ARM 37.98.3

ARM 37.98.3 Administrative Provisions

This regulation establishes administrative licensing requirements for Montana youth residential outdoor/wilderness programs licensed under ARM 37.98, including application procedures, license restrictions, denial/revocation processes, administrative policies, quality assessment, confidentiality of youth records, reporting obligations, and child abuse/neglect reporting requirements. Operators must submit detailed applications with program policies, display licenses publicly, report changes and serious incidents to DPHHS, and maintain active quality assessment programs. The chapter governs residential programs serving youth in outdoor and expedition settings, not standard behavioral health or foster care facility types.

37.98.301
 LICENSE APPLICATION PROCESS 

(1)
 
Application for a license accompanied by the required fee must be made to the Department of Public Health and Human Services, Quality Assurance Division, Licensure Bureau, 2401 Colonial Drive, P.O. Box 202953, Helena, MT 59620-2953. 

(2)
 
The application for a license must be made on forms provided by the department and shall include full and complete information as to the identity of: 

(a)
 
each officer and director of the corporation, if organized as a corporation; 

(b)
 
each general partner if organized as a partnership or limited liability partnership; 

(c)
 
name of the administrator and administrator's qualifications; 

(d)
 
name, address and phone number of the management company if applicable; 

(e)
 
physical location address, mailing address and phone number of the program; and 

(f)
 
maximum number of beds in the program. 

(3)
 
The application for a license must also include the program management policies such as: 

(a)
 
the program statement and description of services; 

(b)
 
policies for decision making, supervision of staff and consultation; 

(c)
 
program strategies, policies and procedures; 

(d)
 
case review policy; 

(e)
 
admission and discharge policies and procedures; 

(f)
 
policies and procedures for support services; 

(g)
 
youth's grievance procedure; 

(h)
 
transportation policies and procedures; 

(i)
 
policies for personnel and financial records; and 

(j)
 
any other policies required by these rules. 

(4)
 
The application for a license must also include the placement agreement intended to be used by the program. 

(5)
 
Every program shall have a distinct identification or name and shall notify the department in writing within 30 days prior to changing such identification or name. 

(6)
 
Each program shall promptly report to the department any plans to relocate the program at least 30 days prior to such a move. 

(7)
 
The current program license must be publicly displayed at the administrative office. 

(8)
 
In the event of a change of ownership, the new owners shall provide the department the following: 

(a)
 
a completed application with fee; 

(b)
 
a copy of the fire inspection conducted within the past year; 

(c)
 
policies and procedures as prescribed in (3) , or if applicable, a written statement indicating that the same policies and procedures will be used; 

(d)
 
a copy of the placement agreement as outlined in (4) ; and 

(e)
 
documentation of compliance with ARM 
37.98.401
. 

Authorizing statute(s):
 Sec. 
50-5-220
, MCA

Implementing statute(s):
 Sec. 
50-5-220
, MCA

History: 
NEW, 2004 MAR p. 1960, Eff. 8/6/04.

37.98.303
 LICENSE RESTRICTIONS 

(1)
 
A license is not subject to sale, assignment or other transfer, voluntary or involuntary. 

(2)
 
A license is valid only for the premises for which the original license was issued. 

(3)
 
The license remains the property of the department and shall be returned to the department upon closing or transfer of ownership. The address for returning the license is Department of Public Health and Human Services, Quality Assurance Division, Licensure Bureau, 2401 Colonial Drive, P.O. Box 202953, Helena, MT 59620-2953. 

Authorizing statute(s):
 Sec. 
50-5-220
, MCA

Implementing statute(s):
 Sec. 
50-5-220
, MCA

History: 
NEW, 2004 MAR p. 1960, Eff. 8/6/04.

37.98.304
 LICENSE DENIAL, SUSPENSION, RESTRICTION, REVOCATION, OR REDUCTION TO PROVISIONAL STATUS AND HEARING PROCEDURES 

(1)
 
The department, after written notice to the applicant, may deny an application for licensure upon finding that the applicant has not met the minimum requirements for licensure established by this subchapter, or upon finding that the applicant has made any misrepresentation to the department, either negligently or intentionally, regarding any aspect of its operations or facility. 

(2)
 
The department, after written notice to a licensed program, may suspend, restrict, revoke or reduce to a provisional status a license upon finding that the program is not in substantial compliance with the minimum requirements for licensure established by this subchapter. Suspension or revocation may be immediate if: 

(a)
 
the department is denied access to the program, to any youth placed in the program by the department, or to any program records; 

(b)
 
the program has made any misrepresentation to the department, either negligently or intentionally, regarding any aspect of its operations or facility; 

(c)
 
the program fails to report known or suspected child abuse or neglect as required by 
41-3-201
 , MCA; 

(d)
 
the initial investigation of a report of child abuse or neglect results in reasonable cause to suspect that a youth in the program may be in danger of harm; 

(e)
 
the program or any member of its staff has been named as the perpetrator in a substantiated report of abuse or neglect; 

(f)
 
the program or any member of its staff has violated a provision of this subchapter that resulted in child abuse or neglect; or 

(g)
 
it is determined on the basis of a department or law enforcement investigation that the program or any member of its staff may pose a risk or threat to the health or welfare of a youth placed in the program. 

(3)
 
Any person denied licensure under the provisions of this subchapter, or whose license has been suspended, restricted, revoked or reduced to a provisional status, may request a hearing as provided in ARM 
37.5.304
, 
37.5.305
, 
37.5.307
, 
37.5.310
, 
37.5.313
, 
37.5.316
, 
37.5.322
, 
37.5.325
, 
37.5.328
, 
37.5.331
, 
37.5.334
 and 
37.5.337
. 

Authorizing statute(s):
 Sec. 
50-2-220
, MCA

Implementing statute(s):
 Sec. 
50-2-220
, MCA

History: 
NEW, 2004 MAR p. 1960, Eff. 8/6/04.

37.98.308
 ADMINISTRATIVE POLICIES AND PROCEDURES 

(1)
 
The program shall have established policies and organizational plans clearly defining legal responsibility, administrative authority and responsibility for services to program participants and the community. 

(2)
 
The program shall have written policies for personnel and financial records. The policies shall be furnished to the department with the initial license application. 

(3)
 
The program shall have written position descriptions for all employees which include a description of duties, responsibilities, limitations of authority, and principal measures of accountability and performances. 

(4)
 
The program shall develop policies and procedures for screening, hiring and assessing staff which include practices that assist the employer in identifying employees that may pose a risk or threat to the health, safety or welfare of any resident and provide written documentation of findings and the outcome in the employee's file. 

Authorizing statute(s):
 Sec. 
50-5-220
, MCA

Implementing statute(s):
 Sec. 
50-5-220
, MCA

History: 
NEW, 2004 MAR p. 1960, Eff. 8/6/04.

37.98.312
 QUALITY ASSESSMENT 

(1)
 
The program shall implement and maintain an active quality assessment program for improving policies, procedures and services. At a minimum, the quality assessment program must include procedures for: 

(a)
 
conducting youth satisfaction surveys at least annually; 

(b)
 
maintaining records on the occurrence, duration and frequency of physical assists and physical restraints used; and 

(c)
 
reviewing, on an ongoing basis, serious incident reports, near misses, grievances, complaints, medication errors, and the use of physical restraints with special attention given to identifying patterns and making necessary changes in how services are provided. 

(2)
 
The program shall prepare and maintain on file an annual report of improvements made as a result of the quality assessment activities specified in this rule. 

Authorizing statute(s):
 Sec. 
50-5-220
, MCA

Implementing statute(s):
 Sec. 
50-5-220
, MCA

History: 
NEW, 2004 MAR p. 1960, Eff. 8/6/04.

37.98.315
 CONFIDENTIALITY OF RECORDS AND INFORMATION 

(1)
 
All records maintained by a program and all personal information made available to a program pertaining to an individual youth must be kept confidential, and are not available to any person, agency or organization except as specified in (2) through (4) . 

(2)
 
All records pertaining to an individual youth are available upon request to: 

(a)
 
the youth's parent, guardian, legal custodian, or attorney absent specific and compelling reasons for refusing such records; 

(b)
 
a court with continuing jurisdiction over the placement of the youth or any court of competent jurisdiction issuing an order for such records; 

(c)
 
a mature youth to whom the records pertain, absent specific and compelling reasons for refusing specific records; or 

(d)
 
an adult who was formerly the youth in care to whom the records pertain, absent specific and compelling reasons for refusing such records. 

(3)
 
All records pertaining to individual youth placed by the department are available at any time to the department or its authorized representatives. 

(4)
 
Records pertaining to individual youth not placed by or in the custody of the department must be available to the department for the purposes of licensing, relicensing or investigating the program. 

Authorizing statute(s):
 Sec. 
50-5-220
, MCA

Implementing statute(s):
 Sec. 
50-5-220
, MCA

History: 
NEW, 2004 MAR p. 1960, Eff. 8/6/04.

37.98.316
 REPORTS 

(1)
 
The program shall submit to the department, upon its request, any reports required by federal or state law or regulation. 

(2)
 
The program shall report any of the following changes in writing to the Department of Public Health and Human Services, Quality Assurance Division, Licensure Bureau, 2401 Colonial Drive, P.O. Box 202953, Helena, MT 59620-2953 prior to the effective date of: 

(a)
 
a change of administrator; 

(b)
 
a change in location; 

(c)
 
a change in the name of the program; or 

(d)
 
any significant change in organization, administration, purposes, programs, or services. 

(3)
 
The program shall report any violation of the requirements of this subchapter to the department within two business days. 

(4)
 
Runaways must be reported immediately to law enforcement and within the next working day to the agency or person who placed the youth. 

(5)
 
Disasters or emergencies which require closure of a residence unit shall be reported to the department within the next working day. 

Authorizing statute(s):
 Sec. 
50-5-220
, MCA

Implementing statute(s):
 Sec. 
50-5-220
, MCA

History: 
NEW, 2004 MAR p. 1960, Eff. 8/6/04.

37.98.319
 CHILD ABUSE OR NEGLECT AND SERIOUS INCIDENTS 

(1)
 
Each program staff member and employee shall read and sign a statement clearly defining child abuse and neglect and explaining the staff member's responsibility to report all known or suspected incidents of child abuse or neglect. 

(2)
 
Any program staff member or employee who knows or has reasonable cause to suspect that an incident of child abuse or neglect has occurred shall report within 24 hours the known or suspected incident to the program administrator, or a person designated by the program administrator, and to the state child abuse hotline (1 (866) 820-5437) as required by 
41-3-201
 , MCA. The program must fully cooperate with any investigation conducted as a result of the report. 

(3)
 
Each program shall have written procedures for handling any suspected incident of child abuse or neglect including: 

(a)
 
a procedure for ensuring that the staff member involved does not continue to provide direct care until an investigation is completed; and 

(b)
 
a procedure for taking appropriate disciplinary measures against any staff member involved in an incident of child abuse or neglect, including, but not limited to: 

(i)
 
termination of employment; 

(ii)
 
retraining of the staff member; or 

(iii)
 
any other appropriate action by the program geared towards the prevention of future incidents of child abuse or neglect. 

(4)
 
Any serious incident involving a youth must be reported within the next working day to the person or agency which placed the youth and to the Department of Public Health and Human Services, Quality Assurance Division, Licensure Bureau, 2401 Colonial Drive, P.O. Box 202953, Helena, MT 59620-2953. 

(5)
 
The report must be in writing, and must include: 

(a)
 
the date and time of the incident; 

(b)
 
the youth and any staff member(s) involved; 

(c)
 
the nature of the incident; and 

(d)
 
a description of the incident and the circumstances surrounding it. 

(6)
 
A copy of the report must be maintained at the program. 

Authorizing statute(s):
 Sec. 
50-5-220
, MCA

Implementing statute(s):
 Sec. 
50-5-220
, MCA

History: 
NEW, 2004 MAR p. 1960, Eff. 8/6/04.