an addictive disease who meets clinical criteria for admission, and who is able to understand and exercise the rights and powers of an individual on voluntary status as defined in O.C.G.A. Secs. 37-3-20 , 37-7-20 . Rule 82-4-1-.04 General Licensing Requirements 1. A license is required to operate a C & A CSU. a. No person, corporation or other entity shall offer or provide crisis stabilization services as defined in these rules unless designated as an emergency receiving and evaluating facility and licensed by the Department as a C & A CSU; b. An applicant shall obtain a license prior to admitting individuals; c. No license shall be issued by the Department unless the C & A CSU is in compliance with these rules. 2. The C & A CSU shall prominently and conspicuously display the license in a public area of the licensed premises that is readily visible to individuals, employees, and visitors. A C & A CSU license shall not be altered. 3. A C & A CSU license shall not be transferred or assigned and each C & A CSU location shall be separately licensed. 4. The C & A CSU shall obtain approval from the Department in writing for any change in bed capacity 5. The C & A CSU shall notify the Department in writing at least thirty (30) days prior to, or in the event of an emergent change, within seventy-two (72) hours of any of the following occurrences: a. Any construction, renovation, or modification of the C & A CSU buildings; b. Date of cessation of operation of the C & A CSU; c. Moving to a new location; d. Change in C & A CSU name or telephone number; e. Change in ownership; or f. Change in agency CEO, medical director, and/or nurse administrator of the CSU. 6. The license shall be returned to the Department immediately after the notification date when a C & A CSU ceases to operate, is moved to another location, changes ownership, or the license is suspended or revoked. Failure to return the C & A CSU license to the Department does not mean the C & A CSU is licensed. If the C & A CSU received notice from the Department that the license is no longer valid, the C & A CSU shall no longer be considered licensed. 7. The Department may deny an agency a license for reasons, including, but not limited to: a. The applicant fails to provide the required application or renewal information; b. Operation of a C & A CSU which has been decertified or had its contract cancelled under the Medicare or Medicaid program in any state; federal Medicare or state Medicaid sanctions or penalties; federal or state tax liens; unsatisfied final judgments; eviction involving any property or space used as a C & A CSU; unresolved state Medicaid or federal Medicare audit; denial, suspension, or revocation of a hospital license belonging to the governing body, owner or operator of an applicant, for a license for any health care facility in any state; a court injunction prohibiting ownership or operation of a facility; c. Violation of any rules, regulations, local, state and federal laws. Rule 82-4-1-.05 Application Requirements 1. An application for a license to provide C & A CSU services shall be submitted on forms made available by the Department in a format acceptable to the Department. No application shall be acted upon by the Department until the application is determined complete by the Department with all required attachments submitted. 2. The applicant shall submit the following documents to the Department no later than ninety (90) calendar days prior to the projected opening date of the C & A CSU: a. An accurate and complete application form; b. A working budget showing projected revenue and expenses for the first year of operation, including revenue plan; c. Documentation of working capital: i. Funds or a line of credit sufficient to cover at least ninety (90) days of operating expenses if the applicant is a corporation, unincorporated organization or association, a sole proprietor or a partnership; ii. Appropriate revenue if the applicant is a state or local governmental agency, board or commission. d. Documentation of authority to conduct business in the State of Georgia; e. A twenty-four hour staffing plan which includes nurses and physicians; f. A floor plan with dimensions and with space and room function designations; g. Number of proposed beds; h. Photocopies of operating agreements with healthcare providers to provide care that is beyond the scope of the C & A CSU; i. A program description signed by the medical director that includes consistent with these rules and Department policy, admission and discharge criteria and procedures, including reasons for denial of admission, for both voluntary and involuntary individuals who do not meet C & A CSU admission criteria; j. Proposed daily schedule of treatment and education options throughout twelve (12) waking hours each day, to include treatment and educational opportunities responsive to the mental health, physical health and addictive disorder issues represented by individuals in service; k. Fire Safety Documentation: a. For new construction, additions, and renovation projects, written approval by the local building authority as well as well as a fire safety report (e.g., Fire Safety Inspection Report or a Certificate of Occupancy in the jurisdiction in which the CSU is based) must be submitted before a license is issued. b. For buildings already constructed, a copy of a fire safety report indicating approval by the local fire authority for the jurisdiction in which the CSU is based (dated within the last twelve (12) months of the projected opening date of the CSU) must be submitted before a license is issued. l. Documentation of agency accreditation as required by Departmental policy; 3. The Department shall conduct announced or unannounced on-site reviews of all facilities and services to determine compliance with the rules and regulations to operate a C & A CSU prior to a license being granted. Rule 82-4-1-.06 Issuance of Initial and Renewal of License 1. When the Department determines that the applicant is in compliance with all applicable rules and regulations, the Department shall issue an initial license to the applicant: a. The initial license for a new facility is valid for the first year of operation. The term of the initial license may not exceed one (1) year from the date of issuance; b. Prior to expiration of the initial license, the Department shall conduct a review of the C & A CSU for compliance with all applicable rules and regulations; c. Pursuant to a satisfactory review, the Department shall issue a license which shall be valid for a period of up to two (2) years. 2. It shall be the responsibility of the C & A CSU to complete and submit a renewal application for licensure, as required by the Department which is postmarked at least ninety (90) calendar days prior to the expiration date of the current license. If the C & A CSU fails to submit the completed renewal application, the Department shall provide notice by certified mail advising that unless the renewal application and licensure review is satisfactorily completed, the C & A CSU is operating without a valid license and is subject to sanctions. Rule 82-4-1-.07 Operational Scope of Services Each C & A CSU shall have a detailed description of the scope of services under which the C & A CSU operates that includes, but is not limited to: 1. The C & A CSU shall describe its capacity to serve both voluntary and involuntary individuals; 2. The C & A CSU shall clearly state in its policy that it is not a treatment facility; as defined in O.C.G.A. Secs. 37-1-29 , 37-3-1(18) ; 3. The services offered within the C & A CSU shall be provided in a community based setting, and shall be described as crisis residential services rather than inpatient or hospital level of care service; 4. The C & A CSU shall not advertise or hold itself out as a hospital nor shall it bill for hospital or inpatient services; 5. The C & A CSU shall be exempt from any requirement of Georgia's Certificate of Need (CON) program; 6. The C & A CSU shall pursue with due diligence operating agreements in writing, with one or more healthcare providers, to provide care that is beyond its scope. Operating agreements shall be updated at a minimum every five (5) years as evidenced by date and signatures on the agreement document; 7. The average annual length of stay in the crisis beds of the C & A CSU shall not exceed fourteen (14) calendar days; 8. The C & A CSU shall report census and length of stay data as required to the Department; 9. The C & A CSU shall give priority consideration to serving those individuals without private health care coverage; 10. Individuals shall be billed in accordance with Departmental policy on payment for services. Fees for individuals served under the Department of Human Services or under the Department of Juvenile Justice shall be set by mutual agreement between Departments; 11. The C & A CSU shall not refuse to receive, evaluate, or stabilize any individual who meets the criteria for services as defined in O.C.G.A. Sec. 37-1-29 and Departmental Policy; 12. The C & A CSU shall not operate solely as a twenty-four hour residential service offering detoxification; 13. The C & A CSU shall not provide study and report services; and 14. The C & A CSU shall not be available for court ordered placement for the purpose of temporary placement only. Rule 82-4-1-.08 Program Description The C & A CSU's description of services shall clearly state the following: 1. The C & A CSU is designed to serve as a first-line community based alternative to hospitalization, offering psychiatric stabilization and detoxification services on a short- term basis; 2. The target population is individuals ages five (5) through seventeen (17) requiring psychiatric or behavioral stabilization, and youth ages thirteen (13) through seventeen (17) with substance related disorders or with co-occurring mental health and substance use needs; 3. When an emancipated minor presents for service at a C & A CSU, the C & A CSU shall assess the individual's life circumstances to determine if the individual is more appropriately served in an adult environment; 4. Psychiatric stabilization and residential detoxification services are offered at a clinical intensity level which supports the level of care in DBHDD contracts and the DBHDD Provider Manual for Community Behavioral Health Providers; 5. The CSU shall have policies and procedures for identifying and managing individuals who meet the diagnostic criteria for a Substance Dependence Disorder; 6. The CSU shall have policies and procedures for providing a planned regimen of twenty-four hour, professionally-driven evaluation, care and treatment services for individuals who meet the diagnostic criteria for a Substance Dependence Disorder; 7. All services offered within the C & A CSU shall be provided under the direction of a physician. It is preferred that the C & A CSU provide services under the direction of a psychiatrist with training or experience in working with children and youth. Consultation by a psychiatrist shall be available if the covering physician is not a psychiatrist; 8. A physician or psychiatrist shall be on call twenty-four hours a day and shall make rounds seven days a week. The physician is not required to be on site twenty-four hours a day; however the physician must respond to staff calls immediately, (delay not to exceed one (1) hour); 9. The C & A CSU shall provide emergency receiving, screening, and evaluation services twenty-four hours a day, seven days a week and shall have the ability to admit and discharge seven days a week; 10. The C & A CSU shall have policies and procedures for identifying and managing individuals at high risk of suicide or intentional self-harm; 11. The functions performed by staff whose practice is regulated or licensed by the State of Georgia are within the scope allowed by state law and professional practice acts; 12. The C & A CSU shall have a full-time position classified as a nursing administrator. It is preferred that the employee serving in this position have training or experience with treating children and youth; 13. The C & A CSU shall have an RN present within the C & A CSU twenty-four hours a day, seven days a week who is the charge nurse for the C & A CSU. For every sixteen (16) C & A CSU beds there shall be one (1) RN present at all times; 14. Staffing shall be established based on the needs of individuals being served as follows: a. At all times there shall be at least three (3) staff present within the C & A CSU including the charge nurse (if the charge nurse is an APRN, then he/she may not simultaneously serve as the accessible physician during the same shift); b. There shall not be more than four (4) individuals for every one (1) staff (including the charge nurse); c. The ratio of nursing staff to individuals shall increase on the basis of the clinical care needs of the individual, including required levels of observation for high risk individuals; d. If a nursing staff is assigned a 1:1 support role, then he/she shall not be counted in the 1:4 ratios above. e. Utilization of licensed practical nurses (LPNs) in C & A CSU shall be to provide support to the registered nurse by performing duties specified in O.C.G.A. Sec. 43-26-3 et seq. 15. Academic needs shall be met through the local school system in accordance with the needs of the individual; 16. Program offerings shall be age appropriate and designed to meet the needs of each individual, and the therapeutic content of the program (group therapy/training, individual therapy/training, education support, etc.) shall be annually approved by a licensed/certified clinician. This content is captured in a master file which will have the licensed clinician's approval, signature and date of review; 17. The C & A CSU shall have protocols with respect to stabilization and transfer of individuals to a different level of care. The treating physician shall make the determination as to the time and manner of transfer so as to ensure no further deterioration of the individual during the transfer between facilities, and shall specify the benefits expected from the transfer in the individual's record; 18. Children or youth shall return to their natural environment as quickly as possible; therefore, the total length of stay in a C & A CSU for any one episode of care shall not exceed twenty-nine (29) calendar days. Rule 82-4-1-.09 Evaluation and Admissions 1. The C & A CSU must have written protocols for screening individuals presenting for evaluation on a voluntary basis or under O.C.G.A. Secs. 37-3-41 , 37-7-41 . If screening results in an individual not being offered services or admitted to the C & A CSU, the C & A CSU shall maintain documentation of the rationale for the denial of services and referral of the individual. 2. Level of Care instruments defined in the DBHDD Provider Manual for Community Behavioral Health Providers will be utilized to determine the required need and resulting level of care for admission to the C & A CSU. The C & A CSU shall not admit individuals presenting with issues listed under "Exclusion Criteria" in the Department's policy on medical exclusion guidelines and criteria. The C & A CSU staff shall ask the referral source for information regarding the medical status of the individual. If there are medical status issues, the C & A CSU physician may request additional information or waive medical clearance when clinically appropriate or when medical clearance is not available. 3. The C & A CSU shall not refuse to receive for evaluation an individual who presents to the C & A CSU for evaluation and/or stabilization. 4. Staff shall conduct a search of the individual, his or her clothing, and all personal effects before admission to the unit. 5. Personal searches of individuals (e.g. strip searches) are to be performed only for cause and shall be ordered by the physician. The rationale for the personal search must be clearly documented in the order. Sequential steps of the search, including documentation of staff involved by name and title, must be recorded in the progress notes section of the clinical record. Mandatory removal of clothing or standing orders for personal searches are not permitted. 6. An initial screening for risk of suicide or harm to others shall be conducted for each individual presenting to the CSU for evaluation. 7. Orders for care shall include the clinically appropriate level of observation for the individual. Rule 82-4-1-.10 Provision of Individualized Care 1. A physician shall assess each individual to establish a diagnosis and write care orders within twenty-four (24) hours of admission, and document appropriate orders for care; an assessment for risk of suicide will be made by a physician. 2. The licensed clinical social worker or licensed professional counselor shall assess the individual within forty-eight (48) hours of admission to the C & A CSU. 3. An Individualized Resiliency Plan (IRP) shall be developed and written within seventy- two (72) hours of admission on the basis of assessments conducted by the physician, registered nurse and professional social work or counseling staff. A major goal of each IRP shall be the individual's stabilization and recovery. For individuals with both substance abuse and mental health diagnoses, the IRP shall address issues relative to both diagnoses. 4. At a minimum, this IRP shall be developed in collaboration with the individual/family and shall include the following: a. A problem statement or statement of needs to be addressed; b. Goals that are consistent with the individual's needs, realistic, measurable, linked to symptom reduction, and attainable by the individual during the individual's projected length of stay; c. Objectives, stated in terms that allow measurement of progress, that build on the individual's strengths; d. Specific treatment offerings, methods of treatment and staff responsible to deliver the treatments; e. Interventions and preferred approaches that are responsive to findings of past trauma and abuse; f. Evidence of involvement by the individual's legal guardian, as documented by his or her signature or refusal to sign; g. Development of a crisis plan for use upon discharge; h. Signatures of all staff participating in the development of the plan; i. Evidence of involvement by the individual and/or family, as documented by the individual's signature that is in a manner that is age/developmentally appropriate; j. A discharge and transition plan. 5. The IRP shall be reviewed at a minimum every seventy-two (72) hours by a treatment team to assess the need for the individual's continued stay in the C & A CSU. The IRP shall be updated as appropriate when the individual's needs or condition change. 6. The physician shall, at a minimum: a. Conduct the initial assessment of the individual; b. Establish a diagnosis and write care orders; c. Document the rationale for medications prescribed; d. Assess the individual's response to care and services provided; and e. Conduct an assessment of the individual at the time of discharge. 7. Discharge summary information shall be provided to the individual at the time of discharge that includes: a. Criteria describing evidence of stabilization and discharge planning; b. Significant findings relevant to the individual's recovery (strengths, needs, preferences); c. Specific instructions provided to the individual and to the legal guardian for ongoing care; d. Individualized recommendations for continued care to include recovery supports, community services, if indicated; and e. Contact information for how to access community services. Rule 82-4-1-.11 Documentation of Care The C & A CSU shall maintain a clinical record for each individual, which may be recorded manually or electronically. The clinical record shall contain chronological information on all matters relating to the admission, care and treatment, discharge and legal status of the individual, and shall include documents relating to the individual. The clinical record shall include at least the following: 1. Record of evaluation for admission and outcome of the evaluation, including the date, time, name and credentials of the professional conducting the evaluation; 2. Legal status documents for admission and continued stay in the C & A CSU, as detailed in O.C.G.A. Secs. 37-3-1 et seq. and 37-7-1 et seq ; 3. Documentation of guardianship, whenever applicable; 4. Documentation of consent for services by the legal guardian; 5. Assessments, to include psychiatric, physical health, nursing and psychosocial status; 6. Physician orders; 7. Every order given by telephone shall be received by an RN or LPN and shall be recorded immediately with the ordering physician's name, and shall be reviewed and signed by a physician within twenty-four (24) hours. Specific to the ordering of medication, documentation shall demonstrate evidence that an order was made by telephone, the content of order, and date of the order; 8. Documentation by the physician of the individual's response to care, including rationale for changes in orders or levels of observation; 9. An IRP which specifies individualized interventions responsive to the needs of the individual; 10. There shall be documentation of consent by the legal guardian to the IRP; 11. Documentation of implementation of interventions, including the individual's response to the interventions; 12. Location and type of treatment or education provided, including the date and time of the treatment or education, the name and credentials of the professional or other staff providing the service, and the response of the individual to the service; 13. Evidence of progress toward stabilization and recovery, or lack thereof; 14. Documentation of medical testing (if any), medical findings and medical care needs or interventions provided; 15. Documentation of continued stay justifications; 16. Documentation at least once per day by an RN as to the status of the individual; 17. Documentation of events or incidents that affect care and treatment, including the individual's response thereto; 18. Record of implementation of emergency safety interventions (seclusion or restraint) of last resort, if implemented; 19. Name and title of staff providing care and treatment; and 20. Discharge notes and aftercare plans, including the individual's status at discharge, ongoing needs, aftercare plan, and the date, time and method of discharge. Rule 82-4-1-.12 Protection and Safety of the Individual and of Others 1. The C & A CSU shall have policies and procedures regarding authorized entry to or exit from the unit. 2. The C & A CSU shall have policies and procedures to protect and respect individuals' rights and privacy while conducting searches. 3. Control of potentially injurious items shall be clearly defined in policy to include, but may not be limited to: a. Prohibition of flammables, toxins, ropes, wire clothes hangers, sharp-pointed scissors, luggage straps, belts, knives, shoestrings, or other potentially injurious items; b. Management of housekeeping supplies and chemicals, including procedures to avoid access by individuals during use or storage. Whenever practical, supplies and chemicals shall be non-toxic and/or non-caustic. 4. Safeguard the use and disposal of nursing and medical supplies including drugs, needles and other "sharps" and breakable items. 5. Except as otherwise provided by law, weapons shall be prohibited at the C & A CSU. The C & A CSU shall post notices regarding the prohibition of weapons at all entrances to the facility and shall have written protocols addressing the same. 6. The C & A CSU shall develop and implement policies and practices, consistent with Departmental policy, that describe interventions to prevent crises and minimize incidents when they do occur, that are organized in a least to most restrictive sequence. The written policies and procedures shall: a. Emphasize positive approaches to interventions; b. Protect the health and safety of the individual served at all times; c. Specify the methods for documenting the use of the interventions; the admission assessment shall contain an assessment of past trauma or abuse, how the individual served would prefer to be approached should he or she become dangerous to him/ herself or to others, and the findings from this initial assessment shall guide the process for determining interventions. 7. The C & A CSU shall develop and implement internal policies and practices for use of time-out, seclusion or restraint that are consistent with federal and state laws, rules, regulations and DBHDD policy: a. Seclusion or restraint, as defined in these regulations, shall be used only as an emergency safety intervention of last resort to ensure the physical safety of the individual and others, and shall be used only after less restrictive interventions have been determined to be ineffective; b. Seclusion or restraint shall not be used as punishment or for the convenience of staff; c. Seclusion and restraint shall not be implemented simultaneously; d. All individuals placed in restraints shall be afforded full privacy away from other individuals receiving services; e. Chemical restraint as defined in the Code of Federal Regulations shall not be utilized under any circumstances; f. Staff, individuals and their legal guardian shall be debriefed immediately following an episode of seclusion or restraint, identifying the circumstances leading up to the seclusion or restraint; g. The individual's IRP shall be updated following the debriefing of what led to a seclusion or restraint episode, including changes that could be made to prevent the situation or better support the individual if future issues occur. 8. The C & A CSU shall develop policies and procedures for implementing suicide prevention interventions addressing: screening, assessments, crisis safety plans, staffing, levels of observation and documentation in accordance with DBHDD policy: a. Policies and procedures shall require constant visual observations of persons clinically determined to be actively suicidal; b. A person assessed to be potentially suicidal shall be on a higher level of supervision; c. Modifications or removal of suicide prevention interventions shall require clinical justification determined by an assessment and shall be specified by the attending physician and documented in the clinical record; d. A registered professional nurse or other licensed/certificate clinician may initiate suicide prevention interventions prior to obtaining a physician/psychiatrist's order, but in all instances must obtain an order within one (1) hour of initiating the intervention; f. Staff shall be debriefed immediately following a suicide attempt, identifying the circumstances leading up to the suicide attempt; g. The individual's IRP shall be updated following the debriefing of what led to the suicide attempt, including changes that could be made to prevent the situation from reoccurring or to better support the individual if future issues do occur; 9. Other high-risk behaviors such as assaultive behavior shall be addressed in the C & A CSU policies and procedure. Rule 82-4-1-.13 Pharmacy Services and Management of Medication 1. All pharmacy operations or services within the C & A CSU must be licensed and under the direct supervision of a registered pharmacist or provided by contract with a licensed pharmacy operated by a registered pharmacist. 2. The C & A CSU must ensure access to pharmacy services for prescription medications within eight (8) hours of the physician's order. 3. Stat medication not maintained in the C & A CSU must be available for administration within one (1) hour of the order to give the medication. 4. Any request for exemptions for requirements regarding a pharmacy license must be submitted in writing to the Georgia State Board of Pharmacy. 5. The C & A CSU shall establish and implement policies, procedures and practices that guide the safe and effective use of medications and shall, at a minimum, address the following: a. Medications and medical care orders shall be written, signed, administered, and implemented upon direct order from by the physician or psychiatrist, as defined in O.C.G.A. Secs. 43-34-23 , 43-34-25 ; b. Medications shall not be administered without the consent of the legal guardian, except in an emergency; c. Medications shall be used solely for the purposes of providing effective treatment and protecting the safety of the individual and other persons and shall not be used as punishment or for the convenience of staff or as chemical restraint; d. There shall be no standing orders for psychotropic medication; e. Medication management policies and procedures shall follow federal and state laws, rules and regulations, and shall direct the management of medication ordering, procurement, prescribing, transcribing, dispensing, administration, documentation, wasting or disposal and security, to include the management of controlled substances, floor stock, and physician sample medications; f. There shall be documented evidence of oversight by the medical director for the accounting of and dispensing of sample medications; g. The C & A CSU shall have a policy on informed consent for medications, including the right of the legal guardian to refuse consent for medication; h. The C & A CSU shall have protocols in place should an individual refuse medication; i. The C & A CSU shall follow the Department's policies and procedures for Informed Consent and Involuntary Administration of Psychotropic Medication; j. There shall be a process to identify, track and correct deviations in medication prescribing, transcribing, dispensing, administration, documentation, or drug security of ordering or procurement of medication that results in a variance; k. The C & A CSU shall develop and implement policies and procedures that describe actions to follow when drug reactions and other emergencies related to the use of medications occur, and emergency medical care that may be initiated by a registered nurse in order to alleviate a life threatening situation; and l. The C & A CSU shall conduct daily checks and maintain temperature logs for all medication room refrigerators. Temperatures for the refrigerator shall be set between 34°F to 41°F (1°C to 5°C). Rule 82-4-1-.14 Laboratory Services 1. Laboratory work and other diagnostic procedures deemed necessary shall be performed as ordered by the physician. 2. Any C & A CSU that processes laboratory tests on-site shall provide documented evidence of a current Clinical Laboratory Improvement Amendment Waiver. Rule 82-4-1-.15 Food Services All C & A CSU food service operations shall comply with current federal and state laws and rules concerning food service: 1. At least three (3) nutritious meals per day shall be served; 2. Nutritional snacks shall be available to each individual; 3. No more than fourteen (14) hours may elapse between the end of an evening meal and the beginning of a morning meal; 4. Therapeutic diets shall be provided when ordered by the physician; 5. Under no circumstances may food be withheld for disciplinary reasons; 6. The C & A CSU must have a sufficient designated area to accommodate meal service. Individuals may eat or be served in shifts during daily operations. The eating area may double as a group or activity area; 7. If food is prepared by the C & A CSU, the C & A CSU must have a satisfactory food service permit score, pursuant to Georgia Department of Human Services, Public Health, Chapter . If applicable, a copy of the current food service permit must be on file in the C & A CSU; 8. The C & A CSU may utilize meal preparation services from an affiliated or contracted entity with a current food service permit. There shall be a formal contract between the C & A CSU and contracted food entity containing assurances that the contracted food entity will meet all food service and dietary standards imposed by this rule; 9. If the C & A CSU elects to have meals prepared off-site, the C & A CSU will have a modified kitchen that includes a microwave, a refrigerator, an ice maker and clean-up facilities; 10. The C & A CSU must maintain a daily temperature log for freezer and refrigerator. Temperatures for the refrigerator shall be set between 34°F and 41°F (1°C to 5°C) and the freezer temperature should be set between 0°F and 10°F (-17°C to -15°C); 11. Food, drinks and condiments shall be dated when opened and discarded when expired; 12. Each C & A CSU shall maintain a three-day supply of non-perishable emergency food and water at all times. Rule 82-4-1-.16 Infection Control and Prevention The C & A CSU shall develop and implement policies and procedures for infection control and prevention that include the following: 1. Standard precautions are defined and the use of personal protective equipment when handling blood, body substances, excretions and secretions are outlined; 2. Proper hand washing techniques are outlined; 3. Proper disposal of biohazards, such as potentially infected waste and spills- management, needles, lancets, scissors, tweezers and other sharp instruments are described; 4. Prevention and treatment of needle stick/sharp injuries are outlined; 5. The management of common illnesses such as, but not limited to Methicillin-Resistant Staphylococcus Aureus ( MRSA), colds and influenza, gastrointestinal viruses, pediculosis and tinea pedis, etc. is described; 6. Specific procedures to manage infectious diseases including but not limited to tuberculosis, hepatitis B, Human Immunodeficiency Virus (HIV), Acquired Immune Deficiency Syndrome (AIDS) or other infectious diseases are described; 7. Handling and maintenance of individual care equipment is described; 8. The C & A CSU's infection control risk assessment and plan is reviewed annually for effectiveness and revision, if necessary; 9. The C & A CSU shall have written hygienic practices and procedures regarding the management of linens and minimizing healthcare-associated infections, including collection, sorting, transport, washing and storage of soiled linens. The practices shall be based upon a cited expert source (such as the U.S. Centers for Disease Control and Prevention) and updated annually to ensure the procedures reflect evolving standard practice. At a minimum, the C & A CSU shall: a. Have immediately available a quantity of clean bed linens and towels, etc., essential for the proper care of individuals at all times; and b. Have collection, sorting, and cleaning procedure shall be designed to prevent contamination of the environment, individuals served, and personnel. 10. In relation to individuals who are carriers of an infectious illness, the transfer and the release of confidential information to select unit medical and nursing staff on a need to know basis is addressed; 11. Hand washing facilities provided in both the kitchen and the bathroom areas shall include hot and cold running water, soap dispensers, disposable towels and/or hand blowers. Rule 82-4-1-.17 Rights and Responsibilities of Individuals 1. The C & A CSU shall safeguard the rights of individuals treated pursuant to applicable state laws and rules and regulations. 2. The rights and responsibilities of individuals and their legal guardians are paramount. It is the expectation that a legal guardian shall be an informed partner in the assessment and treatment of individuals. The individual under the age of eighteen (18) served should also be an informed participant. Although the individual's consent is not legally mandated, it should be encouraged and promoted in every treatment element. Documentation shall support the provision of the following: a. Each C & A CSU shall maintain a written statement of rights and responsibilities for individuals receiving services and their legal guardian, as articulated in DBHDD rule and policy; b. During admission or orientation to the C & A CSU, each individual and the individual's legal guardian shall receive a written statement of his or her rights and responsibilities. Receipt of this information shall be documented in the clinical record and validated by the signature of the individual and their legal guardian. If the legal guardian is unable or unwilling to sign, this shall be recorded; c. The C & A CSU shall inform the individual and the legal guardian in writing of any changes in rights and responsibilities; d. Individual rights related to required notices, lengths of stay on involuntary status, or other processes related to rights specified in Georgia law, DBHDD rule or policy, shall be maintained. Rule 82-4-1-.18 Confidentiality 1. The C & A CSU shall have records management policies, procedures and practices to manage and to protect the confidentiality and protected health information of individuals' records, to include electronic records. 2. The C & A CSU's records management policies shall support secure, organized records and shall be consistent with all applicable policies and procedures and federal and state laws and regulations. 3. The C & A CSU shall ensure that the individual's rights regarding his or her own confidential and protected health information are protected, including but not limited to, access to protected health information, requesting amendment to the clinical record, requesting restriction of disclosure, and requesting an accounting of disclosures that have been made. 4. The C & A CSU shall have a Notice of Privacy Practices regarding confidentiality of the individual's protected health information, which Notice shall comply with the requirements of Health Insurance Portability and Accountability Act (HIPAA). 5. The C & A CSU shall post the Notice of Privacy Practices at all times in the admissions area and in prominent locations where it is reasonable to expect individuals to be able to read the notice. Additional copies must be available for distribution upon request. 6. The C & A CSU shall provide a copy of the Notice of Privacy Practices to the individual and his or her legal guardian, as defined by state law, upon the individual's admission. 7. The C & A CSU shall have policies, procedures and practices that are compliant with the requirements of HIPAA regarding: a. Complaints regarding violation of confidentiality and privacy rights; b. Reports of breaches of HIPAA to the Department, and as required by law when applicable to the individual, to the United States Secretary of Health and Human Services, and to the media; c. Sanctions of employees for violations of HIPAA; and d. Identifying business associates, as defined by HIPAA, of the C & A CSU and obtaining satisfactory assurances of the business associates' compliance with the requirements of HIPAA. 8. The clinical record, information about an individual contained in incident reports and any documents that are not part of the clinical record, and all information about an individual whether oral or written, and regardless of how stored, is confidential. 9. Unless authorized in writing by a valid authorization signed by the legal guardian, or by applicable law, the C & A CSU shall not: a. Confirm or deny whether an individual is receiving or has received services from the C & A CSU; or b. Disclose any confidential or protected health information regarding the individual. Rule 82-4-1-.19 Documentation of Legal Status The legal status of each individual shall be clearly recorded within the clinical record to include: 1. Documenting the legal and clinical basis for the individual's admission to the C & A CSU, whether voluntary or involuntary consistent with all applicable state laws, rules and regulations; 2. Documentation of the legal and clinical basis for continued admission to the C & A CSU for purposes of evaluation when consistent with all applicable state laws, rules and regulations; 3. A record of voluntary or involuntary status change, to include the date and time of such change and consent by the parent or legal guardian; 4. Where an individual is found to be in need of treatment and suitable for treatment at said facility, the facility must obtain consent for treatment from the parent or legal guardian of the individual who shall receive treatment unless such minor is emancipated O.C.G.A. Sec. 37-3-20(a) ; 5. Documentation of the assessment of the individual's capacity to understand and exercise the rights and powers of voluntary admission; and 6. Where specific Departmental legal forms exist to document any of the above mentioned actions, those forms shall be utilized. Rule 82-4-1-.20 Performance Improvement Plan and Activities The C & A CSU shall develop a quality assurance plan and update it annually: 1. The quality assurance plan shall address and ensure a comprehensive integrated review of all services and practices which shall include but not be limited to the following: a. High risks situations and special cases (such as suicide, death, serious injury, violence and abuse of any individual) are reviewed within twenty-four (24) hours; b. Medical emergencies; c. Medication variance; d. Infection control; e. Emergency safety interventions including seclusion or restraint; f. Environmental safety and maintenance; including an environment scan which self- assesses risk for individuals served by or working in the facility and identified strategies and subsequent plans for mitigating those risks; g. Clinical outcome measures. 2. The quality assurance plan shall use performance measures and data collection that continually assess and improve the quality of the services being delivered; 3. The quality assurance committee shall submit a quarterly report to the nursing administrator, medical director, agency CEO, and governing body for their review and appropriate action if necessary; 4. The CEO and governing body shall evaluate the C & A CSU's effectiveness in improving performance. Rule 82-4-1-.21 Environment of Care Areas accessible by individuals shall meet the following requirements: 1. The CSU shall maintain an environment that is clean and in good repair; 2. The environment of the C & A CSU shall have natural light and exterior views; 3. The general architecture of the C & A CSU, along with tools and technology, shall provide for optimal line-of-sight observations from the nurses' station throughout the unit, mitigating hidden spots and blind corners; 4. The C & A CSU shall be a locked facility; 5. The C & A CSU shall have sleeping areas that are gender and age specific; 6. Interior finishes, lighting, and furnishings shall conform to applicable fire and safety codes; as classified for Health Care Occupancy/Limited Care Facilities in the current edition of National Fire Protection Association's NFPA 101 Life Safety Code Handbook, Chapter 18/19: New and Existing Health Care Occupancies; 7. Furnishings, hardware, fixtures, or protrusions must be: a. Made of materials which mitigate the risk of use as weapons or for self- harm (hanging, cutting, etc.); b. Intact and functional; c. Maintained in good condition, and ; d. Tamper resistant. 8. The ceiling and the air distribution devices, lighting fixtures, sprinkler heads, and other appurtenances shall be of the tamper-resistant type; 9. Doors of the C & A CSU must meet the following requirements: a. Doors in seclusion and/or restraint rooms shall not be locked from within; b. The C & A CSU shall have a policy in effect to address locking doors in bedrooms and bathrooms which will address an individual's privacy and safety and which addresses staff access at all times to supervise and monitor that individual's clinical status and safety; c. The CSU must have written risk management protocols in place to address situations in which an attempt might be made to prevent access to any area of the C & A CSU; d. If the C & A CSU is equipped with electronic locks on internal doors or egress doors, the C & A CSU shall ensure that such locks have manual common key mechanical override that will operate in the event of a power failure or fire; 10. Light switches and electrical outlets shall be secured with -tamper-resistant type screws; 11. For C & A CSUs which are new facilities and who apply for licensure on or after (PUBLISH DATE OF NEW RULES), sprinkler heads shall be flush mounted on ceilings lower than nine (9) feet. Sprinklers shall have institutional heads that are recessed and drop down when activated; 12. Security and safety devices shall be mounted, installed, or secured in a manner which: a. Mitigates the risk of use as weapons or for self-harm (hanging, cutting, etc.); b. Prevents interference; and c. Prevents any attempt to render inoperable with its purpose as a security devise. 13. Upon request, the C & A CSU shall provide a means of locked storage for any individual's valuables or personal belongings; 14. The C & A CSU must have policies/procedures to address identification, detection, handling, and storage of individuals' belongings that are determined to be potentially harmful; 15. The C & A CSU shall maintain the environmental temperature between 65°F and 82°F(18°C to 27°C); 16. The interior and grounds of the C & A CSU shall be non-smoking; 17. Lighting fixtures shall be recessed and tamper-resistant with Lexan or other strong translucent materials; 18. Windows shall be protected with Lexan or other shatter-resistant material that will minimize breakage; 19. The C & A CSU shall be equipped and maintained so as to provide a sufficient amount of hot water for individuals' use. a. Heated water provided for individuals' use must be maintained between 110°F and 120°F(43°C and 48°C); b. The C & A CSU must have policies/procedures to routinely check and document hot water temperature at various outlets throughout the C & A CSU and to correct any variance from the standard temperature if needed; 20. The C & A CSU shall have consistently available drinking water for individuals' access using mechanisms which meet general expectations of infection control and procedures; 21. The pre-admission waiting area, including restroom(s), must meet all safety requirements applicable to designated individual areas; 22. The C & A CSU shall have written policies and procedures for the provision of or arrangement for, services for individuals with physical disabilities (including those with sensory impairments) in compliance with all federal rules and regulations; 23. The C & A CSU shall have facilities accessible to and usable by physically disabled individuals which meet the minimum requirements of Section 504 of the Rehabilitation Act of 1973. The C & A CSU shall install required alterations or modifications in accordance with the 1984 Law of Georgia regarding Access to and Use of Public Facilities by Physically Handicapped Persons, O.C.G.A. Sec. 30-3-1 et seq ; 24. The C & A CSU shall maintain safety equipment to include an Automated External Defibrillator (AED) and all other necessary medical safety supplies; 25. The C & A CSU shall provide laundry facilities on the premises for the individual's personal laundry; 26. Entrances and exits, sidewalks, and escape routes shall be constantly maintained, free of all impediments and hazards; 27. The C & A CSU shall have at least one (1) operable, non-pay telephone which is private and accessible at reasonable times for use by individuals; and 28. The C & A CSU physical environment shall provide for space that accommodates the developmental needs of the individual and shall, at a minimum, have the following designated areas within its facility which meet the following requirements: a. A screening area with capacity to be locked where searches can be done in a private and safe manner, respecting individual rights and privacy; b. Exam room; c. Bedrooms : i. Beds and other heavy furniture capable of use to barricade a door shall be secured to the floor or wall; ii. The use of beds with springs, cranks, rails or wheels, including hospital beds, rollaway beds, cots, bunk beds, stacked beds, hide-a beds and studio couches is prohibited; iii. Rooms utilized for more than one individual shall have a minimum of sixty (60) square feet per individual; a private room shall not be less than eighty (80) square feet; iv. Windows may be textured to provide privacy without the use of curtains or blinds. d. Bathrooms: i. The C & A CSU shall have gender specific bathrooms with proper ventilation; ii. Exposed plumbing pipes shall be covered to prevent access by individuals; iii. The C & A CSU shall have a minimum of one (1) shower for each six (6) individuals receiving services and one (1) toilet and lavatory for each six (6) individuals receiving services; iv. Individual shower stalls and dressing areas shall be provided; v. The C & A CSU shall have a bathroom facility that is in compliance with the American Disabilities Act (ADA) for use by individuals with physical disabilities. It shall include a toilet, lavatory, shower and flush-mounted safety grab bars; vi. Access to a bathroom shall not be through another individual's bedroom; vii. The shower head shall be recessed or have a smooth curve from which items cannot be hung; viii. Overhead rods, fixtures, privacy stalls supports or protrusions must be selected and installed in a manner which mitigates the risk of use of weapons or for self- harm (hanging, cutting, etc.) If the physical plant space of the C & A CSU is prohibitive of this, there must be written policies and protocols to monitor and reduce this risk with supporting evidence of compliance to these policies and protocols; ix. The toilet shall be secured and tamper resistant; x. Mirrors shall not be common glass and must be fully secured and flat mounted to the wall. e. Seclusion and/or Restraint Room. For C & A CSUs which apply for licensure on or after (PUBLISH DATE OF NEW RULES), the privacy of the person is protected by the seclusion and/or restraint room location either being not visible from the common consumer areas, or if visible, the seclusion and/or restraint room is constructed to be offset from main thoroughfares and have restricted visibility to the interior of the room; i. At least one (1) identified room used for seclusion and/or restraint shall have a bed commercially designed for use with restraints that is bolted to the floor and without sharp edges. The surface of the bed must be impermeable to resist penetration by body fluids; ii. The floors and walls, up to a height of three (3) feet, shall be finished to resist penetration of body fluids or be constructed of a high impact sheetrock; iii. For C & A CSUs which apply for licensure on or after (PUBLISH DATE OF NEW RULES), the seclusion and/or restraint room shall have a minimum of seventy (70) square feet with one wall of the room no less than nine (9) feet in length; iv. For C & A CSUs which apply for licensure after (PUBLISH DATE OF NEW RULES), the ceiling height of seclusion and/or restraint rooms shall be at least nine (9) feet. v. The door to the room shall open outward; vi. The bed placement in the seclusion and/or restraint room shall provide adequate space for staff to apply restraints and shall not allow individuals to access the lights, smoke detectors or other items that may be in the ceiling of the room; vii. Rooms used for seclusion and/or restraint must provide staff full visual access of the individual, and shall include a vision panel installed in the door; viii. Where the interior of the seclusion and/or restraint room is padded, it is in good repair and must be fully intact. f. Fenced Recreational Area: i. The C & A CSU shall have an age appropriate outdoor area enclosed by a privacy fence no less than six (6) feet high, where individuals may have access to fresh air and exercise. It must provide privacy from public view and shall not provide access to contact with the public; ii. This area shall be constructed to retain individuals inside the area and minimize elopements from the area; iii. The fenced area shall be designed for safety without blind corners to be readily visible by one staff person standing in a central location; and designed to minimize elopement. 29. The C & A CSU shall meet rules specified in Rule , Environment of Care or shall submit a Risk Mitigation Plan to the Department for approval addressing a particular citation and related protocols for safety management. This shall be submitted at the time of licensing review and annually thereafter. Rule 82-4-1-.22 Fire Prevention and Safety Requirements 1. Each C & A CSU shall have an emergency fire and disaster plan that includes the following: a. Protocols for and documentation of practice of monthly fire drills rotated so that all shifts have had at least one (1) drill quarterly, including time taken to complete the drill and follow-up with recommendations for drills that are unsatisfactorily completed; b. Disaster drills protocols such as flood, tornado, hurricane are practiced at least quarterly; c. Direction for evacuation of the C & A CSU utilizing posted evacuation routes; d. Preparation of the individuals for evacuation; e. Documentation of monthly fire extinguisher inspection; f. Documentation of at least annual inspections of other safety mechanisms such as sprinklers, smoke alarms, emergency lights, kitchen range/hood, etc; g. Provision for annual review and revision of the fire and emergency safety plan; h. Procedures for training staff on all emergency and disaster drills. 2. The C & A CSU shall comply with all federal, state, local, and accreditation fire safety standards. Local fire codes with more stringent standards or additional requirements shall supersede over the minimum requirements set forth in this rule. Rule 82-4-1-.23 Human Resources 1. The C & A CSU shall develop and implement policies and procedures that address the hiring, training, promotion and termination of staff. 2. The C & A CSU shall define the responsibilities, qualifications, and competencies of staff For all positions. 3. The C & A CSU shall ensure that the type and number of professional staff attached to the unit are: a. Properly licensed or credentialed in the professional field as required; b. Present in numbers to provide adequate supervision to staff; c. Present in numbers to provide services, supports, care and treatment to individuals as required; d. Experienced and competent in the profession they represent; and e. At least one (1) staff trained in Basic Cardiac Life Support (BCLS) and first aid shall be on duty at all times. In addition, one staff trained in the use of the Automated External Defibrillator (AED) equipment shall also be on duty. 4. Paraprofessionals working in mental health, addictive diseases and co-occurring disability services must complete the standard training requirements for paraprofessionals. 5. The C & A CSU shall have procedures for verifying licenses, credentials, experience and competence of staff: a. The C & A CSU shall document implementation of these procedures for all staff attached to the C & A CSU; and b. Licenses and credentials shall be current as required by the field. 6. The C & A CSU shall ensure that all persons providing services comply with all applicable laws, rules and regulations regarding professional licenses, qualifications and requirements related to the scope of practice. 7. The C & A CSU shall comply with all applicable laws, rules and regulations governing criminal history records checks. 8. The C & A CSU shall have processes for managing personnel information and records. 9. The C & A CSU shall have provisions for sanctioning or removal of staff when: a. Staff are determined to have deficits in required competencies; or b. Staff are accused of abuse, neglect or exploitation of individuals. 10. The C & A CSU shall ensure that, prior to providing direct care to individuals, all staff, volunteers, and contactors shall be trained and show evidence of competence in all areas as defined in the DBHDD Provider Manual for Community Behavioral Health Providers. 11. The C & A CSU shall ensure that, within the first sixty (60) days of providing direct care to individuals, all staff, volunteers and contractors having direct contact with individuals shall receive training in all areas as defined in DBHDD Provider Manual for Community Behavioral Health Providers. 12. The C & A CSU shall have documentation of an annual training plan that addresses 100% of staff who deliver therapeutic content is trained in at least one (1) clinical and programmatic content topic related to the delivery of care. 13. The C & A CSU shall ensure that all employees are tested for tuberculosis prior to direct contact with individuals and are retested at least annually thereafter. Rule 82-4-1-.24 Transportation The C & A CSU shall assist in the coordination of necessary transportation through transfer and/or discharge to assure the youth's safe passage to the appropriate destination. Rule 82-4-1-.25 Incident and Complaint Reporting and Investigation Procedures 1. The C & A CSU shall report critical incidents to the Department as defined by the Departmental policy on reporting of incidents. 2. The C & A CSU shall have internal mechanisms to document, investigate and take appropriate action for complaints and incidents which are not required to be reported to the Department. 3. The C & A CSU shall also post in a visible area the procedure to be taken to make a complaint directly to the Department through the Department's Office of External Affairs. 4. The C & A CSU shall notify the parent(s) or legal guardian(s) as soon as possible, and in no case later than twenty-four (24) hours, after a serious occurrence. Rule 82-4-1-.26 Department Complaint and Incident Investigation Procedures 1. The Department shall be authorized to conduct investigations: a. Investigations shall be conducted to ensure compliance with all applicable laws, rules and regulations; b. Department representatives shall be authorized to enter the premises of a C & A CSU at any time to survey or investigate to ensure compliance with or prevent a violation of any rule or regulation and/or to ensure the quality and integrity of care provided to individuals; c. The Department shall have complete access to, including but not limited to authorization to examine and reproduce, any records required to be maintained in accordance with contracts, standards, laws, rules and regulations of the Department; d. The Department shall maintain the confidentiality of C & A CSU records as specified by federal and/or state law. 2. The Department shall have the authority to conduct announced or unannounced on-site reviews at its discretion at any time or as part of the investigation of complaints or incidents. The Department shall issue written findings within a reasonable period of time. Based on its findings of the review, the Department may: a. Require corrective action that is approved by the Department; i. When the Department finds that any licensee has violated any provision of this Chapter, the Department will prepare a written report identifying each violation and anticipated corrective action. ii. The facility shall submit to the Department a written plan of correction in response to the report of violations, which includes details related to the types of anticipated corrections along with stated timeframes for completions of corrections. The facility may, in addition, offer an explanation for the violation or dispute the findings of the Department as long as an acceptable plan of correction is submitted within thirty (30) days of the facility's receipt of the written report of inspection. iii. If the initial plan of correction is unacceptable to the Department, the facility will be provided with at least one (1) opportunity to revise the unacceptable plan of correction. Failure to submit an acceptable plan of correction may result in the Department initiating enforcement procedures; iv. The facility shall comply with its plan of correction. b. Prohibit admissions to the C & A CSU for a defined period of time; c. Temporarily suspend the C & A CSU license upon findings determined to be of significant risk to health or safety of individuals; or d. Revoke the license. Rule 82-4-1-.27 Enforcement The Department shall have the authority to impose any one or more of the sanctions enumerated in Rules 82-4-1.28 and 82-4-1.29 upon a finding that an applicant or licensee has: 1. Knowingly made any verbal or written false statement of material fact either in connection with the application for a license or on documents submitted to the Department as part of any inspection or investigation or in the falsification or alteration of facility records made or maintained by the facility; 2. Failed or refused, without legal cause, to provide the Department with access to the premises subject to regulation or information pertinent to the initial and continued licensing of the facility; 3. Failed to comply with any licensing requirements of this state; or 4. Failed to comply with the provisions of state law or with any provisions of these rules. Rule 82-4-1-.28 Sanctions and Penalties 1. Sanctions against Licensees. When the Department finds that any licensee has violated any provision of these rules and regulations, the Department, subject to notice and opportunity for a hearing, may impose any one or more of the sanctions in subparagraphs (a) through (e) below: a. Administer a Public Reprimand. If the sanction of public reprimand is finally imposed, as defined by a final adverse finding, the public reprimand shall consist of a notice prepared by the Department that the C & A CSU has been reprimanded; such notice shall include a written report of the Department's findings along with the C & A CSU's response and corrective action plan; b. Suspend any License. The Department may suspend any license for a definite period or for an indefinite period in connection with any condition which may be attached to the restoration of said license; c. Prohibit Persons in Management or Control. The Department may prohibit a licensee from allowing a person who previously was involved in the management or control of any C & A CSU which has had its license revoked or application denied within the past twelve (12) months to be involved in the management or control of such C & A CSU. Any such person found by the Department to have acted diligently and in good faith to ensure correction of violations in a C & A CSU which has had its license revoked or denied; however, shall not be subject to this prohibition if that person became involved in the management or control of the C & A CSU after the C & A CSU was notified by the Department of violations of licensing requirements giving rise to a revocation or denial action. This subparagraph shall not be construed to require the Department to obtain any information that is not readily available to it regarding any person's involvement with a C & A CSU. For the purpose of this Rule, the twelve (12) month period will begin to run from the date of any final adverse finding or the date that any stay of enforcement ceased, whichever occurs first; d. Revoke any License. The Department may revoke any license. If the sanction of license revocation is finally imposed, as defined by a final adverse finding, the Department shall effectuate it by requiring the C & A CSU to return its license to the Department; e. Limit or Restrict any License. The Department may limit or restrict any license as the Department deems necessary for the protection of the public (a provisional or temporary time limited license granted by the Department shall not be considered to be a limited or restricted license). 2. Sanctions against Applicants. When the Department finds that any applicant for a license has violated any provision of Rule 83-3-1.27, Enforcement, the Department, subject to notice and opportunity for a hearing, may impose any one or more of the following sanctions in subparagraphs (a) through (c) below: a. Refuse to Grant License. The Department may refuse to grant (deny) a license and that the Department may do so without first holding a hearing prior to taking such action: i. The Department may deny an application for a license where the C & A CSU has failed to demonstrate compliance with licensing requirements. Additionally, the Department may deny an application for a license where the applicant or alter ego of the applicant has had a license denied, revoked, or suspended within one (1) year of the date of an application, or where the applicant has transferred ownership or governing authority of a C & A CSU within one (1) year of the date of a new application when such transfer was made in order to avert denial, revocation, or suspension of a license; ii. For the purpose of determining the one (1) year denial period, the period shall begin to run from the date of the final adverse finding, or the date any stay of enforcement ceased, whichever occurs first. In further determining whether to grant or deny a license, the Department may consider the applicant's overall record of compliance with licensing requirements; b. Prohibit Persons in Management or Control. The Department may prohibit an applicant from allowing a person who previously was involved in the management or control of any C & A CSU which has had its license revoked or application denied within the past twelve (12) months to be involved in the management or control of such C & A CSU. Any such person found by the Department to have acted diligently and in good faith to ensure correction of violations in a C & A CSU which has had its license revoked or denied, however, shall not be subject to this prohibition if that person became involved in the management or control of the C & A CSU after the C & A CSU was notified by the Department of violations of licensing requirements giving rise to denial action. This subparagraph shall not be construed to require the Department to obtain any information that is not readily available to it regarding any person's involvement with a C & A CSU. For the purpose of this rule, the twelve (12) month period will begin to run from the date of any final adverse finding or the date that any stay of enforcement ceased, whichever occurs first; c. Limit or Restrict any License. The Department may limit or restrict any license as it deems necessary for the protection of the public (a provisional or temporary time- limited license granted by the Department shall not be considered to be a limited or restricted license). 3. Standards for Taking Sanctions. In taking any of the actions pursuant to this rule, the Department shall consider the seriousness of the violation or violations, including the circumstances, extent, and gravity of the prohibited act or acts or failure to act, and the hazard or potential hazard created to the physical or emotional health and safety of the public including the individuals served within the C & A CSU. 4. Non-Compliance with Sanctions. Failure on the part of any C & A CSU to abide by any sanction, which is finally imposed against it, shall constitute grounds for the imposition of additional sanctions, including revocation. 5. Settlements. With regard to any contested case instituted by the Department pursuant to this Chapter or other provisions of law or regulation which may now or hereafter authorize remedial or disciplinary grounds and action, the Department may, in its discretion, dispose of the action so instituted by settlement. In such cases, the Department, the C & A CSU, and those persons deemed by the Department to be successors in interest to any settlement agreement, shall be bound by the terms specified therein. Violation thereof by any applicant or licensee, their agents, employees, or others acting on their behalf, shall constitute grounds for the imposition of any sanctions enumerated in this Chapter, including revocation. Rule 82-4-1-.29 Extraordinary Sanctions Where Imminent and Substantial Danger Where the commissioner of the Department determines that individuals in the care of C & A CSU subject to licensure are subject to an imminent and substantial danger, the commissioner may order any of the extraordinary sanctions listed in any part of this rule to take effect immediately unless otherwise specified in the order, without notice and opportunity for hearing prior to the order taking effect: 1. Content of the Order. The order shall contain the following: a. The scope of the order; b. Reasons for the issuance of the order; c. Effective date of the order if other than the date the order is issued; d. Person to whom questions concerning the order are to be addressed; and e. Notice of the right to obtain a preliminary hearing and an administrative hearing after the issuance of the order regarding the emergency order as a contested case. 2. Emergency Relocation. The commissioner may order emergency relocation of the individual of any C & A CSU subject to licensure to the nearest appropriate facility. Prior to issuing an emergency order, the commissioner may consult with persons knowledgeable in the field of psychiatric care and a representative of the C & A CSU to determine if there is a potential for greater adverse effects on the individual or the individual's care as a result of the proposed issuance of an emergency order. The commissioner shall provide notice to the individual, his or her legal guardian, and his or her physician of the emergency relocation and the reasons therefore; relocation to the nearest appropriate C & A CSU designed to ensure the welfare and, when possible, the desires of the individual; 3. Emergency Placement of Monitor. The commissioner may order the emergency placement of a monitor in a C & A CSU subject to licensure when conditions at the C & A CSU require immediate oversight for the safety of the individual; 4. Emergency Prohibition of Admissions. The commissioner may order the emergency prohibition of admissions to a C & A CSU when such C & A CSU has failed to correct a violation of Departmental permit rules within a reasonable period of time, as specified in the Department's corrective order, and the violation could either jeopardize the health and safety of any individuals if allowed to remain uncorrected or is a repeat violation over a twelve (12) month period, which is intentional or due to gross negligence; 5. Emergency Suspension of Admissions. The commissioner may order admissions to a C & A CSU suspended until the Department has determined that the violation has been corrected or until the Department has determined that the C & A CSU has undertaken the action necessary to effect correction of the violation; 6. Preliminary Hearing. The C & A CSU affected by the commissioner's emergency order may request that the Department hold a preliminary hearing within the Department on the validity of the order and the need for its continuation. Such hearing shall occur within ten (10) days following the request; 7. Cumulative Remedy. The Department shall not be limited to a single emergency action under these rules, nor is the Department precluded from other actions permitted by other law or regulations during the time an emergency order is in force. Rule 82-4-1-.30 Waivers and Variances The Department may, in its discretion, grant waivers and variances of specific rules upon application or petition being filed on forms provided by the department. The Department may establish conditions which must be met by the program in order to operate under the waiver or variance granted. Waivers and variances may be granted in accordance with the following considerations: 1. Variance. A variance may be granted by the Department upon a showing by the applicant or petitioner that the particular rule or regulation that is the subject of the variance request should not be applied as written because strict application of the rule would cause undue hardship. The applicant or petitioner must also show that adequate standards affording protection for the health, safety and care of individuals exist and will be met in lieu of the exact requirements of the rule or regulations in question; 2. Waiver. The Department may dispense entirely with the enforcement of a rule or regulation by granting a waiver upon a showing by the applicant or petitioner that the purpose of the rule or regulation is met through equivalent standards affording equivalent protection for the health, safety and care of individuals; 3. Experimental Variance or Waiver. The Department may grant waivers and variances to allow experimentation and demonstration of new and innovative approaches to delivery of services upon a showing by the applicant or petitioner that the intended protections afforded by the rule or regulation which is the subject of the request are met and that the innovative approach has the potential to improve service delivery. Rule 82-4-1-.31 Severability In the event that a rule, sentence, clause or phrase of any of these rules and regulations may be construed by any court of competent jurisdiction to be invalid, illegal, unconstitutional or otherwise unenforceable, such determination or adjudication shall in no manner affect the remaining rules or portions thereof. The remaining rules or portions thereof shall remain in full force and effect, as if such rule or portions thereof so determined, declared or adjudged invalid or unconstitutional were not originally a part of these rules. Rule 82-4-1-.32 Repealed Rule 82-4-1-.33 Repealed Rule 82-4-1-.34 Repealed Rule 82-4-1-.01 Legal Authority Rule 82-4-1-.02 Title and Purpose Rule 82-4-1-.03 Definitions Rule 82-4-1-.04 General Licensing Requirements Rule 82-4-1-.05 Application Requirements Rule 82-4-1-.06 Issuance of Initial and Renewal of License Rule 82-4-1-.07 Operational Scope of Services Rule 82-4-1-.08 Program Description Rule 82-4-1-.09 Evaluation and Admissions Rule 82-4-1-.10 Provision of Individualized Care Rule 82-4-1-.11 Documentation of Care Rule 82-4-1-.12 Protection and Safety of the Individual and of Others Rule 82-4-1-.13 Pharmacy Services and Management of Medication Rule 82-4-1-.14 Laboratory Services Rule 82-4-1-.15 Food Services Rule 82-4-1-.16 Infection Control and Prevention Rule 82-4-1-.17 Rights and Responsibilities of Individuals Rule 82-4-1-.18 Confidentiality Rule 82-4-1-.19 Documentation of Legal Status Rule 82-4-1-.20 Performance Improvement Plan and Activities Rule 82-4-1-.21 Environment of Care Rule 82-4-1-.22 Fire Prevention and Safety Requirements Rule 82-4-1-.23 Human Resources Rule 82-4-1-.24 Transportation Rule 82-4-1-.25 Incident and Complaint Reporting and Investigation Procedures Rule 82-4-1-.26 Department Complaint and Incident Investigation Procedures Rule 82-4-1-.27 Enforcement Rule 82-4-1-.28 Sanctions and Penalties Rule 82-4-1-.29 Extraordinary Sanctions Where Imminent and Substantial Danger Rule 82-4-1-.30 Waivers and Variances Rule 82-4-1-.31 Severability Rule 82-4-1-.32 Repealed Rule 82-4-1-.33 Repealed Rule 82-4-1-.34 Repealed