[40 Pa.B. 6109]
[Saturday, October 23, 2010]
[Continued from previous Web Page] § 23.57. Mental health worker and mental health aide.
(a) The mental health worker shall be responsible for implementing therapeutic interventions.
(b) The mental health worker shall meet one of the following requirements:
(1) Have at least 1 year of experience in a children's behavioral health program whose operating principles were in accordance with CASSP principles and a bachelor's degree, with at least 12 credit hours of education in psychology, sociology, social work, counseling, nursing, education or theology.
(2) Be a licensed RN and have at least 1 year of experience in a children's behavioral health program whose operating principles were in accordance with CASSP principles.
(3) Have a high school diploma or equivalent and at least 4 years of experience in a children's behavioral health program whose operating principles were in accordance with CASSP principles.
(c) A mental health aid shall have a high school diploma or general education development certificate.
§ 23.58. Staff ratios.
(a) The staff to child ratio during awake hours must reflect the needs of the population being served. The minimum staff ratios in this chapter apply unless the Department's clinical consultants determine these minimum staff ratios are inadequate to meet the needs of the population being served as described in the RTF service description.
(b) Staff to child ratios are as follows:
(1) There shall be at least one mental health professional available either onsite or by telephone when a child is at the RTF.
(2) During awake hours, one mental health worker shall be present with every four children.
(3) A mental health worker or mental health aide who is counted in the worker to child ratio must be 21 years of age or older.
(4) For RTFs serving six or more children, whenever six or more children are present at the RTF, there shall be at least one mental health professional for every six children present at the RTF during awake hours.
(5) During sleep hours, one mental health worker or mental health aide shall be present with every six children.
(6) Staff may not sleep while being counted in the staff to child ratios.
§ 23.59. Primary contact.
(a) At the time of a child's admission, an RTF shall designate either a mental health professional or a mental health worker to be the child's primary contact during the child's stay at the RTF, to have primary responsibility for coordination of the child's care. The assignment of a primary contact will, at no time, preclude a parent, or when applicable, a guardian or custodian from communicating directly with the treating physician or other staff about the child.
(b) The primary contact's responsibilities include the following:
(1) Liaison activities for coordination and collaboration with other individuals and systems involved with the child, including the following:
(i) The family.
(ii) The behavioral health care manager at the appropriate behavioral health managed care organization.
(iii) The county intensive case manager.
(iv) The education system.
(v) The child welfare system, if applicable.
(vi) The juvenile justice system, if applicable.
(2) Participation in the High Fidelity Wraparound, if the child and family have a High Fidelity Wraparound team.
(3) Promoting resiliency through risk reduction and asset-building strategies.
(4) Coordinating the child's aftercare plan with the community agencies that will provide services after discharge, the education system, natural supports and the family prior to the child's return home by doing the following:
(i) Providing an aftercare agency with a comprehensive written discharge summary that includes information on the child's discharge diagnosis, treatment rendered during the RTF stay, treatment plans and the extent to which the child attained identified goals, and treatment team recommendations for the next level of care, following discharge. In addition, the written discharge summary must identify each psychotropic medication and dose, and describe the clinical rationale for each medication.
(ii) Ensuring that medications that the child will need until an appointment with the community based psychiatrist are prepared for discharge.
(iii) Assisting the family in determining whether the prescribed medications are covered by MA. If a medication is not covered, the primary contact shall assist so that an appropriate substitute, which is covered, can be prescribed.
(c) The primary contact shall arrange for an onsite meeting with the parents and, when applicable, the guardians or custodians, within the first 7 days of the child's admission including day of admission and assist in developing the family participation plan as specified in § 23.42 (relating to documentation of efforts for family contacts).
§ 23.60. Family advocacy.
(a) For every 48 children, an RTF shall have on staff, or contract for the services of, a full-time equivalent family advocate. If an RTF serves fewer than 48 children, the RTF shall have on staff, or contract for the services of, a family advocate whose work hours are prorated according to the number of children in the RTF.
(b) The responsibilities of the family advocate include the following:
(1) Participating in quality improvement activities.
(2) Ensuring restraint reduction activities.
(3) Promoting the observance of children's rights.
(4) Reviewing of grievances.
(5) Ensuring availability to families and children as requested.
(6) Monitoring of general conditions.
(7) Facilitating family involvement plans.
(8) Participating in ISPT meetings at family request.
(9) Meeting with children regularly.
§ 23.61. Supervision.
(a) An RTF shall ensure that a child is supervised during awake and sleeping hours by conducting observational checks of each child at least every 15 minutes.
(b) Observational checks of a child specified in subsection (a) must include actual viewing of each child.
(c) Observational checks shall be documented.
§ 23.62. Staff training.
(a) Orientation. Prior to working with a child, staff, including temporary staff and volunteers, shall have an orientation to their specific duties and responsibilities; policies and procedures of the RTF, including reportable incident reporting; discipline, care and management of children; and use of restrictive procedures.
(b) Training. Prior to working alone with a child and within 120 calendar days after the date of hire, staff, including temporary staff, shall have at least 30 hours of training in the areas specified in this subsection. If staff has completed comparable training within 12 months prior to the date of hire, the requirement for training in this subsection does not apply. Training must include at least the following areas:
(1) The requirements of this chapter.
(2) The requirements of 23 Pa.C.S. §§ 6301—6386 (relating to the Child Protective Services Law) and Chapter 3490 (relating to child protective services).
(3) Fire safety.
(4) First aid, Heimlich techniques, cardiopulmonary resuscitation and blood-borne pathogen training taught by an individual certified as a trainer by a hospital or other recognized health care organization.
(5) Crisis intervention, including use of relationships and de-escalation approaches, positive behavior support, suicide prevention and proper, safe use of restraint when it is necessary as an emergency measure to maintain the safety of the child and others, using the least restrictive restraint intervention needed to address the crisis.
(6) Health and other special issues affecting the population.
(7) Use of assessment, evaluation and treatment plans as guides to understanding a child's strengths and needed supports in the milieu.
(8) Principles of milieu treatment and the specific roles of staff in maintaining the therapeutic milieu.
(c) Ongoing annual training.
(1) After initial training, staff, including temporary staff, shall have at least 40 hours per year of training relating to the care and management of children. This requirement does not apply to the initial year of employment unless the person to be trained was exempt from subsection (b).
(2) Staff shall complete training in first aid, Heimlich techniques and cardiopulmonary resuscitation taught by an individual certified as a trainer by a hospital or other recognized health care organization. Staff shall demonstrate their competency on an annual basis even if the certification is for longer than 1 year.
(3) In an RTF serving more than 20 children, staff shall complete training in fire safety taught by a fire safety expert.
(4) In an RTF serving 20 or fewer children, staff shall complete training in fire safety taught by a staff trained by a fire safety expert. Video tapes prepared by a fire safety expert are acceptable for the training if accompanied by an onsite staff trained by a fire safety expert.
(5) A total of 20 hours of training in the following:
(i) Professional ethics and conduct and legal issues including professional boundaries with children and their families; child and general protective services; mandated child abuse reporting; and confidentiality.
(ii) CASSP principles and implementing and supporting those principles in clinical practice.
(iii) Cultural competency as described in the Cultural Competence Clinical/Rehabilitation Standards of Practice published by the Department and available at www.parecovery.org.
(iv) The Department's Special Transmittal on Strategies and Practices to Eliminate the Unnecessary Use of Restraint issued on January 30, 2006, or subsequent updates.
(v) RTF policy, including the ability to effectively transfer the application of policy and procedure to the direct care work with a child and a child's family.
(vi) Trauma-informed care, including its provision as part of ongoing care, and attachment issues.
(vii) Signs and symptoms of abuse and neglect.
(viii) Serious emotional or behavioral disorders and other behavioral health needs in children as they relate to the biopsychosocial needs of the children being served.
(ix) Applicable State laws related to the scope of practice for medication administration.
(x) Psychotropic medications, including types, appropriate uses and possible side effects.
(xi) The discharge process.
(xii) Cross-system training appropriate to the population the RTF serves.
(xiii) Current clinical practice and methodologies, including evidence-based practices to address the unique characteristics of the children served and the role of staff in maintaining a therapeutic milieu.
(xiv) Documentation skills and requirements.
(xvi) Recovery and resiliency in children and their families, including how to integrate these philosophies and concepts into treatment approaches for a child and the child's family during the child's RTF stay.
(xvii) Principles of participation on a high fidelity wraparound team.
(xviii) Principles of child development appropriate for the age of the children served.
(xv) Other topics appropriate to the age, characteristics, diagnosis and developmental needs of the children served.
(d) Restrictive procedure training.
(1) In addition to the ongoing annual training listed in subsection (c), staff who are responsible for administering restrictive procedures shall demonstrate competency on a semiannual basis in the use of interventions they are permitted to use, and knowledge of the specific circumstances and limited indications for their use.
(2) Only staff trained in the application of the type of restraint to be used may restrain a child during an emergency safety situation.
(3) Training in restraint techniques must include the following:
(i) Techniques to identify staff and child behaviors, events and environmental factors that may trigger circumstances that require the use of a restraint.
(ii) De-escalation techniques and alternative nonrestrictive strategies.
(iii) Knowledge of normal behavior reactions to stress at various ages.
(iv) Nonphysical intervention skills.
(v) The least restrictive intervention based on an individualized assessment of a child's medical or behavioral status or condition.
(vi) Techniques and procedures appropriate for the age and weight of the children served.
(vii) The safe application and use of restraints used, including how to recognize and respond to signs of physical and psychological distress, for example, positional asphyxia.
(viii) Health risks for a child associated with use of specific procedures.
(ix) Monitoring of the physical and psychological well-being of a child who is restrained, including respiratory and circulatory status, skin integrity, vital signs and any special requirements specified by policy associated with the 1-hour face-to-face evaluation.
(x) First-aid techniques and certification in the use of cardiopulmonary resuscitation, including required annual recertification.
(xi) Response to the child's emotional and mental state after use of a restrictive procedure.
(xii) First-hand experience of the specific techniques taught after demonstration by a qualified trainer.
(xiii) A testing process to demonstrate understanding of and ability to apply specific procedures. Staff may only apply procedures in which they have been trained and shown mastery.
(e) Serving children with ASD.
(1) Staff of an RTF that proposes to treat children with ASD shall have training specific to the needs of children with ASD.
(2) The trainings under paragraph (1) must be in protocols that yield success with children diagnosed with ASD, such as applied behavior analysis, relationship-based interventions, targeted social skills instruction, strategies to support sensory needs and functional behavioral assessment.
(f) Record of training. A record of training including the name of the trained individual, along with the date, source, content, length of each course and copies of any certificates and documentation of competencies received, shall be kept in each staff training file.
PHYSICAL SITE § 23.81. Physical accommodations and equipment.
An RTF shall provide or arrange for physical site accommodations and equipment necessary to meet the health and safety needs of a child with a disability.
§ 23.82. Poisons.
(a) Poisonous materials shall be kept locked and inaccessible to a child.
(b) Poisonous materials shall be stored in their original, labeled containers.
(c) Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.
§ 23.83. Heat sources.
Heat sources, such as hot water pipes, fixed space heaters, hot water heaters and radiators, exceeding 120° F that are accessible to a child, shall be equipped with protective guards or insulation to prevent a child from coming in contact with the heat source.
§ 23.84. Sanitation.
(a) Sanitary conditions shall be maintained.
(b) There may be no evidence of infestation of insects or rodents in an RTF.
(c) Trash shall be removed from the premises at least once a week.
(d) Trash in kitchens and bathrooms shall be kept in covered trash receptacles that prevent the penetration of insects and rodents.
(e) Trash outside the RTF shall be kept in covered trash receptacles that prevent the penetration of insects and rodents.
§ 23.85. Ventilation.
Living areas, recreation areas, dining areas, bathrooms, bedrooms and kitchens shall be ventilated by at least one operable window or mechanical ventilation.
§ 23.86. Lighting.
Rooms, hallways, interior stairs, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to avoid accidents.
§ 23.87. Surfaces.
(a) Floors, walls, ceilings, windows, doors and other surfaces shall be free of hazards.
(b) An RTF may not use asbestos products for renovations or new construction.
§ 23.88. Water.
(a) An RTF shall have hot and cold water under pressure.
(b) Hot water temperature in areas accessible to a child may not exceed 120° F.
(c) An RTF that is not connected to a public water system shall have a coliform water test at least every 3 months, by a Department of Environmental Protection-certified laboratory, stating that the water is safe for drinking. Documentation of the certification shall be kept.
§ 23.89. Air temperature.
(a) Indoor temperature shall be at least 65° F during awake hours when a child is present in the RTF.
(b) Indoor temperature may not be less than 62° F during sleeping hours.
(c) When indoor temperature exceeds 90° F, mechanical ventilation such as fans or air conditioning shall be used.
§ 23.90. Communication system.
(a) An RTF shall have a working, non-coin-operated, telephone with an outside line that is accessible to staff in emergencies.
(b) An RTF shall have a communication system to allow staff to contact other staff in the RTF for assistance in an emergency.
§ 23.91. Emergency telephone numbers.
Telephone numbers for the nearest hospital, police department, fire department, ambulance and poison control center shall be posted on or by a telephone with an outside line.
§ 23.92. Screens.
Windows, including windows in doors, must be securely screened when doors or windows are open.
§ 23.93. Handrails and railings.
(a) A ramp, interior stairway and outside steps exceeding two steps must have a well-secured handrail.
(b) A porch that has over an 18-inch drop must have a well-secured railing.
§ 23.94. Landings and stairs.
(a) There must be a landing which is at least as wide as the doorway, beyond each interior and exterior door which opens directly into a stairway.
(b) Interior stairs must have nonskid surfaces.
§ 23.95. Furniture and equipment.
(a) Furniture and equipment must be free of hazards.
(b) There shall be enough seating furniture to accommodate the largest group of children that may routinely congregate in a room so that no child is required to sit on the floor.
(c) Power equipment shall be kept in safe condition.
(d) Power equipment, excluding normal household appliances, shall be stored in a place that is inaccessible to children.
(e) Power equipment, excluding normal household applications, may not be used by children except under supervision of staff.
§ 23.96. First aid supplies.
An RTF shall have a first aid manual, nonporous disposable gloves, antiseptic, assorted band-aids, adhesive bandages, gauze pads, thermometer, tape, tweezers and scissors that are stored together.
§ 23.97. Elevators.
An elevator must have a valid certificate of operation from the Department of Labor and Industry in accordance with 34 Pa. Code § 7.15 (relating to inspection).
§ 23.98. Indoor activity space.
An RTF shall have separate indoor activity space for activities such as studying, recreation and group activities.
§ 23.99. Recreation space.
An RTF shall have regular access to outdoor, or large indoor, recreation space and equipment.
§ 23.100. Exterior conditions.
(a) The exterior of the building and the building grounds or yard must be free of hazards.
(b) Outside walkways must be free of ice, snow and obstruction.
§ 23.101. Firearms and weapons.
Firearms, weapons and ammunition are not permitted in an RTF or on the RTF grounds, except for those carried by law enforcement personnel.
§ 23.102. Child bedrooms.
(a) A single bedroom must have at least 70 square feet of floor space per child measured wall to wall, including space occupied by furniture.
(b) A shared bedroom must have at least 60 square feet of floor space per child measured wall to wall, including space occupied by furniture.
(c) No more than two children may share a bedroom.
(d) Children of the opposite sex may not share a bedroom.
(e) Ceiling height in each bedroom must be at least an average of 7 1/2 feet.
(f) A bedroom must have a window with a source of natural light.
(g) A child shall have the following in the bedroom:
(1) A bed with solid foundation and fire-retardant mattress in good repair.
(2) A pillow and bedding appropriate for the temperature in the RTF.
(3) A storage area for clothing.
(h) Cots or portable beds are not permitted.
(i) Bunk beds must allow enough space between each bed and the ceiling to allow a child to sit up in bed.
(j) Bunk beds must be equipped with securely attached ladders capable of supporting at least 250 pounds.
(k) The top bunk of bunk beds must be equipped with a secure safety rail on each open side and open end of the bunk.
(l) A bedroom may not be used as a means of egress from or access to another part of the RTF.
§ 23.103. Bathrooms.
(a) There shall be at least one flush toilet for every six children.
(b) There shall be at least one sink for every six children.
(c) There shall be at least one bathtub or shower for every six children.
(d) There shall be slip-resistant surfaces in bathtubs and showers.
(e) Privacy shall be provided for toilets, showers and bathtubs by partitions or doors.
(f) There shall be at least one wall mirror for every six children.
(g) An individual towel, washcloth, comb, hairbrush and toothbrush shall be provided for a child.
(h) Toiletry items including toothpaste, shampoo, deodorant and soap shall be provided.
(i) Bar soap is not permitted unless there is a separate bar clearly labeled for each child.
§ 23.104. Kitchen areas.
(a) An RTF shall have a kitchen area with a refrigerator, sink, cooking equipment and cabinets for storage.
(b) Utensils for eating, drinking and food serving and preparation shall be washed and rinsed after each use.
(c) Food shall be protected from contamination while being stored, prepared, transported and served.
(d) Uneaten food from a person's dish may not be served again or used in the preparation of other dishes.
(e) Cold food shall be kept at or below 40° F. Hot food shall be kept at or above 140° F. Frozen food shall be kept at or below 0° F.
§ 23.105. Laundry.
Bed linens, towels, washcloths and clothing shall be laundered at least weekly.
§ 23.106. Swimming.
(a) Above-ground and in-ground outdoor pools must be fenced with a gate that is locked when the pool is not in use.
(b) Indoor pools shall be made inaccessible to children when not in use.
(c) A certified lifeguard shall be present with the children at all times while children are swimming.
(d) The certified lifeguard specified in subsection (c) may not be counted in the staff to child ratios specified in §§ 23.56 and 23.58 (relating to mental health professional; and staff ratios).
FIRE SAFETY § 23.121. Unobstructed egress.
(a) Stairways, hallways, doorways, passageways and egress routes from rooms and from buildings must be unlocked and unobstructed, unless the fire safety approval specified in § 23.15 (relating to fire safety approval) permits locking of certain means of egress under the following circumstances:
(1) A locked facility is medically necessary for the safety of a child through:
(i) Internal locks within the building or external locks.
(ii) Secure fencing around the premises of the building.
(2) A child needs immediate admission to locked facility for treatment of behavioral health needs and has associated child-safety or protection needs as determined by CCYA or the juvenile court.
(3) An RTF service description has been approved by the Department and contains information regarding the security of the RTF in addition to information that demonstrates a level of clinical treatment that is beyond the standard level of service expected within a nontreatment focused locked residential facility.
(b) Doors used for egress routes from rooms and from buildings may not be equipped with key-locking devices, electronic card operated systems or other devices which prevent immediate egress of a child from the building.
§ 23.122. Exits.
If more than four children sleep above the ground floor, there must be a minimum of two interior or exterior exits from each floor. If a fire escape is used as a means of egress, it shall be permanently installed.
§ 23.123. Evacuation procedures.
There shall be written emergency evacuation procedures that include staff responsibilities, means of transportation and emergency location.
§ 23.124. Notification of local fire officials.
An RTF shall notify local fire officials in writing of the address of the RTF, location of bedrooms and assistance needed to evacuate in an emergency. The notification shall be kept current.
§ 23.125. Flammable and combustible materials.
(a) Combustible materials may not be located near heat sources.
(b) Flammable materials shall be used safely, stored away from heat sources and inaccessible to children.
§ 23.126. Furnaces.
(a) Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company or trained maintenance staff.
(b) Documentation of the inspection and cleaning shall be maintained in the business of the RTF.
§ 23.127. Portable space heaters.
The use of portable space heaters, defined as heaters that are not permanently mounted or installed, is not permitted.
§ 23.128. Wood and coal burning stoves.
The use of wood and coal burning stoves is not permitted.
§ 23.129. Fireplaces.
(a) Fireplaces must be securely screened or equipped with protective guards while in use.
(b) Staff shall be present with a child while a fireplace is in use.
(c) A fireplace chimney and flue shall be cleaned when there is an accumulation of creosote. Written documentation of the cleaning shall be kept.
§ 23.130. Smoke detectors and fire alarms.
(a) An RTF shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
(b) There shall be an operable automatic smoke detector located within 15 feet of a bedroom door.
(c) The smoke detectors specified in subsections (a) and (b) shall be located in common areas or hallways.
(d) Smoke detectors and fire alarms must be of a type approved by the Department of Labor and Industry or listed by Underwriters Laboratories.
(e) If the RTF serves four or more children or if the RTF has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the RTF or an automatic fire alarm system that is audible throughout the RTF.
(f) If one or more children or staff are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms must be equipped so that a person with a hearing impairment will be alerted in the event of a fire.
(g) If a smoke detector or fire alarm becomes inoperative, repair or replacement shall be completed within 48 hours of the time the detector or alarm was found to be inoperative.
(h) There shall be a written procedure for fire safety monitoring if the smoke detector or fire alarm becomes inoperative.
§ 23.131. Fire extinguishers.
(a) There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic.
(b) If the indoor floor area on a floor including the basement or attic is more than 3,000 square feet, there shall be an additional fire extinguisher with a minimum 2-A rating for each additional 3,000 square feet of indoor floor space.
(c) A fire extinguisher with a minimum 2A-10BC rating shall be located in a kitchen. The kitchen fire extinguisher will meet the requirement for one operable fire extinguisher for each floor as required in subsection (a).
(d) Fire extinguishers must be listed by Underwriters Laboratories or approved by Factory Mutual Systems.
(e) Fire extinguishers must be accessible to staff. A fire extinguisher may be kept locked if access to the extinguisher by a child may cause a safety risk to the child. If fire extinguishers are kept locked, staff shall be able to immediately unlock the fire extinguisher in the event of a fire emergency.
(f) Fire extinguishers shall be inspected and approved annually by a fire safety expert. The date of the inspection must be on the extinguisher.
§ 23.132. Fire drills.
(a) An unannounced fire drill shall be held at least once a month.
(b) Fire drills shall be held during normal staffing conditions and not when additional staff are present.
(c) A written fire drill record shall be kept of the following:
(1) Date.
(2) Time.
(3) Amount of time for evacuation.
(4) Exit route used.
(5) Number of children in the RTF at the time of the drill.
(6) Problems encountered.
(7) Whether the fire alarm or smoke detector was operative.
(d) The evacuation route must allow children to evacuate the entire building into a public thoroughfare, or to a fire-safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employee of the RTF.
(e) A fire drill shall be held during sleeping hours at least every 6 months.
(f) Alternate exit routes shall be used during fire drills at least every 3 months.
(g) Fire drills shall be held on different days of the week, at different times of the day and night and on different staffing shifts.
(h) Children shall evacuate to a designated meeting place outside the building or within the fire-safe area during a fire drill.
(i) A fire alarm or smoke detector shall be set off during each fire drill.
(j) An elevator may not be used during a fire drill or a fire.
§ 23.133. False alarms.
An RTF shall document false alarms internally and make the documentation available for review by the Department. The frequency of false alarms should be considered as part of the overall quality assurance plan.
CHILD HEALTH § 23.141. Child health and safety.
(a) A child shall have a written health and safety assessment within 24 hours of admission.
(b) The assessment shall be completed or coordinated, signed and dated by medical personnel or staff trained by medical personnel as specified in an RTF training policy approved by the Department.
(c) The assessment must include the following:
(1) Identification of strengths of the child and family.
(2) Known or suspected suicide or self-injury attempts or gestures and emotional history which may indicate a predisposition for self-injury or suicide.
(3) Known incidents of aggressive or violent behavior.
(4) Substance abuse history.
(5) Sexual history or behavior patterns that may place the child or other children at a health or safety risk.
(6) Medical information and health concerns such as allergies; medications; immunization history; hospitalizations; medical diagnoses; family history of medical problems; issues experienced by the child's mother during pregnancy; special dietary needs; illnesses; injuries; dental, mental or emotional problems; body positioning and movement stimulation for children with disabilities; and ongoing medical care needs.
(7) Trauma history.
(8) Potential medical or psychological contraindications to the use of manual restraint.
(d) A copy of the health and safety assessment shall be kept in the child's record.
(e) An RTF shall develop a policy for revising and updating the health and safety assessment, which must be approved by the Department.
§ 23.142. Health and safety plan.
If the health and safety assessment in § 23.141 (relating to child health and safety) identifies a health or safety risk, a written plan to protect the child shall be developed and implemented within 24 hours after the assessment is completed.
§ 23.143. Child health examination.
(a) A child shall have a health examination within 3 days after admission and annually thereafter or more frequently, as specified at specific ages in the periodicity schedule recommended by the American Academy of Pediatrics in the most current version of Recommendations for Preventive Pediatric Health Care (RE9939) available at http://practice.aap.org/content.aspx?aid=1599.
(b) If a child had a health examination prior to admission that meets the requirements of subsection (e) within the periodicity schedule specified in subsection (a), and there is written documentation of the examination, an initial examination within 3 days is not required. The next examination must occur within the periodicity schedule specified in subsection (a).
(c) If a child will participate in a program that requires physical exertion; a health examination shall be completed before the child is scheduled to participate in the physical exertion portion of the program.
(d) The health examination shall be completed, signed and dated by a licensed physician, CRNP or licensed PA. Written verification of completion of each health examination shall be kept in the child's medical record specifying the following:
(1) Date of the examination.
(2) Results of the examination.
(3) Name and address of the examining practitioner.
(4) Follow-up recommendations.
(e) The health examination must include the following:
(1) A comprehensive health and developmental history, which includes both physical and behavioral health development and the following:
(i) The following information about the child's mother's pregnancy, if available:
(A) Use of alcohol, drugs, cigarettes and prescribed medications during the child's mother's pregnancy and signs of fetal alcohol spectrum disorder.
(B) Complications during the child's mother's pregnancy.
(C) Child's weight at birth.
(D) Whether child's birth was early, late or term.
(E) Type and nature of delivery and complications, if applicable.
(F) Child's mother's postpartum complications.
(G) Domestic violence victimization of the child's mother during or after pregnancy.
(ii) Developmental milestones.
(iii) Emotional complications.
(iv) Medical illnesses, injuries, surgeries and hospitalizations.
(v) Drug allergies.
(vi) History of abuse or neglect.
(vii) Out-of-home placements.
(viii) Use of psychotropic medications and responses.
(ix) Regular or special education placement in school.
(x) Nature of special education settings, if applicable.
(xi) Psychological or educational testing and results.
(2) A comprehensive, unclothed physical examination.
(3) Immunizations, screening tests and laboratory tests as recommended by the American Academy of Pediatrics in the most current version of Recommendations for Preventative Pediatric Health Care (RE9939) available at http://practice.aap.org/content.aspx?aid=1599 including the following laboratory tests:
(i) CBS, differential and platelets.
(ii) Electrolytes.
(iii) Liver function studies.
(iv) BUN and creatinine (renal).
(v) Fasting blood glucose.
(vi) Lipid profile.
(vii) Blood level if one or more of the following medications are being taken:
(A) Lithium.
(B) Depakote.
(C) Tegretol.
(D) Wellbutrin.
(viii) Blood level assessments for a child under 5 years of age, unless the examining practitioner determines that the testing is unnecessary, after reviewing the results of previously conducted blood lead testing, which review and conclusion is documented in the child's medical record.
(ix) Sickle cell screening for a child who is African-American unless the examining practitioner determines that the testing is unnecessary, after reviewing the results of previously conducted sickle cell testing, which review and conclusion is documented in the child's medical record.
(4) A gynecological examination including a breast examination and a Pap test as recommended by medical personnel.
(5) Urine screen for drugs.
(6) Calculation of BMI.
(7) Communicable disease detection, if recommended by medical personnel based on a child's health status and with required written consent in accordance with applicable laws.
(8) Specific precautions to be taken if the child has a communicable disease, to prevent spread of the disease to other children.
(9) An assessment of the child's health maintenance needs, medication regimen and the need for blood work at recommended intervals.
(10) Special health or dietary needs of the child, including consideration of the child's BMI.
(11) Allergies or contraindicated medications.
(12) Medical information pertinent to diagnosis and treatment in case of an emergency.
(13) Physical or mental disabilities of the child, if any.
(14) Health education, including anticipatory guidance.
(15) Recommendations for follow-up physical and behavioral health services, examinations and treatment.
(f) Immunization records, screening tests and laboratory tests may be completed, signed and dated by an RN or licensed practical nurse instead of a licensed physician, CRNP or licensed PA.
§ 23.144. Dental care.
(a) A child shall receive dental care, at as early an age as necessary, needed for relief of pain and infections, restoration of teeth and maintenance of dental health.
(b) A child who is 3 years of age or older shall have a dental examination performed by a licensed dentist and teeth cleaning performed by a licensed dentist or dental technician at least semiannually. If a child has not had a documented dental examination and teeth cleaning within 6 months prior to admission, a dental examination and teeth cleaning shall be performed within 30 days after admission.
(c) Follow-up dental work indicated by the examination, such as treatment of cavities and application of protective sealants, shall be provided in accordance with recommendations by the licensed dentist.
(d) A written record of completion of each dental examination, including the preadmission examination permitted in subsection (b), shall be kept in the child's record, specifying the following:
(1) Date of the examination.
(2) Dentist's name and address.
(3) Procedures completed.
(4) Follow-up treatment recommended.
(5) Dates follow-up treatment was provided.
§ 23.145. Vision care.
(a) A child shall receive vision screening and services to include diagnosis and treatment, including eyeglasses, for defects in vision.
(b) A child who is 3 years of age or older shall receive vision screening within 30 days after admission in accordance with the periodicity schedule recommended by the American Academy of Pediatrics in the most current versions of ''Guidelines for Health Supervision,'' and ''Eye examination and Vision Screening in Infants, Children and Young Adults (RE9625).''
(c) If a child had a documented vision screening prior to admission that meets the requirements of subsection (a) within the periodicity schedule specified in subsection (b) an initial examination within 30 days after admission is not required. The next screening must occur within the periodicity schedule specified in subsection (b).
(d) Follow-up treatment and services, such as provision of eyeglasses, shall be provided as recommended by the treating practitioner.
(e) A written record of completion of a vision screening, including the preadmission screening permitted in subsection (c), shall be kept in the child's record, and include the following:
(1) Date of the screening.
(2) Treating practitioner's name and address.
(3) Results of the screening.
(4) Follow-up recommendations.
(5) Dates follow-up services and treatment were provided.
§ 23.146. Hearing care.
(a) A child shall receive a hearing screening and services to include diagnosis and treatment, including hearing aids, for defects in hearing.
(b) A child who is 3 years of age or older shall receive a hearing screening within 30 days after admission in accordance with the periodicity schedule recommended by the American Academy of Pediatrics in the most current version of ''Guidelines for Health Supervision.''
(c) If a child had a documented hearing screening prior to admission that meets the requirements of subsection (a) within the periodicity schedule specified in subsection (b) an initial examination within 30 days after admission is not required. The next screening must occur within the periodicity schedule specified in subsection (b).
(d) Follow-up treatment and services, such as provision of hearing aids, shall be provided as recommended by the treating practitioner.
(e) A written record of completion of each hearing screening, including the preadmission screening permitted in subsection (c), shall be kept in the child's record, specifying the following:
(1) Date of the screening.
(2) Treating practitioner's name and address.
(3) Results of the screening.
(4) Follow-up recommendations.
(5) Dates follow-up services and treatment were provided.
§ 23.147. Use of tobacco.
(a) Use or possession of tobacco products by a child is prohibited.
(b) Use or possession of tobacco products by staff is prohibited in the RTF and during transportation provided by the RTF.
(c) If staff use tobacco products outside but on the premises of the RTF, the following apply:
(1) An RTF shall have written fire safety procedures. Procedures must include extinguishing procedures and requirements that smoking shall occur at least 100 yards from the RTF and at least 100 yards from flammable or combustible materials or structures.
(2) Written safety procedures shall be followed.
(3) Use of tobacco products shall be out of the sight of the children.
§ 23.148. Health and behavioral health services.
(a) An RTF shall identify acute and chronic conditions of a child and arrange for or provide appropriate medical treatment.
(b) Medically necessary physical and behavioral health services, diagnostic services, follow-up examinations and treatment, such as medical, nursing, pharmaceutical, dental, dietary, hearing, vision, blood lead level, psychiatric and psychological services that are planned or prescribed for the child, shall be arranged for or provided.
§ 23.149. Emergency medical plan.
(a) An RTF shall have a written emergency medical plan listing the following:
(1) The hospital or source of health care that will be used in an emergency.
(2) The method of transportation to be used.
(3) An emergency staffing plan for an emergency situation where staff counted in staff ratio are required to leave the RTF.
(4) Medical and behavioral health conditions or situations under which emergency medical care and treatment are warranted.
(b) A child's parent and, when applicable, a child's guardian or custodian, shall be given a copy of the emergency medical plan upon admission.
(c) A child's parent and, when applicable, a child's guardian or custodian, shall be notified immediately if the emergency plan is implemented for the child.
STAFF HEALTH § 23.151. Staff health statement.
(a) Staff or volunteers who come into direct contact with a child or who prepare or serve food, shall submit a staff health statement that the staff or volunteer is free of serious communicable disease that may be spread through casual contact or that the staff or volunteer has a serious communicable disease that may be spread through casual contact, but is able to work in the RTF if specific precautions are taken that will prevent the spread of the disease to children.
(b) The staff health statement shall be signed and dated by a licensed physician, CRNP or licensed PA within 12 months prior to working with a child or food service and every 2 years thereafter.
(c) The RTF shall follow the written instructions and precautions specified in subsection (a).
NUTRITION § 23.161. Three meals a day.
An RTF shall provide at least three meals and one snack a day to the children.
§ 23.162. Quantity of food.
(a) The quantity of food served shall meet minimum daily requirements as recommended by the United States Department of Agriculture, unless otherwise recommended in writing by a licensed physician, CRNP or licensed PA for a specific child.
(b) Additional portions of meals shall be available for a child.
§ 23.163. Food groups and alternative diets.
(a) A meal must contain at least one item from the dairy, protein, fruits and vegetables and grain food groups, unless otherwise recommended in writing by a licensed physician, CRNP or licensed PA for a specific child.
(b) Dietary alternatives shall be available for a child who has special health needs, including a need to lower BMI, religious beliefs regarding dietary restrictions or vegetarian preferences.
§ 23.164. Withholding or forcing of food prohibited.
(a) An RTF may not withhold meals or drink as punishment.
(b) A child may not be forced to eat food or drink.
TRANSPORTATION § 23.171. Safe transportation.
The following requirements apply whenever an RTF, staff or volunteer provides transportation for a child. These requirements do not apply if transportation is provided by a source other than the RTF.
(1) The mental health worker-to-child ratios specified in § 23.58 (relating to staff ratios) apply.
(2) A child shall be in an individual, age and size appropriate, safety device at all times when the vehicle is in motion.
(3) Restraints may not be used routinely for transport and may only be used in the event of an emergency safety situation as specified in §§ 23.201 and 23.206 (relating to general information; and restrictive procedure records).
(4) A driver of a vehicle shall be 21 years of age or older.
(5) Vehicles utilized for transportation of a child must comply with local, State and Federal laws.
MEDICATIONS § 23.181. Storage of medications.
(a) Prescription and over-the-counter medications shall be kept in their original containers.
(b) Prescription and potentially poisonous over-the-counter medications shall be kept in an area or container that is locked.
(c) Prescription and potentially poisonous over-the-counter medications stored in a refrigerator shall be kept in a separate locked container.
(d) Prescription and over-the-counter medications shall be stored separately.
(e) Prescription and over-the-counter medications shall be stored under proper conditions of sanitation, temperature, moisture and light.
(f) Discontinued and expired medications, and prescription medications for a child who is no longer served at the RTF, shall be disposed of in a safe manner.
§ 23.182. Labeling of medications.
(a) The original container for prescription medications must be labeled with a pharmacy label that includes the child's name, the name of the medication, the date the prescription was issued, the prescribed dosage and the name of the prescribing physician.
(b) Over-the-counter medications must be labeled with the original label.
§ 23.183. Use of prescription medications.
(a) The clinical rationale for a prescribed medication shall be clearly documented in a child's medical record.
(b) A change in medication shall be documented in a child's medical record.
(c) The prescribing physician shall obtain and document consent from the responsible party for medication prescribed, explaining the medication's expected effects, expected side effects and the expected effects of withholding the medication. The responsible party is the individual who initially consented for child's treatment, including the child 14 years of age and older, the child's parent or, when applicable, the child's guardian or custodian.
(d) Psychotropic medication orders shall be written by a physician.
(e) A psychiatrist shall see a child on psychotropic medications at least every 30 days, and more frequently until the child's condition is stable, and document in the child's medical record the child's progress and clinical status.
(f) Dosage changes do not require additional consent; however, an RTF shall notify, by phone or in writing, the child's parents and, when applicable, the child's guardian or custodian, whenever dosage changes are made.
(g) The clinical rationale for a prescribed medication shall be clearly documented on a child's discharge summary or final evaluation.
(h) A prescription medication shall be used only by the child for whom the medication was prescribed.
(i) A child and the child's family may not be threatened or incur negative consequences, including discharge, when they disagree with or refuse a clinical recommendation for medication.
(j) An RTF shall put in place strategies that promote choice in medication decisions including the following:
(1) Full access to information for a child and the child's family about medications, including side effects.
(2) Staff who are willing and able to help a child and the child's family explore and understand the positive and negative possible consequences of taking or not taking a medication.
(3) Processes which are immediately responsive to concerns or side effects which the family or child suspect are related to the medication, including a consult with the prescribing physician within 24 hours, or sooner if necessary.
(4) Staff who are able to identify alternative or complementary strategies which address the areas of concern that the medication seeks to address, including relaxation and coping processes which match a child's interests, temperament, culture and developmental levels.
(k) Prescribed medications shall be included on the ISP.
§ 23.184. Medication log.
(a) A medication log shall be kept for each child. The medication log shall be made available to members of the treatment team.
(b) A child's medication log must include the following:
(1) A list of prescription medications.
(2) The prescribed dosage.
(3) Possible side effects.
(4) Contraindicated medications.
(5) Specific administration instructions, if applicable.
(6) The name of the prescribing physician.
(7) A list of over-the-counter medications.
(c) For prescription and over-the-counter medication, including insulin administered or self-administered, documentation in the medication log must include the medication that was administered, route of administration, dosage, date, time and the name of the person who administered or self-administered the medication.
(d) The information in subsection (c) shall be logged at the same time a dosage of medication is administered or self-administered.
§ 23.185. Medication errors.
(a) Documentation of a medication error shall be kept in the child's medication log. A medication error includes the failure to administer medication, administering the incorrect medication, administering the correct medication in an incorrect dosage or administering the correct medication at the incorrect time.
(b) After a medication error, follow-up action to prevent a future medication error shall be taken and documented.
§ 23.186. Adverse reaction.
If a child has a suspected adverse reaction to a medication, an RTF shall notify the prescribing physician, the child's parent and, when applicable, the child's guardian or custodian, no later than 24 hours after the suspected adverse reaction occurs. Documentation of adverse reactions and the physician's response shall be kept in a child's medical record.
§ 23.187. Administration.
(a) Prescription medications, including injections, shall be administered by one of the following:
(1) A licensed physician, licensed dentist, PA, RN, CRNP, licensed practical nurse or licensed paramedic.
(2) A graduate of an approved nursing program functioning under the direct supervision of an RN who is present in the RTF.
(3) A student nurse of an approved nursing program functioning under the direct supervision of a member of the nursing school faculty who is present in the RTF.
(4) A child, if the child meets the requirements in § 23.188 (relating to self-administration).
(5) Staff who have completed a medication training approved by the Department under certain circumstances listed in § 23.189 (relating to special circumstances).
(b) A prescription medication and an injection shall be administered according to the directions specified by a licensed physician, CRNP or licensed PA.
§ 23.188. Self-administration.
A child is permitted to self-administer medications, insulin injections and epinephrine injections for insect bites, food and latex allergies, if the following requirements are met:
(1) A person who meets the qualifications of § 23.187(a)(1)—(3) and (5) (relating to administration) is physically present observing the administration and immediately records the administration in accordance with § 23.184 (relating to medication log).
(2) A child recognizes and distinguishes the medication and knows the condition or illness for which the medication is prescribed, the correct dosage and when the medication is to be taken.
§ 23.189. Special circumstances.
Staff who have completed a medication training approved by the Department are permitted to administer medications in the following circumstances:
(1) The staff who have completed the medication administration training are accompanying one or more children away from the RTF and the person who meets the qualifications in § 23.187(a)(1)—(3) (relating to administration) is not with the group.
(2) Staff who meet the qualifications in § 23.187(a)(1)—(3) are not present at the RTF during sleep hours, and the medication is prescribed to be administered during sleep hours.
(3) A person who meets the qualifications in § 23.187(a)(1)—(3) is unavailable do to an emergency situation caused by a natural disaster, weather related condition, or unexpected illness.
§ 23.190. Medication performance monitoring.
To assist in measuring the quality of care provided and outcomes achieved for a child in an RTF, an RTF shall provide a report to the Department on the following every 6 months:
(1) The number and percentage of children under 21 years of age who are receiving 3 or more psychotropic medications.
(2) The number and percentage of children under 21 years of age who are receiving 1 or more antipsychotic medications.
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