New Licensing Standards - 2960

DOC to license/certify:DOC to license/certify: ALLALL Group Residential Group Residential DetentionDetention SecureSecure Restrictive Restrictive

TechniquesTechniques CorrectionsCorrections ShelterShelter

DHS to license/certifyDHS to license/certify:: ALLALL Group ResidentialGroup Residential Chemical DependencyChemical Dependency Mental HealthMental Health ShelterShelter TransitionalTransitional Restrictive TechniquesRestrictive Techniques

Administrative Standards

ALLALL

2960.0010 Purpose And Applicability

Governs the licensing of Governs the licensing of providers of residential providers of residential care for children in out-care for children in out-

of-home placement.of-home placement.

2960.0010 - Providers

Unit of governmentUnit of government IndividualIndividual CorporationCorporation Limited liability Limited liability

corporationcorporation PartnershipPartnership Voluntary associationVoluntary association Other organization or Other organization or

entityentity Controlling individualControlling individual

2960.0010 Scope of the Rule

residential care {residential care {on a 24-hour on a 24-hour basisbasis

treatment treatment detention detention foster foster rehabilitation servicerehabilitation service

Juvenile sex offender treatment programs Juvenile sex offender treatment programs also governed by MN Rule also governed by MN Rule

Definitions

Time outTime out

Disciplinary room timeDisciplinary room time

License

Not transferable to Not transferable to anotheranother

individual/entityindividual/entity

locationlocation

2960.0030 - Application

Form providedForm provided applicant's name and address applicant's name and address name and location of the program name and location of the program geographic area to be served geographic area to be served license or certification being license or certification being

requested requested requested license capacityrequested license capacity age limitsage limits

Application

Organizational Organizational chart depicting chart depicting organizational organizational authorityauthority

2960.0030 Subpart 2B-4Application

The applicant must The applicant must provide: provide:

description of the description of the servicesservices

program's philosophyprogram's philosophy target populationtarget population program outcomesprogram outcomes

2960.0030 Subpart 2B-5Approvals

Health: Department of Health Health: Department of Health or local health inspectoror local health inspector

Local building code inspectorLocal building code inspector Local zoning authority Local zoning authority Fire: State Fire Marshal or Fire: State Fire Marshal or

approved local code inspectorapproved local code inspector or Document waiver or Document waiver

2060.0030 Subpart 2B-6Community Analysis

Description of the neighborhood Description of the neighborhood demographic characteristicsdemographic characteristics• racerace• socioeconomic characteristics socioeconomic characteristics • crime statisticscrime statistics• vehicle traffic vehicle traffic • proximity of the proposed proximity of the proposed

facility to schools, day care facility to schools, day care providersproviders

Neighborhood Demographics

• public transportationpublic transportation

• public and private public and private recreation facilitiesrecreation facilities

• neighborhood religious neighborhood religious and spiritual and spiritual organizationsorganizations

Neighborhood Demographics

• Information about local business Information about local business groups, community groups, block groups, community groups, block clubs, and service organizations. clubs, and service organizations.

2960.0030 Subpart 2B-7County Role in Screening

• The license holder must discuss The license holder must discuss with the county social services with the county social services agency of the county in which agency of the county in which the facility is located, the the facility is located, the facility's policy regarding the facility's policy regarding the county's role in screening county's role in screening facility residents. facility residents.

County Role in Screening

• The facility must The facility must document document the the contact with the contact with the county and any county and any agreement agreement between the between the county and the county and the facility regarding facility regarding the county's role the county's role in screening in screening facility residents. facility residents.

2960.0030 Subpart 2DFee

• An applicant for Department of An applicant for Department of Human Services Human Services licensure or licensure or certification mustcertification must pay a pay a licensing fee which is calculated licensing fee which is calculated according to parts 9545.2000 to according to parts 9545.2000 to 9545.2040. 9545.2040.

2960.0030 Subpart 3DOC Criteria

A.A. Primarily serve delinquent Primarily serve delinquent children who are at least ten years old, children who are at least ten years old, but younger than 21 years old, in a but younger than 21 years old, in a

residential setting;residential setting;

B. B. Operate a detention or group Operate a detention or group residential facility for children alleged residential facility for children alleged

to be delinquent;to be delinquent;

C. C. Be certified to provide residential Be certified to provide residential program services for residents who program services for residents who need correctional programming.need correctional programming.

2960.0030 Subpart 4DHS Criteria

A.A. Serve children through the age of 19 Serve children through the age of 19

B.B. Operate a group residential program Operate a group residential program with possible certifications in the with possible certifications in the areas of:areas of: chemical dependency treatmentchemical dependency treatment treatment for severe emotional treatment for severe emotional

disturbancedisturbance shelter servicesshelter services transitional servicestransitional services

2960.0030 Subpart 5Multiple Program

Certifications

The Department of Human Services The Department of Human Services and the Department of Corrections and the Department of Corrections

shall determine which shall determine which commissioner will license or certify commissioner will license or certify

the applicant.the applicant.

2060.0030 Subpart 6Variance Request

A.A. The part or parts of the standardThe part or parts of the standard

B.B. Reason for the varianceReason for the variance

C.C. Period of time of the variance Period of time of the variance

D.D. Written approval from the fire Written approval from the fire marshal, building inspector, or marshal, building inspector, or health authority as applicablehealth authority as applicable

E.E. Alternative equivalent measuresAlternative equivalent measures

2960.0030 Subpart 6EVariance Authority

Department of Human Services – Department of Human Services –

M. S. 245A.04, subdivision 9.M. S. 245A.04, subdivision 9.

Department of Corrections – Department of Corrections –

M. S. 241.021.M. S. 241.021.

The decision of the commissioner of The decision of the commissioner of human services or corrections to grant human services or corrections to grant or deny a variance request is final and or deny a variance request is final and not subject to appeal under Minnesota not subject to appeal under Minnesota Statutes, Chapter 14.Statutes, Chapter 14.

Denial of Application

compliance with laws or rules compliance with laws or rules health or safety deficiencies health or safety deficiencies hazardous condition hazardous condition fire, building, zoning, health fire, building, zoning, health

approvalapproval

Denial of ApplicationFailure to comply may be indicated

by: Department of Education: Department of Education:

lack of approval of on-site lack of approval of on-site schoolschool

Disqualification of the Disqualification of the applicant/ controlling applicant/ controlling individual individual

Failure to submit a completed Failure to submit a completed applicationapplication

DHS Denial = DOC DenialDHS Denial = DOC Denial

2960.0030 Subpart 9Drug and Alcohol Use

Prohibited

Includes prescription Includes prescription drugsdrugs

Policy requiredPolicy required Training in the drug policyTraining in the drug policy

2960.0030 Subpart 11Policy and Procedure Review

The license holder The license holder must submit the must submit the facility's program facility's program policies and policies and procedures to the procedures to the commissioner of commissioner of human services or human services or corrections for corrections for review.review.

2960.0030 Subpart 11 License/Certification Terms

name of the license holdername of the license holder address of the programaddress of the program effective date and expiration dateseffective date and expiration dates type of licensetype of license maximum number and ages of maximum number and ages of

residentsresidents any special conditions of licensureany special conditions of licensure certification(s) grantedcertification(s) granted

Subpart 12Licensing Actions

Department of Human Services: Department of Human Services: Minnesota Statutes, Chapter Minnesota Statutes, Chapter 245A. 245A.

Department of Corrections: Department of Corrections:

Minnesota Statutes, Section Minnesota Statutes, Section 241.021.241.021.

2060.0040Statement of Intended Use

Target population served:Target population served: cultural backgroundcultural background gendergender license holders expertise and license holders expertise and

qualifications to provide the qualifications to provide the services services

ageage medically fragile conditionmedically fragile condition

Statement of Intended Use

legal status: chips, delinquency, legal status: chips, delinquency, voluntary placement, self-voluntary placement, self-referralreferral

primary needs of residents met primary needs of residents met in the licensed facilityin the licensed facility

resident services provided by resident services provided by programs outside the settingprograms outside the setting

Statement of Intended Use

Specific extent and limitations of Specific extent and limitations of the programthe program

Restrictive procedures-extent and Restrictive procedures-extent and limitationslimitations

Involvement of the resident's Involvement of the resident's cultural or ethnic community to cultural or ethnic community to ensure culturally appropriate careensure culturally appropriate care

2960.0500 - Basic Rights

reasonable observance of reasonable observance of cultural and ethnic practice and cultural and ethnic practice and religion religion

reasonable degree of privacy reasonable degree of privacy participate in development of the participate in development of the

resident's treatment and case resident's treatment and case plan plan

positive and proactive adult positive and proactive adult guidance, support, and guidance, support, and supervision supervision

2960.0500 - Basic Rights

free from abuse, neglect, free from abuse, neglect, inhumane treatment, and inhumane treatment, and sexual exploitation sexual exploitation

adequate medical care adequate medical care nutritious and sufficient meals nutritious and sufficient meals

and sufficient clothing and and sufficient clothing and housing housing

clean, safe surroundingsclean, safe surroundings public educationpublic education

2960.0500 - Basic Rights

Reasonable communication Reasonable communication and visitation, which may and visitation, which may include:include: AttorneyAttorney

TherapistTherapist PhysicianPhysician Religious-Religious-

Spiritual Spiritual advisoradvisor

Case Case managermanager

ParentParent Extended Extended

family family membersmembers

SiblingsSiblings Legal Legal

guardianguardian CaseworkerCaseworker

2960.0500 - Basic Rights

access to protection and access to protection and advocacy services advocacy services

state-appointed ombudsman state-appointed ombudsman personal property personal property courteous and respectful courteous and respectful

treatment treatment Minnesota Statutes, Sections Minnesota Statutes, Sections

144.651 Patients Bill of Rights 144.651 Patients Bill of Rights

253B.03 Rights of Patients253B.03 Rights of Patients

2960.0500 - Basic Rights

grievance procedure grievance procedure

free from restraint or seclusion used for a free from restraint or seclusion used for a purpose other than to protect the purpose other than to protect the resident from imminent danger to self or resident from imminent danger to self or others; others; except for the use of disciplinary except for the use of disciplinary room time as it is allowed in the room time as it is allowed in the correctional facility's discipline plancorrectional facility's discipline plan

free from bias and harassment regarding free from bias and harassment regarding race, gender, age, disability, spirituality, race, gender, age, disability, spirituality, and sexual orientation and sexual orientation

2960.0500 - Basic Rights

nutritious and sufficient meals nutritious and sufficient meals and sufficient clothing and and sufficient clothing and housing housing

clean, safe surroundingsclean, safe surroundings

public educationpublic education

2960.0500License Holder Duties

provide basic services provide basic services develop operational policies develop operational policies

and procedures which and procedures which correspond to the basic rights correspond to the basic rights

give the resident a written copy give the resident a written copy of the resident's basic rightsof the resident's basic rights

2960.0500Basic Rights Information

explain to the resident in a explain to the resident in a language that the resident can language that the resident can understandunderstand

rights related to the resident's rights related to the resident's care explained within 24 hours care explained within 24 hours of admissionof admission

procedures which correspond to procedures which correspond to the basic rights the basic rights

2960.0500Basic Rights Information

tell the resident's parent, guardian, or tell the resident's parent, guardian, or custodian within a reasonable time custodian within a reasonable time that the information regarding rules is that the information regarding rules is available available

Post resident rights in the:Post resident rights in the: Residents and staff areaResidents and staff area Staff stationStaff station

how to contact the appropriate state-how to contact the appropriate state-appointed ombudsman: name, appointed ombudsman: name, address, and telephone numberaddress, and telephone number

2960.0060Statement of Program

Outcomes written policies that identify written policies that identify

program outcomes and promote program outcomes and promote the resident's development as a the resident's development as a physically and mentally healthy physically and mentally healthy person person

the program services offered by the program services offered by the license holder must be the license holder must be consistent with the resident's consistent with the resident's case plancase plan

2960.0060

Outcome Measures

the measurement must document the the measurement must document the degree to which the license holder's degree to which the license holder's services provided to the resident, or the services provided to the resident, or the resident's family, have been successful in resident's family, have been successful in achieving the intended outcome of the achieving the intended outcome of the services offered to the resident and the services offered to the resident and the resident's familyresident's family

measure the success in achieving measure the success in achieving statement outcomes statement outcomes

specific factors as required by DHS/DOCspecific factors as required by DHS/DOC

2960.0060Outcome Measures

specific factors as required by specific factors as required by DHS/DOCDHS/DOC

the program services offered by the program services offered by the license holder must be the license holder must be consistent with the resident's consistent with the resident's case plancase plan

2960.0060Program Evaluation

annually evaluate strengths and annually evaluate strengths and weaknesses of the program using at weaknesses of the program using at least the following performance least the following performance indicators: indicators: accidents accidents use of restrictive procedures use of restrictive procedures grievances grievances adverse maltreatment findings adverse maltreatment findings

and legal actions against the and legal actions against the license holderlicense holder

2960.0060

Program Evaluation

satisfaction survey results satisfaction survey results critical incidentscritical incidents

Must be kept for two licensing Must be kept for two licensing periodsperiods

Must use the program evaluation Must use the program evaluation findings to make program findings to make program improvementimprovement

Independent Program Audit

comply and cooperate with comply and cooperate with independent program audits independent program audits DHS/DOC DHS/DOC

comply with the findingscomply with the findings document with operational policies document with operational policies

and procedures and procedures retain demographic information on a retain demographic information on a

resident resident document the extent of the resident's document the extent of the resident's

program completion on designated program completion on designated form form

Community Involvement

Board of directors or advisory Board of directors or advisory committee that represents the committee that represents the interests, concerns, and needs of interests, concerns, and needs of the residents and community the residents and community served and comply with the served and comply with the findings findings

The Board or advisory committee The Board or advisory committee must meet at least annuallymust meet at least annually

Community Involvement The license holder meet at least The license holder meet at least

annually with community annually with community regarding:regarding: the nature of the programthe nature of the program types of residents servedtypes of residents served results of the services the program results of the services the program

provided to residentsprovided to residents number of residents served in the number of residents served in the

past 12 monthspast 12 months the number of residents likely to be the number of residents likely to be

served in the next 12 months.served in the next 12 months.

2960.0070Admission Process

The license holder must have The license holder must have written specific identifiable written specific identifiable admission criteria consistent with admission criteria consistent with the statement of intended use.the statement of intended use. The License holder must:The License holder must:

Have resources and qualified Have resources and qualified staff to respond to residents staff to respond to residents with disabilities with disabilities

Admission Process

The license holder must:The license holder must:

Admission Process

Consider placing a female Consider placing a female resident when there are few resident when there are few other female residents in the other female residents in the facilityfacility

Whether the facility could Whether the facility could offer gender-specific offer gender-specific services for female residentsservices for female residents

Admission Process

Consider placing a male resident Consider placing a male resident when there are few other male when there are few other male residents in the facilityresidents in the facility

Whether the facility could offer Whether the facility could offer gender-specific services for gender-specific services for male residentsmale residents

Seek approval of the Seek approval of the commissioner of corrections to commissioner of corrections to serve those over age 19serve those over age 19

2960.0070 Subpart 3Admission Documentation

Within 5 working days after Within 5 working days after admissionadmission legal authority for resident legal authority for resident

placementplacement date and time of admissiondate and time of admission name and nicknamesname and nicknames last known address and permanent last known address and permanent

addressaddress name, address, and telephone name, address, and telephone

number of parents, guardian, and number of parents, guardian, and advocateadvocate

Admission Documentation

date and place of birthdate and place of birth race or cultural heritagerace or cultural heritage languages the resident speaks languages the resident speaks

and writesand writes tribal affiliationtribal affiliation

Admission Documentation

description of presenting description of presenting problemproblem

medical problemsmedical problems circumstances leading to circumstances leading to

admissionadmission mental health concernsmental health concerns safety concerns: assaultive safety concerns: assaultive

behavior, victimization behavior, victimization concernsconcerns

Admission Documentation

resident assets and strengthsresident assets and strengths and and related information from the related information from the resident, family, and concerned resident, family, and concerned persons persons

name, address, and telephone name, address, and telephone number for the last educational number for the last educational program contact person program contact person

spiritual or religious affiliation spiritual or religious affiliation placing agency's case plan goals placing agency's case plan goals

for the residentfor the resident

2960.0070 Subpart 4Resident Property

inventory the resident's personal inventory the resident's personal property (including clothing) property (including clothing)

resident and the license holder sign resident and the license holder sign the inventory upon admissionthe inventory upon admission (resident refusal: two staff sign)(resident refusal: two staff sign)

ensure resident use and availability ensure resident use and availability of personal funds/property unless of personal funds/property unless restrictions justified in treatment restrictions justified in treatment planplan

2960.0070 Subpart 4Resident Funds

Whenever the license holder assists Whenever the license holder assists with residents funds they must:with residents funds they must: Keep separate facility and resident Keep separate facility and resident

fundsfunds When safekeeping funds/propertyWhen safekeeping funds/property

Document receipt and disbursement Document receipt and disbursement Must have signatures of resident/ Must have signatures of resident/

conservator/payeeconservator/payee Return to the resident funds/property Return to the resident funds/property

within 3 working days request.within 3 working days request.

Funds-Must Nots

borrow money from a residentborrow money from a resident purchase personal items from a purchase personal items from a

residentresident sell merchandise, except canteen-sell merchandise, except canteen-

type servicetype service sell personal services to a residentsell personal services to a resident require a resident to buy items for require a resident to buy items for

which the facility is reimbursed which the facility is reimbursed use of funds that would violate part use of funds that would violate part

9505.0425, subpart 3.9505.0425, subpart 3.

2960.0070 - Screenings Required

health screening health screening history of abuse history of abuse vulnerability to abusevulnerability to abuse potential for self-injurypotential for self-injury current medicationscurrent medications most recent physician's/clinic'smost recent physician's/clinic's

namename addressaddress numbernumber

Screenings Required

mental health screening mental health screening education screening Minnesota education screening Minnesota

Statutes, section 125A.52 Statutes, section 125A.52 chemical abuse or chemical chemical abuse or chemical

dependency screeningdependency screening (The license holder will provide or (The license holder will provide or

contact the resident's case contact the resident's case manager, if applicable, to arrange manager, if applicable, to arrange a screening to determine if the a screening to determine if the resident is chemically dependent)resident is chemically dependent)

Screenings Required

screening for sexually abusive screening for sexually abusive behavior; behavior; written risk management plans written risk management plans

(resident, other residents, staff, (resident, other residents, staff, community) community)

vulnerability assessment vulnerability assessment culture culture gender-specific needs screening gender-specific needs screening psychosocial needs of the resident psychosocial needs of the resident needs regarding the gender of the needs regarding the gender of the

staffstaff

2960.0070 Subpart 5CScreening Time Lines

other screenings: other screenings: begin - 3 working begin - 3 working days, completed - 6 working daysdays, completed - 6 working days

health screening - health screening - within 24 hours of within 24 hours of admissionadmission

May substitute screening or May substitute screening or assessment completed within the last assessment completed within the last 6 months6 months if on fileif on file no reason to believe condition has no reason to believe condition has

changedchanged

Screening Time Lines

If a resident is transferred from If a resident is transferred from another facility - Request of sending another facility - Request of sending facility records needs to be facility records needs to be immediate*immediate*

Screenings must include Screenings must include documenteddocumented inquiries regarding the degree to inquiries regarding the degree to which the family desires to be which the family desires to be involved during the residents stayinvolved during the residents stay

*(N/A to residents on detention status *(N/A to residents on detention status for less than 6 working days)for less than 6 working days)

2960.0080 - Basic Services

Must provide services that fulfill the Must provide services that fulfill the basic rights of the residentbasic rights of the resident

Must have stated objectives and Must have stated objectives and measurable outcomesmeasurable outcomes

Must coordinate and ensure off-Must coordinate and ensure off-campus program services if campus program services if applicableapplicable

Must meet the basic needs of the Must meet the basic needs of the residents served by the facility.residents served by the facility.

2960.0080 Subpart 3Cooperation

Cooperate with case Cooperate with case manager/other appropriate manager/other appropriate parties in creating and parties in creating and delivering basic servicesdelivering basic services residentresident parentparent legal representativelegal representative case managercase manager treatment teamtreatment team

2960.0080 Subpart 3AImplementation of Case Plan

coordinate facility plan with placing coordinate facility plan with placing agency's case plan agency's case plan

work with the placing agency to work with the placing agency to identify:identify: projected length of stay projected length of stay conditions for family reunification conditions for family reunification

or permanency plan or permanency plan license holder actions to help carry license holder actions to help carry

out the planout the plan

B - Identify and Share Information

(Per case plan)(Per case plan) about the resident's treatment about the resident's treatment about major treatment outcome about major treatment outcome

plansplans including attaining including attaining

developmentally developmentally necessary/appropriate life skillsnecessary/appropriate life skills

communicate as necessary with communicate as necessary with previous school and current schoolprevious school and current school

D - Identify and Share Information

report the resident's behaviors report the resident's behaviors and other important information and other important information to the placing agencyto the placing agency

recommend case plan changes to recommend case plan changes to the placing agency;the placing agency;

F - Identify and Share Information

Share information (as allowed Share information (as allowed by law)by law) resident's therapistresident's therapist physicianphysician professional treating the professional treating the

residentresident agencies providing discharge agencies providing discharge

servicesservices

Identify and Share Information

Provide records to Provide records to parent/guardianparent/guardian

Respond to court orders and Respond to court orders and authorized information release authorized information release requests in 3 business daysrequests in 3 business days

2960.0080 Subpart 4Facility Rules/Due Process

communicate verbally to the communicate verbally to the resident and resident and in writingin writing facility's facility's rules and due process systemrules and due process system

acceptable and unacceptable acceptable and unacceptable behaviors and the reasons why behaviors and the reasons why

consequences applied in consequences applied in recognizing and rewarding recognizing and rewarding acceptable behavior and modifying acceptable behavior and modifying unacceptable behaviorunacceptable behavior

2960.0080 Facility Rules/Due Process

circumstances, if any, that will circumstances, if any, that will result in time-out or restrictive result in time-out or restrictive procedure use procedure use

due process system for due process system for disciplinary consequencesdisciplinary consequences

relationship of IEP discipline relationship of IEP discipline recommendations to the facilitiesrecommendations to the facilities

2960.0080 Subpart 5Discipline Policy/Procedures

Policies and procedure must Policies and procedure must consider:consider: Abuse history Abuse history Developmental needsDevelopmental needs Culture needsCulture needs Disability needsDisability needs Gender needsGender needs

2960.0080 Subpart 5Prohibition of Corporal

Punishment • Rough handlingRough handling• ShovingShoving• Ear or hair Ear or hair

pullingpulling• ShakingShaking• SlappingSlapping• KickingKicking

• KickingKicking• BitingBiting• PinchingPinching• HittingHitting• Throwing Throwing

ObjectsObjects• SpankingSpanking

2960.0080 Prohibition of Verbal Abuse • name callingname calling• derogatory statements about the derogatory statements about the

resident/ family resident/ family • racerace• gendergender• disabilitydisability• sexual orientationsexual orientation• religionreligion• cultureculture

2960.0080 Prohibition of Verbal Abuse

• statements intended to statements intended to • shameshame• threatenthreaten• humiliatehumiliate• frightenfrighten

2960.0080 Discipline Prohibited

punishment for lapses in toilet punishment for lapses in toilet habits, bed wetting and soiling habits, bed wetting and soiling

withholding of:withholding of: drinking waterdrinking water clothingclothing hygiene facilitieshygiene facilities normal sleeping conditionsnormal sleeping conditions nutritious dietnutritious diet

2960.0080 Subpart 5A-4 Discipline Prohibited

Withholding of:Withholding of: proper lightingproper lighting educational serviceseducational services exercise activitiesexercise activities ventilation and proper temperatureventilation and proper temperature mailmail family visitsfamily visits positive reinforcementpositive reinforcement medical care medical care nurturingnurturing

2960.0080 Discipline

However, a resident who However, a resident who destroys bedding or clothing or destroys bedding or clothing or uses these or other items to uses these or other items to harm self or others, may be harm self or others, may be deprived according to the deprived according to the residents case planresidents case plan

2960.0080 Discipline Prohibited

assigning work that is dangerous assigning work that is dangerous or not consistent with the or not consistent with the residents case planresidents case plan

disciplining one resident for the disciplining one resident for the unrelated behavior or action of unrelated behavior or action of another, except recognized another, except recognized treatment program peer group treatment program peer group restrictionsrestrictions

2960.0080Discipline Prohibited

Inappropriate use of restrictive Inappropriate use of restrictive techniques or procedurestechniques or procedures as punishmentas punishment for the convenience of stafffor the convenience of staff as compensation for in as compensation for in

adequate staffingadequate staffing as a substitute for program as a substitute for program

servicesservices

2960.0080 Subpart 5A-9Discipline Prohibited

communication restrictions beyond communication restrictions beyond treatment/case plan treatment/case plan

prohibited punishments such as:prohibited punishments such as:• extended time in uncomfortable or fixed extended time in uncomfortable or fixed

positions positions • marchmarch• standstand• kneel kneel

delegation of authority to punish another delegation of authority to punish another residentresident

2960.0080Discipline

License holder must comply License holder must comply with 9525.2700, subpart 2, item with 9525.2700, subpart 2, item G, regarding the use of aversive G, regarding the use of aversive or deprivation procedures with a or deprivation procedures with a resident who has mental resident who has mental retardation or a related retardation or a related condition condition

2960.0080 Subpart 5DTime-out Requirements

time-out must be used as a non-time-out must be used as a non-emergency behavior emergency behavior management technique which is management technique which is used to intervene in a resident's used to intervene in a resident's undesirable behavior and to allow undesirable behavior and to allow the resident to reflect and the resident to reflect and become calm before returning to become calm before returning to ongoing activities at the facility ongoing activities at the facility

2960.0080Time-out Requirements

Must be usedMust be used under the direction of: under the direction of: mental health professionalmental health professional facility directorfacility director program managerprogram manager

Must be consistent with treatment planMust be consistent with treatment plan A staff must escort a resident to safe A staff must escort a resident to safe

unlocked room or other separate living unlocked room or other separate living spacespace

Staff must assess Staff must assess at least every 30 at least every 30 minutesminutes

2960.0080Training Requirement Time-

OutStaff must be trained in the Staff must be trained in the

following:following: the needs and behaviors of the needs and behaviors of

residentsresidents building relationships with residentsbuilding relationships with residents alternatives to time-outalternatives to time-out de-escalation methodsde-escalation methods avoiding power struggles with avoiding power struggles with

residentsresidents documentation standards for the documentation standards for the

use of time-outuse of time-out

2960.0080Time-out Requirements

Treatment team review of time-out Treatment team review of time-out use for each resident during the use for each resident during the treatment plan reviewtreatment plan review

Document use of time-out in recordDocument use of time-out in record • cause factorscause factors• circumstances circumstances • resident's response resident's response • resident's ability to de-escalate resident's ability to de-escalate • acceptable behavior after time-outacceptable behavior after time-out

2960.0080 Subpart 5ECertification Required

Staff must have restrictive Staff must have restrictive procedures certification procedures certification (2960.0710) prior to the use of (2960.0710) prior to the use of restrictive procedures with a restrictive procedures with a residentresident

2960.0080 Subpart 6Daily Resident Activities

written schedule of daily written schedule of daily activitiesactivities

know the whereabouts of each know the whereabouts of each residentresident

immediately notify the referring immediately notify the referring or placing agency of runaway / or placing agency of runaway / missing residentmissing resident

2960.0080 Subpart 7Culturally Appropriate Care

document culturally appropriate document culturally appropriate care providedcare provided

opportunities to associate with opportunities to associate with culturally and racially similar culturally and racially similar adults, peers, and role modelsadults, peers, and role models

opportunities to participate in opportunities to participate in positive experiences related to the positive experiences related to the resident's cultural and racial groupresident's cultural and racial group

2960.0080Culturally Appropriate Care culturally appropriate program culturally appropriate program

services that address the needs of all services that address the needs of all residents in careresidents in care

cultural sensitivity, including the cultural sensitivity, including the provision of interpreters and English provision of interpreters and English language skill development*language skill development*

* ( Laws 1995, Chapter 226, article 3, * ( Laws 1995, Chapter 226, article 3, section 60, subdivision 2, paragraph (2), section 60, subdivision 2, paragraph (2), clause (v).)clause (v).)

2960.0080 Subpart 8 Spirituality

Opportunity for voluntary participation in Opportunity for voluntary participation in spirituality services, activities, and spirituality services, activities, and counseling counseling

A resident must not be required to attend A resident must not be required to attend the services or activitiesthe services or activities

Service/activities must be held in a location Service/activities must be held in a location which allows choice which allows choice

Attendance or lack of attendance cannot Attendance or lack of attendance cannot affect rights/privilege affect rights/privilege

Must arrange spiritual counseling if Must arrange spiritual counseling if

requested by a resident.requested by a resident.

2960.0080 Subpart 8Spirituality

Accommodate a resident or a Accommodate a resident or a resident's family's request regarding resident's family's request regarding spiritual needs, spiritual needs,

If unable: document the reason. If unable: document the reason. Within reasonable safety and security Within reasonable safety and security

rulesrules Allow private interviews or counseling Allow private interviews or counseling

regarding spiritual, personal, or regarding spiritual, personal, or family problems family problems

Opportunity to meet with a spiritual Opportunity to meet with a spiritual or religious person of their choice.or religious person of their choice.

2960.0080 Subpart 9

Educational Services

Facilitate the resident's admission Facilitate the resident's admission to an accredited public school or to an accredited public school or other lawful school other lawful school

Facility- on grounds schoolFacility- on grounds school Year-round basis, if required by Year-round basis, if required by

lawlaw Approval of the education Approval of the education

services from the Department services from the Department of Education of Education

Cooperate with the school Cooperate with the school district. district.

Educational Services

Facilitate the resident's school Facilitate the resident's school attendance and homework attendance and homework activitiesactivities

Inquire at least every 90 daysInquire at least every 90 days Report educational problems to Report educational problems to

the case manager or placing the case manager or placing agencyagency

Chemical health education to Chemical health education to the resident with inappropriate the resident with inappropriate chemical use problemchemical use problem

2960.0080 Subpart 11Health and Hygiene Services

Timely access toTimely access to:: qualified persons that meet the qualified persons that meet the

resident's needs resident's needs basicbasic emergencyemergency specialized medicalspecialized medical mental healthmental health dental care dental care treatment servicestreatment services

Health and Hygiene Services: Pregnant Resident

Ongoing and appropriate Ongoing and appropriate prenatal care from a medically prenatal care from a medically licensed personlicensed person

Prenatal, postnatal, and Prenatal, postnatal, and parenting information parenting information

Health and Hygiene Services

Ensure provision of Ensure provision of appropriate medical and appropriate medical and dental services dental services

Compliance with medical or Compliance with medical or dental insurance dental insurance

2960.0080 Subpart 11Health Provider Gender

Consideration of resident's request Consideration of resident's request for a male or female health care for a male or female health care providerprovider

If a female resident requests a If a female resident requests a female health care provider, and one female health care provider, and one is not available, the license holder is not available, the license holder must request permission from the must request permission from the health care provider that an adult health care provider that an adult female be allowed to be present female be allowed to be present during the health care procedure during the health care procedure

Likewise for male residentsLikewise for male residents

2960.0080 Subpart 11BHealth Records

Illness reported by the residentIllness reported by the resident

Action taken by the license Action taken by the license holderholder

Date of the resident's medical, Date of the resident's medical, psychological, or dental carepsychological, or dental care

2960.0080 Subpart 11

Medication Plan Maintaining stock supplies of Maintaining stock supplies of

prescription drugs at the prescription drugs at the facility is prohibited. facility is prohibited.

Medication plan (developed Medication plan (developed with medically licensed person) with medically licensed person) for the safe storage and for the safe storage and delivery of medicine. delivery of medicine.

2960.0080 Subpart 11D-1

Medication Plan Contact a newly admitted residents Contact a newly admitted residents

prescribing medically licensed prescribing medically licensed person to verifyperson to verify:: instructions about how to instructions about how to

administer the medication administer the medication symptoms that the medication will symptoms that the medication will

alleviatealleviate the symptoms that would warrant the symptoms that would warrant

consultation with the physicianconsultation with the physician

2960.0080 Subpart 11D-2Medication Plan

Documentation of attempts to Documentation of attempts to contact the child's parent or contact the child's parent or guardian to seek permission for the guardian to seek permission for the facility to administer the facility to administer the medication.medication. If permission is denied and the If permission is denied and the

parent has the legal right to deny parent has the legal right to deny permission, then the medication permission, then the medication will be discontinued under the will be discontinued under the supervision of a physician unless a supervision of a physician unless a court order to administer the court order to administer the medication is obtained.medication is obtained.

Medication Plan

List of the side effects of List of the side effects of medicationmedication

Document and follow the Document and follow the prescribing physician's prescribing physician's directions for monitoring directions for monitoring medications used by the medications used by the residentresident

2960.0080 Subpart 11-5Medication Training

Medication assistance training (non Medication assistance training (non medically licensed person)medically licensed person)

Medication aide program completion Medication aide program completion Postsecondary institutionPostsecondary institution Formalized training program Formalized training program

• Offered by the license holder Offered by the license holder • Taught by a registered nurseTaught by a registered nurse

Documented in staff personnel Documented in staff personnel recordsrecords

Medication Review

MonthlyMonthly medication administration medication administration review by medically licensed review by medically licensed person person

Resident prescription drug recordResident prescription drug record quantity initially received from the quantity initially received from the

pharmacypharmacy amount of medication givenamount of medication given dosagedosage time takentime taken refusal to take prescription refusal to take prescription

medicationmedication

Medication

Prescription medicine belonging to Prescription medicine belonging to a resident must be given to the a resident must be given to the resident's parent or legal guardian resident's parent or legal guardian upon the resident's release or must upon the resident's release or must be disposed of according to a be disposed of according to a pharmacy-approved plan. pharmacy-approved plan.

The license holder must note the The license holder must note the disposition of the resident's disposition of the resident's medicine in the resident's file.medicine in the resident's file.

Medication

Upon release, the license holder Upon release, the license holder must give a resident who is 18 must give a resident who is 18 years of age or older the years of age or older the prescription medication prescription medication prescribed for the resident.prescribed for the resident.

2960.0080 Subpart 12Food and Nutrition

Balanced diet consisting of foods Balanced diet consisting of foods and beverages:and beverages: palatablepalatable adequate quantity and varietyadequate quantity and variety prepared and served at prepared and served at

appropriate temperaturesappropriate temperatures• prevent food-borne illnessprevent food-borne illness• conserve nutritional valueconserve nutritional value

Food and Nutrition

Provide a medically prescribed Provide a medically prescribed diet, if ordereddiet, if ordered

Offer a diet that does not Offer a diet that does not conflict with the resident's conflict with the resident's religious or cultural dietary religious or cultural dietary regimen.regimen.

2960.0080 Subpart 13Clothing, Bedding, and

Laundry adequate amount of clean adequate amount of clean

clothing appropriate for the clothing appropriate for the seasonseason

appropriate sized, clean, fire-appropriate sized, clean, fire-retardant mattress*retardant mattress*

two sheets or one sheet and two sheets or one sheet and clean mattress coverclean mattress cover

sufficient clean blankets to sufficient clean blankets to provide appropriate warmth for provide appropriate warmth for the seasonthe season

Clothing, Bedding, and Laundry

One pillow and one pillowcase that is One pillow and one pillowcase that is antiallergenicantiallergenic

Adequate bath towels and washclothsAdequate bath towels and washcloths Bedding and linens furnished upon Bedding and linens furnished upon

admissionadmission Bedding and linens cleaned once a Bedding and linens cleaned once a

week or moreweek or more No worn out/unfit bedding and linensNo worn out/unfit bedding and linens

2960.0080 Subpart 14Emergency Plan

Develop a written emergency Develop a written emergency plan: plan: firefire natural disasternatural disaster serious illnessserious illness severe weathersevere weather disappearance of a residentdisappearance of a resident law enforcement/emergency law enforcement/emergency

response situation.response situation.

2960.0080 Subpart 14Emergency Plan

Developed with the advice of local Developed with the advice of local fire and emergency response fire and emergency response authorities. Including emergency authorities. Including emergency care/Special assistance if needed care/Special assistance if needed by a resident.by a resident.

Staff and residents plan review Staff and residents plan review every six monthsevery six months..

Compliance documentation of the Compliance documentation of the plan and the review.plan and the review.

Subpart 15Communication and

Visitation Written communications and Written communications and

visiting policy visiting policy Use of the telephoneUse of the telephone MailMail Adaptive communications Adaptive communications

devicesdevices Other means of communication, Other means of communication,

compatible with needs/case plancompatible with needs/case plan

Subpart 16Communication and

Visitation

No restriction of the parents No restriction of the parents visiting rights beyond case visiting rights beyond case plan/court order plan/court order limitations(M.S.260C.201) limitations(M.S.260C.201)

Accommodation of parent's Accommodation of parent's scheduleschedule

Subpart 17Critical Incident/Maltreatment

Reports Report critical incidents to Report critical incidents to

licensing within 10 days on licensing within 10 days on approved formsapproved forms

Maintain records of all critical Maintain records of all critical incidents on file in the facilityincidents on file in the facility

Comply with mandatory Comply with mandatory maltreatment reporting*maltreatment reporting*

* (Minnesota Statutes, sections 626.556 * (Minnesota Statutes, sections 626.556 and 626.557)and 626.557)

Maltreatment Policy Policies and procedures to Policies and procedures to

follow if maltreatment is follow if maltreatment is suspectedsuspected

Annual review of maltreatment Annual review of maltreatment policiespolicies

Policy revision: Policy revision: comply with changes in lawcomply with changes in law meet identified needsmeet identified needs review of incident & quality review of incident & quality

assurance reports indicate a assurance reports indicate a change is warrantedchange is warranted

2060.0080 Subpart 18Resident & Family Grievance

Procedures

Develop & follow written grievance policyDevelop & follow written grievance policy Allow others in residents life to make a Allow others in residents life to make a

formal complaint or suggestion or formal complaint or suggestion or express concern about any aspect of express concern about any aspect of the residents carethe residents care

Staff may not influence a residents Staff may not influence a residents statement about the facility in a statement about the facility in a grievancegrievance

Resident & Family Grievance Procedures

The written grievance procedure The written grievance procedure must require:must require: Must give resident forms and Must give resident forms and

assistance to file the grievanceassistance to file the grievance Identify the person authorized to Identify the person authorized to

resolve the complaint & appeal resolve the complaint & appeal informationinformation

Upon request, the grievance must Upon request, the grievance must be carried to the highest be carried to the highest administration or placing agencyadministration or placing agency

Subpart 19Family Involvement

If family involvement is a goal in a If family involvement is a goal in a resident's case plan, the license resident's case plan, the license holder must:holder must: list procedures and program plans list procedures and program plans

which are in accordance with a which are in accordance with a resident's case plan, resident's case plan,

facilitate the involvement of the facilitate the involvement of the resident's family or other resident's family or other concerned adult, in the resident's concerned adult, in the resident's treatment or program activities.treatment or program activities.

2960.0090 Subpart 2No Eject Policy

Written no eject policyWritten no eject policy Confer with other interested Confer with other interested

persons to review the issuespersons to review the issues Review process must not exceed Review process must not exceed

five working daysfive working days Any additional strategies to resolve Any additional strategies to resolve

the issues and prevent dischargethe issues and prevent discharge

No Eject Policy

If discharge is warranted the reasons If discharge is warranted the reasons for it and the alternatives considered for it and the alternatives considered or attempted must be documented or attempted must be documented

A resident may be temporarily A resident may be temporarily removed from the facility during the removed from the facility during the five-day review periodfive-day review period

This subpart does not apply to a This subpart does not apply to a resident removed by the placing resident removed by the placing authority or a parent or guardianauthority or a parent or guardian

Subpart 3Property Return

The license holder must return all of the The license holder must return all of the resident's personal property to the resident's personal property to the residentresident

Signed receipt upon discharge, unless Signed receipt upon discharge, unless prohibited to do so by law or case planprohibited to do so by law or case plan

Discrepancies between the resident's Discrepancies between the resident's inventoried property turned over to the inventoried property turned over to the facility at admission and the property facility at admission and the property returned to the resident at discharge, returned to the resident at discharge, and the resolution of the discrepancy, and the resolution of the discrepancy, must be documented by facility staffmust be documented by facility staff

2960.0100Staffing Plan

Approved by the Commissioner Approved by the Commissioner of Human Services or of Human Services or CorrectionsCorrections

Identifies the assignments of Identifies the assignments of facility stafffacility staff

Meets the cultural and ethnic Meets the cultural and ethnic needs of the facility residents needs of the facility residents to the extent permitted by lawto the extent permitted by law

2960.0100 Subpart 2Recruitment of Culturally

Balanced Staff

To the extent permitted by law, it is the To the extent permitted by law, it is the license holder's responsibility to actively license holder's responsibility to actively recruit, hire, and retain full-time staff recruit, hire, and retain full-time staff who are responsive to the diversity of who are responsive to the diversity of the population servedthe population served

If the facility staffing plan does not meet If the facility staffing plan does not meet the cultural and racial needs of facility the cultural and racial needs of facility residents the license holder must residents the license holder must document the reasonsdocument the reasons

Recruitment of Culturally Balanced Staff

Work with cultural or racial communities Work with cultural or racial communities to meet the needs of residents.to meet the needs of residents.

In addition, the license holder must In addition, the license holder must contact a cultural or racial community contact a cultural or racial community group related to the resident's cultural or group related to the resident's cultural or racial minority background and seek racial minority background and seek information about how to provide information about how to provide opportunities for the resident to opportunities for the resident to associate with adult and peer role associate with adult and peer role models with similar cultural and racial models with similar cultural and racial backgrounds on a regular basis.backgrounds on a regular basis.

2960.0100 Subpart 3 Orientation

The license holder must provide The license holder must provide training for staff that is training for staff that is modified modified annuallyannually to meet to meet the current the current needs of individual staff personsneeds of individual staff persons..

The training must be directly The training must be directly related to serving the program's related to serving the program's target population and to achieving target population and to achieving the program's outcomes.the program's outcomes.

Orientation

The license holder must ensure that The license holder must ensure that staff who will have direct contact staff who will have direct contact with residents attend and with residents attend and successfully complete orientation successfully complete orientation training before having unsupervised training before having unsupervised contact with residents.contact with residents.

Orientation TrainingEmergency Procedures

evacuation routesevacuation routes

emergency telephone numbersemergency telephone numbers

severe storm and tornado severe storm and tornado proceduresprocedures

location of facility alarms and location of facility alarms and equipmentequipment

Orientation TrainingStatutes, Rules

Relevant statutes and Relevant statutes and administrative rules and legal administrative rules and legal issuesissues

Reporting requirements for abuse Reporting requirements for abuse and neglect specified in Minnesota and neglect specified in Minnesota Statutes, sections 626.556 and Statutes, sections 626.556 and 626.557626.557

Other reporting requirements Other reporting requirements based on the ages of the residentsbased on the ages of the residents

Orientation Training Diversity

Cultural diversity Cultural diversity Gender sensitivityGender sensitivity Culturally specific servicesCulturally specific services Information about Information about

discrimination and racial bias discrimination and racial bias issues to ensure that caregivers issues to ensure that caregivers have cultural sensitivity and will have cultural sensitivity and will be culturally competent to care be culturally competent to care for residentsfor residents

Orientation Training Diversity

General and special needs, General and special needs, including disability needs, of including disability needs, of residents and families servedresidents and families served

Operational policies and Operational policies and procedures of the license holderprocedures of the license holder

Orientation

Data practices regulations and Data practices regulations and issues.issues.

The license holder must ensure The license holder must ensure that staff who have direct that staff who have direct contact with residents receive contact with residents receive ongoing training. Training must ongoing training. Training must help staff meet the needs of help staff meet the needs of residents and must include skills residents and must include skills development.development.

2960.0100 Subpart 3BOngoing Training

The license holder must ensure The license holder must ensure that staff who have direct that staff who have direct contact with residents receive contact with residents receive ongoing training.ongoing training.

Training must help staff meet Training must help staff meet the needs of residents and the needs of residents and must include skills must include skills developmentdevelopment..

Subpart 4Specialized Training

If needed, license holders and If needed, license holders and staff must have specialized staff must have specialized training to develop skills to training to develop skills to care for residents care for residents

Specialized training must be Specialized training must be directly related to serving the directly related to serving the program's target population program's target population and to meeting the program's and to meeting the program's certification requirementscertification requirements

2960.0100 Subpart 5Personnel Policies

Documentation of training. The Documentation of training. The license holder must document license holder must document the date and number of hours of the date and number of hours of orientation and in-service orientation and in-service training completed by each staff training completed by each staff person in each topic area and person in each topic area and the name of the entity that the name of the entity that provided the training. provided the training.

Subpart 6Qualifications

The license holder and staff The license holder and staff must have the education and must have the education and experience required to meet experience required to meet the functions and program the functions and program activities that the license activities that the license holder declared in the facility holder declared in the facility statement of intended use statement of intended use according to part 2960.0040. according to part 2960.0040.

Staff Qualifications

Responsible, mature, healthy adult Responsible, mature, healthy adult who is able to carry out the license who is able to carry out the license holder's duties. holder's duties.

Able to accomplish the license Able to accomplish the license holder's duties to the resident's holder's duties to the resident's case plan and treatment plan and case plan and treatment plan and meet the resident's needs. meet the resident's needs.

Trained in gender-based needs and Trained in gender-based needs and issues. issues.

At least 21 years old.At least 21 years old.

Subpart 7Background Study

A license holder and individuals A license holder and individuals identified in Minnesota Statutes, identified in Minnesota Statutes, DHS: Minnesota Statutes, DHS: Minnesota Statutes,

section 245A.04, subdivision 3.section 245A.04, subdivision 3. DOC: Minnesota Statutes, DOC: Minnesota Statutes,

section 241.021, subdivision 6.section 241.021, subdivision 6.

must submit to a background must submit to a background study.study.

2960.0110 PHYSICAL ENVIRONMENT /

EQUIPMENT

The facility must be equipped The facility must be equipped and maintained in a manner and maintained in a manner that conforms to its statement that conforms to its statement of intended use. of intended use.

The physical environment The physical environment must provide for the comfort, must provide for the comfort, privacy, and dignity of privacy, and dignity of residents.residents.

2960.0110 Subpart 3Facilities

The license holder must ensure The license holder must ensure that food services, storage, that food services, storage, housekeeping, laundry, and housekeeping, laundry, and maintenance are operated on a maintenance are operated on a consistent, healthy basis.consistent, healthy basis.

If food service is contracted to a If food service is contracted to a food service vendor, the food food service vendor, the food service vendor must meet health service vendor must meet health code requirements.code requirements.

Facilities

If the license holder provides If the license holder provides educational services on site, the educational services on site, the classrooms must provide an classrooms must provide an atmosphere that is conducive to atmosphere that is conducive to learning and meets the resident's learning and meets the resident's special physical, sensory, and special physical, sensory, and emotional needs.emotional needs.

The license holder must provide The license holder must provide adaptive equipment and furnishings adaptive equipment and furnishings to meet the resident's special needs.to meet the resident's special needs.

Subpart 4First Aid Kits

A facility must have first aid kits A facility must have first aid kits readily available for use by readily available for use by residents and staff. The kits residents and staff. The kits must be sufficient to meet the must be sufficient to meet the needs of residents and staff. needs of residents and staff.

2960.0120Physical Plant Standards

Fire, health, zoning, and building Fire, health, zoning, and building code code

Sleeping rooms for 4 or lessSleeping rooms for 4 or less Multi-bed bedrooms: ambulatory Multi-bed bedrooms: ambulatory

residentsresidents 60 square feet per resident of 60 square feet per resident of

useable flood space useable flood space three feet between beds placed side three feet between beds placed side

by side by side one foot between beds placed end to one foot between beds placed end to

end end

Subpart 2Code Compliance

Multi-bed bedrooms: non-ambulatory Multi-bed bedrooms: non-ambulatory residentsresidents 80 square feet per resident of 80 square feet per resident of

useable floor space useable floor space adequate space for clothing and adequate space for clothing and

personal possessionspersonal possessions appropriate furnishings to appropriate furnishings to

accommodate these items.accommodate these items.

Code Compliance

Outdoor recreational spaceOutdoor recreational space One shower or bathtub/sink/toilet One shower or bathtub/sink/toilet

per 8 residentsper 8 residents Hot and cold waterHot and cold water Heating plant providing comfortable Heating plant providing comfortable

temperature in all resident areas temperature in all resident areas Lighting appropriate to function of Lighting appropriate to function of

areaarea

Code Compliance

Sufficient indoor space Sufficient indoor space For quiet group program For quiet group program

activitiesactivities On site education: Facility On site education: Facility

must meet the DOE must meet the DOE provisions of educational provisions of educational servicesservices

Private intake admission areaPrivate intake admission area