Specific Rules for Residential Treatment Agencies for Children and Youth Providing Maternity Care

PURPOSE: This rule sets forth the requirements for agencies providing maternity care, including health care plan, program, and relinquishment of the infant. (1) In addition to the rules for basic core agencies, an agency desiring to provide maternity care shall meet these additional general requirements— (A) A maternity residence upon request shall provide a written description of its program to the residents, parent(s), guardian, or legal custodian and to the division; (B) Written financial policies and expectations shall be made available upon request to the division and to the parent(s), guardian, or legal custodian upon admission into the maternity residence; (C) A training plan shall be developed to ensure that staff working with pregnant and parenting adolescents develop skills and knowledge regarding infant and adolescent care; (D) Maternity residences shall be separate from other treatment programs; and (E) At least two (2) direct-care pursuant to 13 CSR 35-71.050(4) (A)1.–5. and (B) trained pursuant to 13 CSR 35-71.045(5)(A)-(Q) and 13 CSR 35-71.045(6)(A)1. and 13 CSR 35-71.045(2)(B)1.–9., (C), and (D)1.–12. staff shall be on site at all times. (2) Health Care. (A) There shall be a written plan for all deliveries to take place in a licensed hospital. (B) Physician’s Services. 1. Each resident shall receive the services of a licensed physician on a regular and continuing basis throughout pregnancy, delivery, and post-delivery checkups. 2. The maternity residence shall provide for consultation from a licensed obstetrician who shall be available in an emergency. 3. A licensed nurse shall be accessible on an as needed basis for pre and post-natal care. (C) Ambulance Service. Ambulance service shall be available for emergencies. (D) Medical Records. The resident’s medical record shall include a medical consent form, the name of the health care provider, a schedule of appointments, documentation of pre and post-natal care, the expected date of delivery, and any special needs or problems. (E) Medication. No prescription or nonprescription medication shall be administered without the specific documented approval of the physician providing obstetric care. (3) Program. (A) The maternity residence shall, at a minimum, provide a program to residents addressing prenatal care, labor, delivery, nutrition, general health and hygiene, postnatal care, family planning, sexually transmitted disease, and child-care techniques. (B) Upon dismissal from the maternity residence, each resident shall be given written information regarding postnatal care. (C) Professional staff shall be responsible for development of a long-term plan for the mother and infant. This plan shall be developed with the involvement of the mother and the legal guardian. (4) Relinquishment of the Infant. (A) The decision to keep or relinquish the infant shall be the right of the birth parent(s). This decision shall be made without undue pressure or influence. (B) At the request of the resident, the professional staff shall arrange for referral to a licensed child-placing agency. (5) Infant/Child Cardio Pulmonary Resuscitation. (A) At least one (1) staff shall be present at all times who is trained in infant/child cardio pulmonary resuscitation. AUTHORITY: sections 210.481, 210.486, and 210.506, RSMo 2000.* This rule originally filed as 13 CSR 40-71.120. Emergency rule filed Nov. 1, 1993, effective Nov. 12, 1993, expired March 11, 1994. Emergency rule filed March 2, 1994, effective March 12, 1994, expired July 9, 1994. Original rule filed Nov. 1, 1993, effective June 6, 1994. Moved to 13 CSR 35-71.120, effective Oct. 30, 2008. Amended: Filed Dec. 16, 2013, effective June 30, 2014. *Original authority: 210.481, RSMo (1982), amended 1985 and 210.486 and 210.506, RSMo (1982), amended 1993. 13 CSR 35-71.130 Specialized Standards—Residential Treatment for Children and Youth PURPOSE: This rule sets forth the requirements for specialized residential treatment, including program director, assessment staff, professional staff, staff/child ratios, training, treatment plan review, and locked isolation. (1) In addition to rules for basic residential treatment for children and youth, an agency seeking to become licensed to provide residential treatment for children and youth, shall meet these additional requirements: (A) Program Director. The program director must be a fulltime staff dedicated solely to the overall treatment program with at least the following minimum qualifications: 1. A master’s degree in social work or human service field from an accredited college or university or licensed as a certified social worker; and 2. Two (2) years’ experience providing treatment services. One (1) year of this experience must have been in a residential treatment setting; (B) Assessment Staff. Staff responsible for developing initial assessment and treatment plan for each child must have at least the following minimum qualifications: 1. A master’s degree in social work or human service field from an accredited college or university or licensed as a certified social worker; and 2. One (1) year of experience in a residential treatment setting; (C) Professional Staff. 1. The agency must have sufficient, appropriately qualified professional staff available on a full-time, part-time, or continuing consultative basis, or any combination of these to address the needs of children in care. 2. The professional staffing plan must be in writing and implemented by the agency. 3. The program director shall document that the number, qualifications, and responsibilities of professional staff are appropriate to the agency’s size and the scope of its program. (D) Staff/Child Ratios. 1. At least one (1) direct care staff for every four (4) children, birth to six (6) years of age, shall be on duty during waking hours. 2. Staff shall be awake during children’s sleeping hours, and maintain staff/child ratios of one (1) staff for every six (6) children from birth to six (6) years of age. 3. At least one (1) direct care staff for every six (6) children, age six (6) years and older shall be on duty during waking hours. 4. Staff shall be awake during children’s sleeping hours and maintain staff/child ratios of one (1) staff for every twelve (12) children age six (6) years and older. 5. An agency licensed, or buildings constructed after (effective the date of this amendment) shall have no more than two (2) children in a sleeping room. (E) Training. All staff working with children must receive at least forty (40) hours annually of in-service training and meet the training requirements in accordance with 13 CSR 35-71.045. At least ten (10) hours of the training must be related specifically to treatment issues with emotionally disturbed, mentally ill, behaviorally disordered, medically fragile, physically disabled, and/or developmentally delayed children. Professional staff providing sexual abuse treatment are required to have fifteen (15) hours of annual training in investigation, treatment, nature, extent, and causes of sexual abuse pursuant to section 660.526, RSMo; (F) Treatment Plan Review. 1. Each child’s treatment plan shall be reviewed and updated at least every three (3) months. 2. If a child shows no progress toward achieving the goals and objectives in the treatment plan since the plan was developed or last reviewed, the reasons for continuing the child in the agency’s program must be included in the child’s record. 3. Appropriate information about the updated treatment plan shall be given to the child and the child’s parent(s), guardian, or legal custodian and documented in the child’s record. 4. A minimum of one (1) hour of individual, group, or family counseling sessions shall be provided to each child at least one (1) time a week with other sessions available as needed. (G) Locked Isolation. 1. Prior to the implementation of a locked isolation room, the agency shall have approval of the State Fire Marshal and the division. 2. Written policies for the use of locked isolation shall be made available to the child’s parent(s), or guardian or legal custodian, or both, and when appropriate, to the child. 3. Agencies utilizing locked isolation shall submit a plan for the emergency evacuation of isolated residents to the licensing unit including documentation that staff has included evacuating residents from locked isolation during fire drills. 4. Locked isolation may be used only as a management method after all other verbal de-escalation measures have been exhausted, and never to replace other more positive measures of control. Documentation of intervention methods used to prevent use of locked isolation must be in the resident’s record. 5. Locked isolation may be used only when a child presents a danger to him/herself or others. 6. Locked isolation shall be used in the shortest intervals possible until the child regains reasonable self-control. 7. The maximum time a child may remain in locked isolation is thirty (30) minutes, unless extensions are approved at the end of every thirty (30) minute period by the program director or a qualified designee. A child shall not remain in locked isolation more than a two (2) hour period. If the child has not regained control after two (2) hours, a medical order shall be obtained. 8. When a child is placed in locked isolation, staff shall physically monitor the child in at least five (5) minute intervals. Staff shall remain in close proximity to the child in locked isolation with no more than one (1) locked door between the staff and the child. Close proximity means that staff are close enough to the child(ren) to be able to hear any sounds the child(ren) might make that would indicate a need for assistance. 9. Not more than one (1) child shall be in a locked isolation room. A locked isolation room shall not be utilized for any other purpose. 10. Within twenty-four (24) hours of each locked isolation incident, treatment staff shall debrief the incident with the resident. 11. The agency shall maintain a record when locked isolation is used, which shall include: A. The name of the child, the date, and the time the child was placed in locked isolation; B. The circumstances that led to the placement of the child in locked isolation and efforts to prevent the use of locked isolation; C. The name of the staff person who requested placement of the child in locked isolation, the staff person who approved locked isolation, and the name of the staff person who monitored the child while in locked isolation; D. The amount of time the child remained in locked isolation, the frequency of monitoring and the time of and reasons for release; E. Documented behavioral observations of the child at each five (5) minute interval; F. Specific notation of any extension of locked isolation including reasons for the extension and by whom approval for extension was given; and G. Documentation of results of debriefing that includes recommendations of staff and resident for avoiding similar situations. 12. For agencies permitting the use of locked isolation, the treatment team shall review its usage at least weekly and sign/ date the isolation report. A. Written policies for the use of locked isolation shall be distributed to staff, and there shall be documented training Reference Chart Age Range Level of Care Direct Care Staff to Resident Ratio Awake Asleep Birth to six (6) years Residential Treatment One (1) staff per four (4) children One (1) staff per six (6) children. Staff must remain awake. Age six (6) and older Residential Treatment One (1) staff per six (6) children One (1) staff per twelve (12) children. Staff must remain awake. provided to staff in the policies and use of locked isolation, which shall include, but not be limited to: (I) Directions for the removal of all dangerous items from the child, including but not limited to, belts, shoelaces, jewelry, items in pockets, matches, and any other items which represent a potential hazard during locked isolation; and (II) Proper written documentation of the use of locked isolation. 13. If the agency does not meet all requirements for the use of locked isolation, the division shall give written notice of the specific deficiencies and the agency shall not use locked isolation until corrections are made and approved by the division. 14. Locked isolation rooms shall be constructed and equipped so that control is maximized, but the risk of suicide or injury to children is minimized. The following shall apply: A. An isolation room shall be constructed to allow for both visual and auditory supervision of a child; B. An isolation room shall have one (1) approved lockingagainst-egress device which shall be used only when staff are immediately present, awake, and in possession of a key. There shall be a backup system which does not rely on a key, i.e., an electronic locking-release mechanism, as approved by the State Fire Marshal; C. Potentially dangerous articles shall be removed from the child prior to placing the child in locked isolation, for example, belts, shoes, matches, and/or contents of pockets; D. An isolation room shall have at least a seven and onehalf foot (7 1/2') ceiling and be of sufficient length and width for the comfort of the child; E. All doors, ceilings, and walls shall be constructed of such strength and noncombustible material that harm to the child is minimized; F. All switches controlling lights, ventilation, and the like, shall be on the outside of the room; G. In order to prevent harm to the child, windows shall be secured and made of tempered material to prevent shattering; H. No functional electrical outlets shall be allowed in the room; I. Tamper-resistant, recessed ceiling lights shall be utilized, and steam or hot water radiators shall be enclosed in a tamper-resistant, protective casing; J. The room shall be properly heated, cooled, and ventilated; K. Normal toileting and bathing facilities shall be available during isolation; and L. The agency shall have a schedule for monthly routine maintenance of the locks. AUTHORITY: sections 210.481, 210.486, and 210.506, RSMo 2000.* This rule originally filed as 13 CSR 40-71.130. Emergency rule filed Nov. 1, 1993, effective Nov. 12, 1993, expired March 11, 1994. Emergency rule filed March 2, 1994, effective March 12, 1994, expired July 9, 1994. Original rule filed Nov. 1, 1993, effective June 6, 1994. Moved to 13 CSR 35-71.130, effective Oct. 30, 2008. Amended: Filed Dec. 16, 2013, effective June 30, 2014. *Original authority: 210.481, RSMo (1982), amended 1985 and 210.486 and 210.506, RSMo (1982), amended 1993.