R501-19A-6. Administration

(1)(a) Each provider shall provide information through print or website sources, on any program service for any client to: (i) OL; (ii) the public; (iii) any potential client; and (iv) a client's parent or legal guardian. (b) The information described in Subsection (1)(a) shall include: (i) a description of each service; (ii) each program requirement and expectation; (iii) current and accurate program contact information; (iv) the complaint reporting and resolution process; (v) identification of each non-clinical, extracurricular, or supplemental service offered or referred; and (vi) each cost, fee, and expense for a service and refund policy. (2) The provider shall maintain a phone number to be used for the purposes described in Subsections 26B-2-124(4)(g) through 26B-2-124(4)(h). (3) The provider shall make every reasonable effort to connect any authorized contact who calls the program in an attempt to contact a client with that client by phone. (4) In conspicuous places where each visitor, staff, and client may see, the provider shall post: (a) abuse reporting laws, as described in Sections 26B-6-205 and 80-2-609; (b) an Americans with Disabilities Act notice; (c) any department notice of agency action; (d) a civil rights notice; (e) a client rights poster, except in a setting serving a client population governed by the settings final rule; (f) a congregate care ombudsman notice form, in compliance with each requirement in Subsection 26B-2-124(7)(a); (g) a provider code of conduct poster; and (h) the program's license. (5) In addition to posting the congregate care ombudsman notice described in Subsection (4)(f), the provider shall ensure each client, the client's parent or legal guardian, OL, and each sending agency or private agency receives a copy of the congregate care ombudsman notice. (6) The provider shall: (a) document notification to the local government for any new service or increased consumer capacity, as described in Section 26B-2-117; (b) maintain compliance with, or documentation of any exemption from, requirements for: (i) a food handler permit for any person preparing meals for any other person; (ii) each capacity determination, including each staff and client on the premises, that does not exceed any capacity limit placed by a local authority; (iii) fire clearance, if conducted separately from a business license; and (iv) licensure and registration of any vehicle used to transport a client. (7) Any provider with local requirements under dispute must resolve the dispute before OL may issue a license in good standing. (8)(a) The provider shall maintain: (i) fire insurance; (ii) general liability insurance; (iii) professional liability insurance, as applicable; (iv) vehicle insurance and registration for any vehicle that transports a client; and (v) any additional insurance as required to cover each program activity. (b) The provider shall make documentation of insurance and registration described in Subsection (8)(a) available to OL upon request. (9) The provider shall ensure: (a) a manager is immediately available when the program is in operation and there is a qualified designee when the manager is absent or unavailable; (b) the implementation of a quality improvement plan addressing any: (i) client or staff grievance; (ii) program feedback; or (iii) trend in licensing noncompliance and incident reports; (c) there is a means to communicate with each client, which may include a language interpreter being available or a referral to an appropriate resource; (d) availability of a current staff list and client list; (e) each entity associated with the provider understands and signs the provider code of conduct before working with any client; and (f) the organizational and governance structure of the program is available to OL upon request and includes: (i) each line of authority and responsibility; and (ii) a job description for each job title, including each duty and qualification. (10) The provider shall notify OL of any program change, as described in Section R380-600-4. (11) Any provider serving or likely to serve any client with a substance use disorder shall ensure: (i) there is an opioid overdose reversal kit on site; and (ii) staff receive training on how to use the kit before being on-duty. (12) Any provider serving a client who is classified as an education entitled child shall: (a) comply, as applicable, with Section 26B-2-116, Rule R277-709, and Rule R277-926 regarding coordination of any educational service, including completion of youth education forms at initial and renewal licensure; and (b) make any necessary accommodation to allow a client to continue that client's education with a curriculum approved by the Utah State Board of Education. (13) Any provider that offers on-site school shall: (a) ensure each client is taught at the appropriate grade level; (b) ensure a staff-to-client ratio of one staff to every four clients in the school setting, unless the provider is an intermediate secure treatment program; (c) ensure staff providing school receive training in behavior intervention. (d) keep the education record of each client; (e) use a curriculum with an educational accreditation in good standing, including the Utah State Board of Education or the National School Accreditation Board; and (f) during discharge, provide proof of high school graduation or equivalent to the client, the client's parent or legal guardian, and the local education agency (LEA). (14) The provider shall ensure any: (a) clinical and medical staff have the appropriate license or certification; (b) clinical and medical staff are in good standing with any license or certification; and (c) unlicensed staff are appropriately supervised in compliance with Title 58, Occupations and Professions. (15) Any provider using telehealth for treatment shall operate within the scope of the provider's professional licensure in accordance with: (a) Section 26B-4-704; and (d) any applicable rule. (16) Any provider offering any behavior intervention service to a client served by the Division of Services for People with Disabilities (DSPD) shall comply with Rule R539-4, which supersedes any conflicting rule under Title R501. (17)(a) The provider shall ensure access to a medical clinic or a licensed medical professional familiar with the program and population served. (b) A licensed medical professional shall oversee the medication management practices for the program. (c) The provider shall ensure that each person involved with the prescription, administration, or dispensing of any controlled substance maintains the appropriate medical or pharmaceutical license and the Drug Enforcement Administration registration numbers, as described in 21 CFR 1301 (2021), published by the Office of the Federal Register, incorporated by reference in this rule. (d) The provider shall ensure at least one CPR and first aid-certified staff is available when any staff or client is present, unless a licensed medical professional is present on site. (18) Any provider that serves a client who has been placed in a Utah program from outside of Utah shall comply with Title 80, Chapter 2, Part 9, Interstate Compact on Placement of Children. (19) The provider may allow a client to remain in the program after the client turns 18 years old, as described in Subsection 26B-2-104(1)(a)(iii), if: (a) the client has remained in the custody of a state entity or the client was admitted and continuously resided in the program for at least 30 days before the client's 18th birthday; (b) the client has a documented need to remain in the program; (c) the provider maintains responsibility for discharge to an appropriate setting when clinically appropriate and no later than the client's 19th birthday; (d) the provider outlines a plan for the protection of any client younger than 18 years old by supervising and separating the client who is 18 years old from any client who is under the age of 16; and (e) the client signs a consent document outlining that: (i) any criminal offense committed may result in being charged as an adult; (ii) if the client is involved in any critical incident posing a risk to the health and safety of any other client, the client who is 18 years old may be discharged from the program; and (iii) the client consents to remain in the program voluntarily and understands the client is not being required to remain in the program against the client's will. (20) The provider shall ensure weekly, confidential communication between the client and any family member or authorized contact of the client, in accordance with Section 26B-2-123. (a) A client's parent or legal guardian shall authorize, in writing, an alternate means of confidential communication when voice-to-voice communication is unavailable. (b) The frequency or form of the confidential communication requirement may only be modified if the provider submits a voice-to-voice variance notification to OL, signed by the provider's clinical director, demonstrating: (i) any extenuating circumstances that exist outside the client treatment plan that inhibit offering voice-to-voice communication; (ii) an alternative that satisfies the requirement of weekly, confidential two-way communication; (iii) the program primarily operates in an area of limited or unreliable phone accessibility or coverage; or (iv) there is a significant risk of harm or danger to the client's emotional, mental, or physical safety by providing the client with unsupervised phone access. (c) The provider shall offer confidential voice-to-voice communication as soon as it is safe to do so. (d) A standardized statement or practice applied to every treatment plan may not be used to satisfy the requirement of individualized documentation. (21) A provider may offer any client step-down privileges, including authorized departures from the program and unsupervised time, if the provider: (a) documents in the client record and communicates to each client's direct care staff: (i) the individualized justification for the step-down privileges; and (ii) which privileges are authorized by a licensed clinical professional; (b) maintains a staff-to-client ratio of one direct care staff for every four clients present in the step-down setting; (c) obtains written parental or legal guardian consent before allowing step-down privileges; and (d) distributes a policy to each client, client's parent or legal guardian, and staff that includes: (i) a description of how each step-down privilege may be achieved or rescinded; (ii) a description of what constitutes authorized departure and unsupervised time; (iii) a statement that no client with step-down privileges is allowed to perform any direct care staff duty; and (iv) a statement that the provider will immediately communicate to each client, client's parent or legal guardian, and direct care staff when any step-down privilege has been rescinded. (22) Any provider that serves any client with a substance use disorder shall ensure each staff and client is screened for tuberculosis as recommended by the local health authority. (23) The provider shall make any program record in this section available to OL for review upon request.