Westridge & Other Schools(Formerly LDS Perceptions thread)

[_Jersey Girl]

marg,

I'm just going to start responding to only excerpts of your posts. Let's go.

marg: I don't believe Eric has argued he's not going to report. I've been pushing in these last exchanges between you, Harm and Liz for all you guys to identify what you think is legal abuse and what you think he's experienced that he should report. It has taken a while to finally get some answers on this. It is what prompted you to find out what is consider legally abusive in utah.

Me: marg, I'm too busy to go in circles with you. I've got the Utah Administrative Code (rules and regs) in front of me and saved on my computer, and returned here prepared to respond to a list of abuses however, I'm not going to chase down a list. The rules and regs are extensive, and it's not a matter of running down one list. It's a matter of running down one list and referencing several others.

Jersey Girl Quote marg is responding to:
Of course, I'm critical of his failure to report current abuse. He claims to have left messages with a "licensing supervisor" that haven't been answered.


marg: Your approach is off putting. It lacks empathy. Look at how you word it.."I'm critical of his failure" It's not failure J.G.

Me: marg, you need to stop attaching unwarranted emotion to the words that I post. The phrase "failure to report current abuse" isn't a statement that Eric himself is a failure. It is a phrase commonly used to described a situation where someone knows of abuse and fails to report it. For example, if I fail to report suspected abuse or neglect, I can be charged with felony. It is not a lack of empathy on my part. If I were writing a report on this matter, that's exactly the phrasing that I would use and so would DHS. It is a failure to report.


marg: It's a matter of having the energy, motivation and knowing what to report.

Me: I have no idea whether or not Eric has the energy or motivation to pursue a complaint. Knowing what to report? I've fed him information from day one, here, marg. I continue to supply information. I've supplied pages of information in the face of your dumping ad hom's on me. I've extended myself in that I'm willing to run through the rules and regs hunting down whatever it is that you give me. If you want someone who is familiar with the terminology to troubleshoot it for you (and Eric) I'm right here. If that isn't agreeable to you, we can suspend these exchanges and just wait to see the outcome of the case Eric is building with his attorney. What I'm not willing to do is play "wag the dog" with you when I have other things to work on.

**What you want on your list are methods of physical restraint, physical punishment (hitting, kicking) , verbal abuse-intimidation-humiliation (What's being said? How is it being said?) removal from the group (circumstances, location, duration), isolation (Where? In a closet? In a room? How large is the room? For how long?) withholding of meals (food and water), withholding of toileting facilities...that sort of thing.

Don't give me instances of children being made to work out of doors in extreme heat or cold weather. I don't have time to hunt down the temperature, windchill, winds, etc. And yes, some states regulate down to temp and duration, wind speeds, windchill factors.

FYI: The **starred items are exactly the type of documentation that Eric needs to come up with including dates/times/names. If you don't want to make a list, there's a sample of what he needs to do if he hasn't already done it.

Editing: And just to give you an inkling of what West Ridge is going to come up with, in my work I have to document every single cut, scrape, bump, bruise, skinned knee. The documentation is in two forms. One form is subject to subpeona (sp?) by a court of law. Accident and Injury reports are reported to the state and responded to by the state, typically with a site visit. Think about the complexity of the program at West Ridge. What I do is minimal compared to what's required of a facility such as that. Every type of state licensed program operates under a mountain of documentation, marg.

Eric cannot compile documentation narrative such as "a kid was walked around on a leash". He needs to be specific. "A staff member tied a 6 foot length of rope around the student's waist outside of his clothing..." or "A staff member tied a 6 foot length of rope around the student's waist inside his clothing so that the rope made skin contact, walked him around for 2 hours and when the rope was removed, it left a visible rope burn that went untreated by medical staff because the student was not permitted to visit the medical clinic."

Like that...

[_marg]

What you want on your list are methods of physical restraint, physical punishment (hitting, kicking) , verbal abuse-intimidation-humiliation (What's being said? How is it being said?) removal from the group (circumstances, location, duration), isolation (Where? In a closet? In a room? How large is the room? For how long?) withholding of meals (food and water), withholding of toileting facilities...that sort of thing.

That's a good outline, it's descriptive. The problem in my opinion isn't any one particular thing, it's the overall program at least what Eric describes in his experiences. Going through that list would be a good start and guide. Probably organizing his thoughts for a book (whether or not it gets published) but condensing what he's written and attaching it to some gov't complaint form might also work, if he's not done something like that already. As Liz says, it can't hurt it can only help by establishing a paper trail.

Don't give me instances of children being made to work out of doors in extreme heat or cold weather. I don't have time to hunt down the temperature, windchill, winds, etc. And yes, some states regulate down to temp and duration, wind speeds, windchill factors.

That's interesting and encouraging that some states are very specific about various abuses. It's also good to know how other states handle the issue.

This has been an issue which has gone on for decades based upon my readings on the Net. It must be very frustrating, daunting, stressful, exhausting, for a traumatized individual to have the fortitude and means to act upon doing something to change the situation.

I don't have the motivation to get involved. It is not something which has impacted me, I don't hear about this situation in Canada going on (not saying that it doesn't). I do think there are people who are highly motivated and focussed working on this issue in the U.S. and they are the ones Eric should keep in touch with.

[_Jersey Girl]

You like descriptions? Here's the Utah Admin Code description for the program at West Ridge. This is the tip of their regulated iceberg.

http://www.rules.utah.gov/publicat/code/r501/r501-19.htm

Rule R501-19. Residential Treatment Programs.
As in effect on March 1, 2009

Table of Contents
R501-19-1. Authority.
R501-19-2. Purpose.
R501-19-3. Definition.
R501-19-4. Administration.
R501-19-5. Staffing.
R501-19-6. Direct Service.
R501-19-7. Physical Facilities.
R501-19-8. Physical Environment.
R501-19-9. Food Service.
R501-19-10. Medication.
R501-19-11. Specialized Services for Substance Abuse.
R501-19-12. Specialized Services for Programs Serving Children and Youth.
R501-19-13. Specialized Services for Division of Services for People With Disabilities.
KEY
Date of Enactment or Last Substantive Amendment
Notice of Continuation
Authorizing, Implemented, or Interpreted Law
R501-19-1. Authority.
Pursuant to Section 62A-2-101 et seq., the Office of Licensing shall license residential treatment programs according to the following rules.

R501-19-2. Purpose.
Residential treatment programs offer room and board and provides for or arranges for the provision of specialized treatment, rehabilitation or habilitation services for persons with emotional, psychological, developmental, or behavioral dysfunctions, impairments, or chemical dependencies. In residential treatment programs, consumers are assisted in acquiring the social and behavioral skills necessary for living independently in the community in accordance with Subsection 62A-2-101(15).

R501-19-3. Definition.
Residential treatment program means a 24-hour group living environment for four or more individuals unrelated to the owner or provider in accordance with Subsection 62A-2-101(15).

R501-19-4. Administration.
A. In addition to the following rules, all Residential Treatment Programs shall comply with R501-2, Core Standards.

B. A current list of enrollment of all registered consumers shall be on-site at all times.

R501-19-5. Staffing.
A. The program shall have an employed manager who is responsible for the day to day resident supervision and operation of the facility. The responsibilities of the manager shall be clearly defined. Whenever the manager is absent there shall be a substitute available.

B. The program shall have a staff person trained, by a certified instructor, in standard first aid and CPR on duty with the consumers at all times.

C. Programs which utilize students and volunteers, shall provide screening, training, and evaluation of volunteers. Volunteers shall be informed verbally and in writing of program objectives and scope of service.

D. Professional staff shall include the following individuals who have received training in the specific area listed below:

1. Mental Health

a. a licensed physician or consulting licensed physician,

b. a licensed psychologist, or consulting licensed psychologist,

c. a licensed mental health therapist,

d. a licensed advanced practice registered nurse-psychiatric mental health nurse specialist, or a consulting advanced practice registered nurse-psychiatric mental health nurse specialist, and

e. if unlicensed staff are used, they shall be supervised by a licensed clinical professional.

2. Substance Abuse

a. a licensed physician, or a consulting licensed physician,

b. a licensed psychologist or consulting licensed psychologist,

c. a licensed mental health therapist or consulting licensed, mental health therapist, and

d. a licensed substance abuse counselor or unlicensed staff who work with substance abusers shall be supervised by a licensed clinical professional.

3. Children and Youth

a. a licensed physician, or consulting licensed physician,

b. a licensed psychologist, or consulting licensed psychologist, and

c. a licensed mental health therapist or consulting licensed mental health therapist, to provide a minimum of one hour of service to the program per week per consumer enrolled.

d. A licensed medical practitioner, by written agreement, shall be available to provide, as needed, a minimum of one hour of service per week for every two consumers enrolled.

e. Other staff trained to work with emotionally and behaviorally disturbed, or conduct disordered children and youth shall be under the supervision of a licensed clinical professional.

f. A minimum of two staff on duty and, a staff ratio of no less than one staff to every four consumers shall exist at all times, except nighttime sleeping hours when staff may be reduced.

g. A mixed gender population shall have at least one male and one female staff on duty at all times.

4. Services for People With Disabilities shall have a staff person responsible for program supervision and operation of the facility. Staff person shall be adequately trained to provide the services and treatment stated in the consumer plan.

R501-19-6. Direct Service.
Treatment plans shall be reviewed and signed by the clinical supervisor. Treatment plans shall be reviewed and signed by the clinical supervisor, or other qualified individuals for Division of Services for People With Disabilities services. Plans shall be reviewed and signed as noted in the treatment plan.

R501-19-7. Physical Facilities.
A. The program shall provide written documentation of compliance with the following items as applicable:

1. local zoning ordinances,

2. local business license requirements,

3. local building codes,

4. local fire safety regulations,

5. local health codes, and

6. local approval from the appropriate government agency for new program services or increased consumer capacity.

B. Building and Grounds

1. The program shall ensure that the appearance and cleanliness of the building and grounds are maintained.

2. The program shall take reasonable measures to ensure a safe physical environment for consumers and staff.

R501-19-8. Physical Environment.
A. Live-in staff shall have separate living space with a private bathroom.

B. The program shall have space to serve as an administrative office for records, secretarial work and bookkeeping.

C. Indoor space for free and informal activities of consumers shall be available.

D. Provision shall be made for consumer privacy.

E. Space shall be provided for private and group counseling sessions.

F. Sleeping Space

1. No more than four persons, or two for Division of Services for People With Disabilities programs, shall be housed in a single bedroom.

2. A minimum of sixty square feet per consumer shall be provided in a multiple occupant bedroom. Storage space will not be counted.

3. A minimum eighty square feet per individual shall be provided in a single occupant bedroom. Storage space will not be counted.

4. Sleeping areas shall have a source of natural light, and shall be ventilated by mechanical means or equipped with a screened window that opens.

5. Each bed, none of which shall be portable, shall be solidly constructed, and be provided with clean linens after each consumer stay and at least weekly.

6. Sleeping quarters serving male and female residents shall be structurally separated.

7. Consumers shall be allowed to decorate and personalize bedrooms with respect for other residents and property.

G. Bathrooms

1. The program shall have separate bathrooms for males and females. These shall be maintained in good operating order and in a clean and safe condition.

2. Bathrooms shall accommodate consumers with physical disabilities as required.

3. Each bathroom shall be properly equipped with toilet paper, towels, soap, and other items required for personal hygiene.

4. Bathrooms shall be ventilated by mechanical means or equipped with a screened window that opens.

5. Bathrooms shall meet a minimum ratio of one toilet, one lavatory, and one tub or shower for each six residents.

6. There shall be toilets and baths or showers which allow for individual privacy.

7. There shall be mirrors secured to the walls at convenient heights.

8. Bathrooms shall be located as to allow access without disturbing other residents during sleeping hours.

H. Furniture and equipment shall be of sufficient quantity, variety, and quality to meet program and consumer needs.

I. All furniture and equipment shall be maintained in a clean and safe condition.

J. Programs which permit individuals to do their own laundry shall provide equipment and supplies for washing, drying, and ironing.

K. Programs which provide for common laundry of linens and clothing, shall provide containers for soiled laundry separate from storage for clean linens and clothing.

L. Laundry appliances shall be maintained in a clean and safe operating condition.

R501-19-9. Food Service.
A. One staff shall be responsible for food service. If this person is not a professionally qualified dietitian, regularly scheduled consultation with a professionally qualified dietitian shall be obtained. Meals served shall be from dietitian approved menus.

B. The staff responsible for food service shall maintain a current list of consumers with special nutritional needs and record in the consumers service record information relating to special nutritional needs and provide for nutrition counseling where indicated.

C. The program shall establish and post kitchen rules and privileges according to consumer needs.

D. Consumers present in the facility for four or more consecutive hours shall be provided nutritious food.

E. Meals may be prepared at the facility or catered.

F. Kitchens shall have clean, safe, and operational equipment for the preparation, storage, serving, and clean up of all meals.

G. Adequate dining space shall be provided for consumers. The dining space shall be maintained in a clean and safe condition.

H. When meals are prepared by consumers there shall be a written policy to include the following:

1. rules of kitchen privileges,

2. menu planning and procedures,

3. nutritional and sanitation requirements, and

4. schedule of responsibilities.

R501-19-10. Medication.
A. The program shall have locked storage for medications.

B. The program shall have locked storage for hazardous chemicals and materials, according to the direction of the local fire authorities.

C. Prescriptive medication shall be provided as prescribed by a qualified physician, according to the Medical Practices Act.

D. The program shall have designated qualified staff, who shall be responsible to:

1. administer medication,

2. supervise self-medication,

3. record medication, including time and dosage, according to prescription, and

4. record effects of medication.

R501-19-11. Specialized Services for Substance Abuse.
A. The program shall not admit anyone who is currently experiencing convulsions, in shock, delirium tremens, in a coma, or unconscious.

B. At a minimum, the program shall document that direct service staff complete standard first aid and CPR training within six months of being hired. Training shall be updated as required by the certifying agency.

C. Before admission, consumers shall be tested for Tuberculosis. Both consumers and staff shall be tested annually or as directed by the local health authority.

R501-19-12. Specialized Services for Programs Serving Children and Youth.
A. Provisions shall be available for adolescents to continue their education with a curriculum approved by the State Office of Education.

B. Programs which provide their own school shall be recognized by an educational accreditation organization, i.e., State Board of Education or the National School Accreditation Board.

C. Individual, group, couple, and family counseling sessions or other appropriate treatment, including skills development, shall be conducted at least weekly, or more often if defined by the treatment plan. The consumer's record shall document the time and date of the service provided and include the signature of the counselor.

D. An accurate record shall be kept of all funds deposited and withdrawn with the residential facility for use by a consumer. Consumer purchases of over $20.00 per item, shall be substantiated by receipts signed by the consumer and appropriate staff.

R501-19-13. Specialized Services for Division of Services for People With Disabilities.
A. Rules governing the daily operation and activities of the facility shall be available to all consumers and visitors, and shall apply to family members, consumers, and staff that come into the facility.

B. The program shall have policy specifying the amount of time family or friends may stay as overnight guests.

C. All consumers in residential programs shall have an individual plan that addresses appropriate day treatment.

D. A monthly schedule of activities shall be shared with the consumer and available on request. Schedules shall be filed and maintained for review.

E. A record of income, earned, unearned, and consumer service fees, shall be maintained by the provider.

F. Residential facilities shall be located where school, church, recreation, and other community facilities are available.

G. An accurate record shall be kept of all funds deposited with the residential facility for use by a consumer. This record shall contain a list of deposits and withdrawals. Consumer purchases of over $20.00, per item, shall be substantiated by receipts signed by the consumer and professional staff. A record shall be kept of consumer petty cash funds.

H. The program, in conjunction with the parent or guardian and the Division of Services for People With Disabilities support coordinator, shall apply for unearned income benefits for which a consumer is entitled.

KEY
human services, licensing

Date of Enactment or Last Substantive Amendment
May 2, 2000

Notice of Continuation
April 25, 2005

Authorizing, Implemented, or Interpreted Law
62A-2-101 et seq.


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Rule converted into HTML by the Division of Administrative Rules.

For questions regarding the content or application of rules under Title R501, please contact the promulgating agency (Human Services, Administration, Administrative Services, Licensing). A list of agencies with links to their homepages is available at http://www.utah.gov/government/agencylist.html.

For questions about the rulemaking process, please contact the Division of Administrative (801-538-3764). Please Note: The Division of Administrative Rules is not able to answer questions about the content or application of these rules.


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The HTML version of this rule is a convenience copy. This information is made available on the Internet as a public service. Please see this disclaimer about information available from http://www.rules.utah.gov.


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[_Jersey Girl]

Here's the core rules for the operation of ALL licensed human services programs in the state of Utah. These are not negotiable. Now hang on to your hat, marg. Look for the section on behavior management.

http://www.rules.utah.gov/publicat/code/r501/r501-02.htm


Rule R501-2. Core Rules.
As in effect on March 1, 2009

Table of Contents
R501-2-1. Definition.
R501-2-2. Program Administration.
R501-2-3. Governance.
R501-2-4. Statutory Authority.
R501-2-5. Record Keeping.
R501-2-6. Direct Service Management.
R501-2-7. Behavior Management.
R501-2-8. Rights of Consumers.
R501-2-9. Personnel Administration.
R501-2-10. Infectious Disease.
R501-2-11. Emergency Plans.
R501-2-12. Safety.
R501-2-13. Transportation.
R501-2-14. Categorical Rules.
R501-2-15. Single Service Program Rules.
KEY
Date of Enactment or Last Substantive Amendment
Notice of Continuation
Authorizing, Implemented, or Interpreted Law
R501-2-1. Definition.
Core Rules are required for Human Service Programs, listed in R501-2-14. Where there is duplication of review by another oversight agency, the Office of Licensing, shall accept that documentation as proof of compliance. Pursuant to 62A-2-106, the Office of Licensing will not enforce rules for licensees under contract to a Division in the Department of Human Services in the following areas:

A. the administration and maintenance of client and service records;

B. staff qualifications; and

C. staff to client ratios.

R501-2-2. Program Administration.
A. The program shall have a written statement of purpose to include the following:

1. program philosophy,

2. description of long and short term goals, this does not apply to social detoxification or child placing adoption agencies,

3. description of the services provided,

4. the population to be served,

5. fee policy,

6. participation of consumers in activities unrelated to treatment plans, and

7. program policies and procedures which shall be submitted prior to issuance of an initial licensing.

B. Copies of the above statements shall be available at all times to the Office of Licensing upon request. General program information shall be available to the public.

C. The program shall have a written quality assurance plan. Implementation of the plan shall be documented.

D. The program shall have clearly stated guidelines and appropriate administrative procedures, to include the following:

1. program management,

2. maintenance of complete, accurate and accessible records, and

3. record retention.

E. The governing body, program operators, management, employees, consultants, volunteers, and interns shall read, understand, follow and sign a copy of the current Department of Human Services Provider Code of Conduct.

F. The program shall comply with State and Federal laws regarding abuse reporting in accordance with 62A-4a-403 and 62A-3-302, and shall post copies of these laws in a conspicuous place within the facility.

G. All programs which serve minors or vulnerable adults shall submit identifying information for background screening of all adult persons associated with the licensee and board members who have access to children and vulnerable adults in accordance with R501-14 and R501-18.

H. The program shall comply with all applicable National Interstate Compact Laws.

I. A licensed substance abuse treatment program shall complete the National Survey of Substance Abuse Treatment annually. Substance abuse treatment programs shall also comply with Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2.

J. The program's license shall be posted where it is easily read by consumers, staff and visitors. See also R501-1-5-F. The program shall post Civil Rights License on Notice of Agency Action, abuse and neglect reporting and other notices as applicable.

K. The program shall not handle the major personal business affairs of a consumer, without request in writing by the consumer and legal representative.

L. Programs providing foster or proctor care services shall adhere to the following:

1. approve homes that comply with Foster Care Rules, R501-12. The agency shall be required to recruit, train, and supervise foster parents as defined by R501-12.

2. foster families meeting requirements shall be approved or certified by the agency. The agency must maintain written records of annual home approval. The approval process shall include a home study evaluation and training plan.

3. the agency must have a procedure to revoke or deny home approval.

4. the agency must have a written agreement with the foster parents which includes the expectations and responsibilities of the agency, staff, foster parents, the services to be provided, the financial arrangements for children placed in the home, the authority foster parents can exercise on children placed in the home, actions which require staff authorization.

5. planning, with participation of the child's legal guardian for care and services to meet the child's individual needs.

6. obtaining, coordinating and supervising any needed medical, remedial, or other specialized services or resources with the ongoing participation of the foster parents.

7. providing ongoing supervision of foster parents to ensure the quality of the care they provide.

R501-2-3. Governance.
A. The program shall have a governing body which is responsible for and has authority over the policies, training and monitoring of staff and consumer activities for all phases of the program. The governing body's responsibilities shall include the following:

1. to ensure program policy and procedures compliance,

2. to ensure continual compliance with relevant local, state and federal requirements,

3. to notify the Office of Licensing within 30 days of changes in program administration and purpose,

4. to ensure that the program is fiscally and operationally sound, by providing documentation by a financial professional that the program is a "going concern",

5. to ensure that the program has adequate staffing as identified on the organizational chart,

6. to ensure that the program has general liability insurance, professional liability insurance as appropriate, vehicle insurance for transport of consumers, and fire insurance, and

7. for programs serving youth, the program director or designee shall meet with the Superintendent or designee of the local school district at the time of initial licensure, and then again each year as the programs renews it's license to complete the necessary student forms including youth education forms.

B. The governing body shall be one of the following:

1. a Board of Directors in a non-profit organization; or

2. commissioners or appointed officials of a governmental unit; or

3. Board of Directors or individual owner or owners of a for-profit organization.

C. The program shall have a list of members of the governing body, indicating name, address and term of membership.

D. The program shall have an organization chart which identifies operating units of the program and their inter-relationships. The chart shall define lines of authority and responsibility for all program staff and identifies by name the staff person who fills each position on the chart.

E. When the governing body is composed of more than one person, the governing body shall establish written by-laws, and shall hold formal meetings at least twice a year, Child Placing Agencies must meet at least quarterly, maintain written minutes, which shall be available for review by the Office of Licensing, to include the following:

1. attendance,

2. date,

3. agenda items, and

4. actions.

R501-2-4. Statutory Authority.
A. A publicly operated program shall document the statutory basis for existence.

B. A privately operated program shall document its ownership and incorporation.

R501-2-5. Record Keeping.
The program shall have, a written record for each consumer to include the following:

A. Demographic information to include Medicaid number as required,

B. Biographical information,

C. Pertinent background information, including the following;

1. personal history, including social, emotional, psychological and physical development,

2. legal status,

3. emergency contact with name, address and telephone number, and

4. photo as needed.

D. Health records of a consumer including the following:

1. immunizations, for children only,

2. medication,

3. physical examinations, dental, and visual examinations, and

4. other pertinent health records and information.

E. Signed consent forms for treatment and signed Release of Information form,

F. Copy of consumer's individual treatment or service plan,

G. A summary of family visits and contacts, and

H. A summary of attendance and absences.

R501-2-6. Direct Service Management.
A. Direct service management, as described herein, is not applicable to social detoxification. The program shall have on file for public inspection a written eligibility policy and procedure, approved by a licensed clinical professional to include the following:

1. legal status,

2. age and sex of consumer,

3. consumer needs or problems best addressed by program,

4. program limitations, and

5. appropriate placement.

B. The program shall have a written admission policy and procedure to include the following:

1. appropriate intake process,

2. age groupings as approved by the Office of Licensing,

3. pre-placement requirements,

4. self-admission,

5. notification of legally responsible person, and

6. reason for refusal of admission, to include a written, signed statement.

C. Intake evaluation.

1. At the time of intake an assessment shall be conducted to evaluate health and family history, medical, social, psychological and, as appropriate, developmental, vocational and educational factors.

2. In emergency situations which necessitate immediate placement, the intake evaluation shall be completed within seven days of admission.

3. All methods used in evaluating a consumer shall consider age, cultural background, dominant language, and mode of communication.

D. A written agreement, developed with the consumer, and the legally responsible person if applicable, shall be completed, signed by all parties, and kept in the consumer's record, with copies available to involved persons. It shall include the following:

1. rules of program,

2. consumer and family expectations,

3. services to be provided and cost of service,

4. authorization to serve and to obtain emergency care for consumer,

5. arrangements regarding absenteeism, visits, vacation, mail, gifts, and telephone calls, when appropriate, and

6. sanctions and consequences.

E. Consumer treatment plan shall be individualized, as applicable according to the following.

1. A staff member shall be assigned to each consumer having responsibility and authority for development, implementation, and review of the plan.

2. The plan shall include the following:

a. findings of intake evaluation and assessment,

b. measurable long and short term goals and objectives,

1) goals or objectives clearly derived from assessment information,

2) goals or objectives stated in terms of specific observable changes in behavior, skills, attitudes or circumstances,

3) evidence that consumer input was integrated where appropriate in identifying goals and objectives, and

4) evidence of family involvement in treatment plan, unless clinically contraindicated,

c. specification of daily activities, services, and treatment, and

d. methods for evaluation,

3. Treatment plans

a. plans shall be developed within 30 days of consumer's admission by a treatment team and reviewed by a clinical professional if applicable. Thereafter treatment plans shall be reviewed by the licensed clinical professional if applicable as often as stated in the treatment plan.

4. All persons working directly with the consumer shall be appropriately informed of the individual treatment plan.

5. Reports on the progress of the consumer shall be available to the applicable Division, the consumer, or the legally responsible person.

6. Treatment record entries shall include the following:

a. identification of program,

b. date and duration of services provided,

c. description of service provided,

d. a description of consumer progress or lack of progress in the achievement of treatment goals or objectives as often as stated in the treatment plan, and

e. documentation of review of consumer's record to include the following:

1) signature,

2) title,

3) date, and

4) reason for review.

7. Transfer and Discharge

a. a discharge plan shall identify resources available to consumer.

b. the plan shall be written so it can be understood by the consumer or legally responsible party.

c. whenever possible the plan shall be developed with consumers participation, or legally responsible party if necessary. The plan shall include the following:

1) reason for discharge or transfer,

2) adequate discharge plan, including aftercare planning,

3) summary of services provided,

4) evaluation of achievement of treatment goals or objectives,

5) signature and title of staff preparing summary, and

6) date of discharge or transfer.

d. The program shall have a written policy concerning unplanned discharge.

8. Incident or Crisis Intervention records

a. The program shall have written policies and procedures which includes: reporting to program manager, documentation, and management review of incidents such as deaths of consumers, serious injuries, fights, or physical confrontations, situations requiring the use of passive physical restraints, suspected incidents of abuse or neglect, unusual incidents, strip searches and other situations or circumstances affecting the health, safety, or well-being of consumers.

b. records shall include the following:

1) summary information,

2) date, time of emergency intervention,

3) action taken,

4) employees and management responsible and involved,

5) follow up information,

6) list of referrals,

7) signature and title of staff preparing report, and

8) records shall be signed by management staff.

c. the report shall be maintained in individual consumer records.

d. when an incident involves abuse, neglect, serious illness, violations of the Provider Code of Conduct or death of a consumer, a program shall:

1) notify the Office of Licensing, legally responsible person and any applicable agency which may include law enforcement.

2) a preliminary written report shall be submitted to the Office of Licensing within 24 hours of the incident.

R501-2-7. Behavior Management.
A. The program shall have on file for public inspection, a written policy and procedure for the methods of behavior management. These shall include the following:

1. definition of appropriate and inappropriate behaviors of consumers,

2. acceptable staff responses to inappropriate behaviors, and

3. consequences.

B. The policy shall be provided to all staff, and staff shall receive training relative to behavior management at least annually.

C. No management person shall authorize or use, and no staff member shall use, any method designed to humiliate or frighten a consumer.

D. No management person shall authorize or use, and no staff member shall use nor permit the use of physical restraint with the exception of passive physical restraint. Passive physical restraint shall be used only as a temporary means of physical containment to protect the consumer, other persons, or property from harm. Passive physical restraint shall not be associated with punishment in any way.

E. Staff involved in an emergency safety intervention that results in an injury to a resident or staff must meet with the clinical professional to evaluate the circumstances that caused the injury and develop a plan to prevent future injuries.

F. Programs using time out or seclusion methods shall comply with the following:

1. The program will have a written policy and procedure which has been approved by the Office of Licensing to include:

a. Time-out or seclusion is only used when a child's behavior is disruptive to the child's ability to learn to participate appropriately, or to function appropriately with other children or the activity. It shall not be used for punishment or as a substitute for other developmentally appropriate positive methods of behavior management.

b. Time-out or seclusion shall be documented in detail and provide a clear understanding of the incident which resulted in the child being placed in that time-out or seclusion.

c. If a child is placed in time out or seclusion more than twice in any twenty-four hour period, a review is conducted by the clinical professional to determine the suitability of the child remaining in the program.

d. Any one time-out or seclusion shall not exceed 4 hours in duration.

e. Staff is required to maintain a visual contact with a child in time-out or seclusion at all times.

f. If there is any type of emergency such as a fire alarm, or evacuation notification, children in time-out or seclusion shall follow the safety plan.

g. A child placed in time-out or seclusion shall not be in possession of belts, matches, weapons, or any other potentially harmful objects or materials that could present a risk or harm to the child.

2. Time-out or seclusion areas shall comply with the following:

a. Time-out or seclusion rooms shall not have locking capability.

b. Time-out or seclusion rooms shall not be located in closets, bathrooms, or unfurnished basements, attic's or locked boxes.

c. A time-out or seclusion room is not a bedroom, and temporary beds, or mattresses in these areas are not allowed. Time-out and seclusion shall not preclude a child's need for sleep, or normal scheduled sleep period.

d. All time-out or seclusion rooms shall measure at least 75 square feet with a ceiling height of at least 7 feet. They shall have either natural or mechanical ventilation and be equipped with a break resistant window, mirror or camera that allows for full observation of the room. Seclusion rooms shall have no hardware, equipment, or furnishings that obstruct observation of the child, or that present a physical hazard or a suicide risk. Rooms used for time out or seclusion shall be inspected and approved by the local fire department

G. The program's licensed clinical professional shall be responsible for supervision of the behavior management procedure.

R501-2-8. Rights of Consumers.
A. The program shall have a written policy for consumer rights to include the following:

1. privacy of information and privacy for both current and closed records,

2. reasons for involuntary termination and criteria for re-admission to the program,

3. freedom from potential harm or acts of violence to consumer or others,

4. consumer responsibilities, including household tasks, privileges, and rules of conduct,

5. service fees and other costs,

6. grievance and complaint procedures,

7. freedom from discrimination,

8. the right to be treated with dignity,

9. the right to communicate by telephone or in writing with family, attorney, physician, clergyman, and counselor or case manager except when contraindicated by the licensed clinical professional,

10. a list of people, whose visitation rights have been restricted through the courts,

11. the right to send and receive mail providing that security and general health and safety requirements are met,

12. defined smoking policy in accordance with the Utah Clean Air Act, and

13. statement of maximum sanctions and consequences, reviewed and approved by the Office of Licensing.

B. The consumer shall be informed of this policy to his or her understanding verbally and in writing. A signed copy shall be maintained in the consumer record.

R501-2-9. Personnel Administration.
A. The program shall have written personnel policies and procedures to include the following:

1. employee grievances,

2. lines of authority,

3. orientation and on-going training,

4. performance appraisals,

5. rules of conduct, and

6. sexual and personal harassment.

B. The program shall have a director, appointed by the governing body, who shall be responsible for management of the program and facility. The director or designated management person shall be available at all times during operation of program.

C. The program shall have a personnel file for each employee to include the following:

1. application for employment,

2. applicable credentials and certifications,

3. initial medical history if directed by the governing body,

4. tuberculin test if directed by the governing body,

5. food handler permit, where required by local health authority,

6. training record,

7. annual performance evaluations,

8. I-9 Form completed as applicable,

9. comply with the provisions of R501-14 and R501-18 for background screening, and

10. a signed copy of the current Department of Human Services Provider Code of Conduct.

D. The program shall follow a written staff to consumer ratio, which shall meet specific consumer and program needs. The staff to consumer ratio shall meet or exceed the requirements set forth in the applicable categorical rules as found in R501-3, R501-7, R501-8, R501-11, and R501-16.

E. The program shall employ or contract with trained or qualified staff to perform the following functions:

1. administrative,

2. fiscal,

3. clerical,

4. housekeeping, maintenance, and food service,

5. direct consumer service, and

6. supervisory.

F. The program shall have a written job description for each position, which includes a specific statement of duties and responsibilities and the minimum level of education, training and work experience required.

G. Treatment shall be provided or supervised by professional staff, whose qualifications are determined or approved by the governing body, in accordance with State law.

H. The governing body shall ensure that all staff are certified and licensed as legally required.

I. The program shall have access to a medical clinic or a physician licensed to practice medicine in the State of Utah.

J. The program shall provide interpreters for consumers or refer consumers to appropriate resources as necessary to communicate with consumers whose primary language is not English.

K. The program shall retain the personnel file of an employee after termination of employment, in accordance with accepted personnel practices.

L. A program using volunteers, substitutes, or student interns, shall have a written plan to include the following:

1. direct supervision by a program staff,

2. orientation and training in the philosophy of the program, the needs of consumers, and methods of meeting those needs,

3. background screening,

4. a record maintained with demographic information, and

5. signed copy of the current Department of Human Services Provider Code of Conduct.

M. Staff Training

1. Staff members shall be trained in all policies of the program, including the following:

a. orientation in philosophy, objectives, and services,

b. emergency procedures,

c. behavior management,

d. current program policy and procedures, and

e. other relevant subjects.

2. Staff shall have completed and remain current in a certified first aid and CPR, such as or comparable to American Red Cross.

3. Staff shall have current food handlers permit as required by local health authority.

4. Training shall be documented and maintained on-site.

R501-2-10. Infectious Disease.
The program shall have policies and procedures designed to prevent or control infectious and communicable diseases in the facility in accordance with local, state and federal health standards.

R501-2-11. Emergency Plans.
A. The program shall have a written plan of action for disaster and casualties to include the following:

1. designation of authority and staff assignments,

2. plan for evacuation,

3. transportation and relocation of consumers when necessary, and

4. supervision of consumers after evacuation or relocation.

B. The program shall educate consumers on how to respond to fire warnings and other instructions for life safety including evacuation.

C. The program shall have a written plan which personnel follow in medical emergencies and arrangements for medical care, including notification of consumer's physician and nearest relative or guardian.

R501-2-12. Safety.
A. Fire drills in non-outpatient programs, shall be conducted at least quarterly and documented. Notation of inadequate response shall be documented.

B. The program shall provide access to an operable 24-hour telephone service. Telephone numbers for emergency assistance, i.e., 911 and poison control, shall be posted.

C. The program shall have an adequately supplied first aid kit in the facility such as recommended by American Red Cross.

D. All persons associated with the program who have access to children or vulnerable adults and who also have firearms or ammunition shall assure that they are inaccessible to consumers at all times. Firearms and ammunition that are stored together shall be kept securely locked in security vaults or locked cases, not in glass fronted display cases. Firearms that are stored in display cases shall be rendered inoperable with trigger locks, bolts removed, or other disabling methods. Ammunition for those firearms shall be kept securely locked in a separate location. This does not restrict constitution or statutory rights regarding concealed weapons permits, pursuant to UCA 53-5-701 et seq.

R501-2-13. Transportation.
A. The program shall have written policy and procedures for transporting consumers.

B. In each program or staff vehicle, used to transport consumers, there shall be emergency information which includes at a minimum, the name, address and phone number of the program and an emergency telephone number.

C. The program shall have means, or make arrangement for, transportation in case of emergency.

D. Drivers of vehicles shall have a valid drivers license and follow safety requirements of the State.

E. Each vehicle shall be equipped with an adequately supplied first aid kit such as recommended by American Red Cross.

R501-2-14. Categorical Rules.
In addition to Core Rules, Categorical Rules are specific regulations which must be met for the following:

A. Child Placing Adoption Agencies R501-7,

B. Day Treatment R501-20,

C. Intermediate Secure Treatment Programs for Minors R501-16,

D. Outdoor Youth Programs R501-8,

E. Outpatient Treatment R501-21,

F. Foster Care R501-12,

G. Residential Treatment R501-19,

H. Residential Support R501-22,

I. Social Detoxification R501-11 and

J. Assisted Living for DSPD Residential R710.

R501-2-15. Single Service Program Rules.
Core Rules of the Office of Licensing do not apply to single service programs.

Single services program Rules are the regulations which must be met for the following:

A. Adult Day Care, which Rules are found in R501-13,

B. Adult Foster Care, which Rules are found in R501-17.

KEY
licensing, human services

Date of Enactment or Last Substantive Amendment
March 17, 2004

Notice of Continuation
November 21, 2007

Authorizing, Implemented, or Interpreted Law
62A-2-101 et seq.


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Rule converted into HTML by the Division of Administrative Rules.

For questions regarding the content or application of rules under Title R501, please contact the promulgating agency (Human Services, Administration, Administrative Services, Licensing). A list of agencies with links to their homepages is available at http://www.utah.gov/government/agencylist.html.

For questions about the rulemaking process, please contact the Division of Administrative (801-538-3764). Please Note: The Division of Administrative Rules is not able to answer questions about the content or application of these rules.


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The HTML version of this rule is a convenience copy. This information is made available on the Internet as a public service. Please see this disclaimer about information available from http://www.rules.utah.gov.

[_Jersey Girl]

See all the references to R501 regs throughout the pages I posted? Those are ADDITIONAL rules/regs that West Ridge has to comply with so long as they are applicable to the circumstances of the program.

And in case you missed it first time around, the accreditation organizations are yet another layer of criteria that the facility is held accountable to.

And the health department and credentialing/licensing organizations and so on and so forth ad nauseum.

The thing is, so far as I'm aware, is that because these regs are updated and revised, one needs to know what regs were in force when the alleged abuse took place. In other words, you can't hang the facility on the current standards of care if the alleged abuse took place under previously existing regs.

[_marg]

Those lists are not very helpful J.G. except to a lawyer or gov't staff. There is too much there and it's too difficult to see easily where the holes are. Obviously if places are being shut down for abuses though typically those are major abuses which are obvious, and if legislation is being looked into to improve upon the legal rights of under 18 year olds in such facilities then the current regulations aren't working effectively. Either they are are inadequate, or they aren't being implemented even though they perhaps are supposed to be, or state gov't personnel are not following up effectively.

by the way I'm still interested in whether or not an independent professional assessment is required by regulation..independent of parents and the school to warrant sending an individual to such a 'treatment' place.

[_Jersey Girl]

marg: Those lists are not very helpful J.G. except to a lawyer or gov't staff.

Me: The rules and regs are there to ensure a standard of quality of services, marg. To be more precise, they ensure a miminum standard of quality. When you add on the accreditation criteria and staff qualifications, that's where you raise up the quality. They are not only helpful, they are mandatory to anyone who works in or administers a Department of Human Services licensed program. The rules/regs that I work under are almost identical to those, the same rules/regs I functioned under as a program adminstrator. Every thing we do, where we do it and how we do it is regulated six ways till Sunday. The fact that West Ridge is a complex program in nature (educational, mental health components, etc), has to tell you how difficult it would be to conceal abuse. Remember that licensed programs are subject to regular DHS site inspections and unannounced site inspections. If I have to report accident/injury to the state, I'm only assuming that a residential youth treatment center/school/foster care licensure requires the same for West Ridge, and then some.

marg: There is too much there and it's too difficult to see easily where the holes are.

Me: Too much? Tell me about it. It's not too difficult to see where the holes are if you work in the rules/regs and are trained to interpret them. That's why...suspected cases of abuse/neglect in licensed programs needs to be reported to DHS. DHS is the expert on DHS rules/regs.

marg: Obviously if places are being shut down for abuses though typically those are major abuses which are obvious, and if legislation is being looked into to improve upon the legal rights of under 18 year olds in such facilities then the current regulations aren't working effectively. Either they are are inadequate, or they aren't being implemented even though they perhaps are supposed to be, or state gov't personnel are not following up effectively.

Me: All of the above. That and the fact that when you speak in terms of abuse/neglect, you need to be familiar with how abuse/neglect is defined in state statutes. I'll give you a demonstration in a new post.

marg: by the way I'm still interested in whether or not an independent professional assessment is required by regulation..independent of parents and the school to warrant sending an individual to such a 'treatment' place.

Me: I haven't seen admission requirements in the Utah Admin Code. I have, however, noticed that on West Ridge website, the conditions for enrollment/admissions includes input from "parents and professionals". I assume that "professionals" (since we're talking in terms of intake) means outside professionals such as medical, psych, etc.)

[_Jersey Girl]

I was going to give you a demo of something, but I want to show you this first, marg.

8. Incident or Crisis Intervention records

a. The program shall have written policies and procedures which includes: reporting to program manager, documentation, and management review of incidents such as deaths of consumers, serious injuries, fights, or physical confrontations, situations requiring the use of passive physical restraints, suspected incidents of abuse or neglect, unusual incidents, strip searches and other situations or circumstances affecting the health, safety, or well-being of consumers.

b. records shall include the following:

1) summary information,

2) date, time of emergency intervention,

3) action taken,

4) employees and management responsible and involved,

5) follow up information,

6) list of referrals,

7) signature and title of staff preparing report, and

8) records shall be signed by management staff.

c. the report shall be maintained in individual consumer records.

Those above, are required documentation in any situation listed in the first para. Those records are inspected during regular DHS inspections. I haven't seen yet, how often licensing inspects in Utah. In my state, programs are inspected every 3 years. That is to say, when DHS arrives for inspection, they will request 3 years of files.

Now watch how West Ridge is required to report it's own abuse/neglect, etc.

d. when an incident involves abuse, neglect, serious illness, violations of the Provider Code of Conduct or death of a consumer, a program shall:

1) notify the Office of Licensing, legally responsible person and any applicable agency which may include law enforcement.

2) a preliminary written report shall be submitted to the Office of Licensing within 24 hours of the incident.

Does West Ridge actually "rat" itself out to licensing in practice? I have no way of knowing that however, if there are hospitalizations and such (law enforcement engaged--student/resident got into a box of meds and overdosed--negligence because any meds are required to be in a locked box and perhaps the student/resident was supposed to be under direct adult supervision/monitoring ) , they have little choice but to report the incident in 24 hours to the state.

[_Jersey Girl]

Watch what I comment on in this excerpt of consumer rights. I'll pull out the excerpt and then comment in bold:


3. freedom from potential harm or acts of violence to consumer or others,

If you're housed with another student who is known to be violent and the student attacks you...that's a violation of the above.


4. consumer responsibilities, including household tasks, privileges, and rules of conduct,

5. service fees and other costs,

6. grievance and complaint procedures,

If you feel you've been violated, you have a right to file a grievance/complaint. It doesn't stipulate what the process is. Who does the complaint go to? Is it in house? Are parents notified?

7. freedom from discrimination,

If you're forced to wear color coded tshirts and if staff regularly demean the "work crew" students, that's a violation of the above.

8. the right to be treated with dignity,

If you're forced to go naked with just a blanket and walked around while tethered, and especially if staff verbally demean you in the process, that's a violation of the above.

9. the right to communicate by telephone or in writing with family, attorney, physician, clergyman, and counselor or case manager except when contraindicated by the licensed clinical professional,

Here's how a facility can prevent the students from talking to parents on the phone. The clinical professional can stop it.

[_marg]

All of this is good information and maybe Eric can get this on his site and maybe the word will get out to those still in what is and what is not acceptable. But it seems to me what's missing in this is there is no regulation which requires that student are informed or have access to an independent body where they can voice their complaints. If parents are informed to not listen to the youth, I think the school would likely make it difficult for youth to complain to a gov't body...but I'm sure few would even know how to do it, or that they could do it.

Quite frankly I don't trust the school to be honest in how it runs its program.