[40 Pa.B. 6109]
[Saturday, October 23, 2010]
[Continued from previous Web Page]
RESTRICTIVE PROCEDURES § 23.201. General information.
(a) If a restrictive procedure is used, the staff who administers the procedure shall have completed training specified in § 23.62(d) (relating to staff training).
(b) Restrictive procedures include time-out, restraint and seclusion.
(c) The only restrictive procedures permitted in an RTF are drugs used as a restraint and manual restraint and those may be used only in an emergency safety situation in accordance with the provisions of this chapter. If the child objects to the administration of a drug used as a restraint, which a physician has determined is needed as a result of an emergency safety situation, an RTF shall have the child evaluated for inpatient psychiatric hospitalization.
(d) A restrictive procedure may not be used in a punitive manner, as a means of coercion, discipline, retaliation or retribution, or for the convenience of staff, or as compensation for lack of staff presence or competency, or as a program substitution.
(e) A restrictive procedure shall be discontinued when a child demonstrates the child has regained self-control. Staff involved in implementing a restrictive procedure shall inform the child during the procedure, in easily understandable language, of the criteria for discontinuation of the restrictive procedure.
(f) A restrictive procedure may not result in harm or injury to a child.
§ 23.202. Restrictive procedure policy.
(a) An RTF shall establish a policy for the use of restrictive procedures and specifically address the use of restraint as an emergency safety intervention in the policy.
(b) The policy must address the requirements set forth in this chapter and applicable Federal laws.
§ 23.203. Written plan to create a restraint-free environment.
(a) An RTF shall submit to the Department a written plan that includes goals and time frames for establishing a trauma-informed care approach to move toward a restraint-free environment within the RTF.
(b) The written plan must include:
(1) Alternative approaches to the use of restraint consistent with a trauma-informed approach and ongoing staff training on alternative approaches and trauma-informed care as specified in § 23.62(d) (relating to staff training).
(2) The data that the RTF will collect and the manner in which the RTF will collect the data based on the requirements of the Department.
(3) Additional data the RTF has chosen to collect.
(4) The RTF's internal performance improvement process to monitor and reduce the use of restraint.
(c) The RTF shall annually review the plan to measure progress toward establishing an environment that is free from the use of restraints and restrictive procedures, modify the plan as needed, and submit any modifications for Department approval.
§ 23.204. Time out.
(a) Time out is used as intervention to provide a child with a period of time in a designated quiet area, such as the child's room or a place away from the area of activity or other child, for the purpose of providing the child an opportunity to learn how to gain self-control.
(b) A child may request time out, or staff who notices a change in a child's behavior that the child has not identified but appears to be escalating, or has escalated, to loss of self-control may ask a child to take time out to retain or regain self-control and function in a more positive manner.
(c) Time out may not be used in a punitive manner or for the purpose of excluding a child from general activities.
(d) Staff shall monitor a child while the child is in time out and record in the child's record the following:
(1) The date and start and end times of the time out.
(2) The reason for the time out, including whether it was requested by the child.
(3) The name of the staff that monitored the time out.
(4) The resolution of the time out, including whether it was or was not successful and the reason for the success or lack of success.
(5) The signature of the monitoring staff.
(c) A child in time out may never be physically prevented from leaving the area where the time out is taking place.
(d) If a child is not permitted to leave the time out area, the intervention ceases to be a time out and is considered seclusion.
§ 23.205. Emergency safety intervention.
(a) Mechanical restraints.
(1) Mechanical restraints are prohibited.
(2) The following devices are not considered mechanical restraints:
(i) A device used to provide support for functional body position or proper balance.
(ii) A device used for medical treatment, such as sand bags to limit movement after medical treatment.
(iii) A wheelchair belt that is used for body positioning and support.
(iv) A helmet used for prevention of injury during seizure activity.
(v) A seatbelt used during transportation.
(b) Seclusion.
(1) Seclusion is prohibited.
(2) Seclusion does not include the use of a time out room as defined in this chapter.
(3) Locking a child in a bedroom during sleeping hours is considered seclusion.
(c) Permissible restraint. A permissible restraint may only be used:
(1) To ensure the safety of a child or others during an emergency safety situation.
(2) After every attempt has been made to anticipate and de-escalate the behavior using methods of intervention less than restraint.
(d) Maintaining restraints. Efforts to calm and de-escalate a child should continue even after a restraint is implemented, with the goal of shortening the time needed to maintain the restraint.
(e) Prohibited interventions. The following interventions are prohibited:
(1) A restraint that applies pressure or weight on a child's respiratory system.
(2) Prone position restraints.
(3) Drugs used as restraint to control acute, episodic behavior that restricts the movement or function of a child, except for the administration of drugs ordered by a licensed physician and administered by licensed/certified/registered medical personnel on an emergency basis.
(4) The application of startling, painful or noxious stimuli, also referred to as adverse conditioning.
(5) The application of pain for the purpose of achieving compliance, except pressure at a child's jaw point for the purpose of bite release, also referred to as pressure point techniques.
(f) Emergency safety intervention. Orders for the use of restraint as an emergency safety intervention.
(1) Prior to ordering and applying a manual restraint, information and history shall be obtained about potential medical or psychological contraindications to the use of manual restraint for a child. This information shall be documented in a child's record and accessible to staff working with the child, including an individual who might order a restraint as an emergency safety intervention.
(2) Manual restraint shall be ordered only by one of the following:
(i) The child's treatment team physician, if available.
(ii) If the child's treatment team physician is not available, one of the following, if permitted by the RTF:
(A) Another physician.
(B) If another physician is not available, a CRNP or PA. Documentation that a physician was not available shall be entered in the restraint log and the child's medical record.
(C) If the individuals specified in clauses (A) and (B) are not available, a licensed psychologist, licensed social worker or licensed clinical social worker. Documentation that individuals specified in clauses (A) and (B) were not available shall be entered in the restraint log and the child's medical record.
(3) If neither the treatment team physician nor one of the alternative individuals specified in paragraph (2) (ii) is available in the RTF at the time of the emergency safety situation, a verbal order for restraint may be obtained from an individual specified in paragraph (2) by an RN or licensed practical nurse (LPN). If an RN or LPN is not in the RTF, a licensed occupational therapist or physical therapist may accept a verbal order for restraint from an individual specified in paragraph (2).
(i) The individual who ordered the restraint must be available to staff for consultation, at least by telephone, throughout the period of restraint.
(ii) A verbal order shall be verified by the individual who ordered the restraint in the child's record.
(4) When a restraint is ordered by someone other than the child's treatment team physician, the treatment team physician shall be contacted and informed about the use of restraint by the individual who ordered the restraint no later than 24 hours after the restraint was ordered.
(5) An order for a restraint shall be entered into a child's record by the ordering individual.
(6) An order for restraint must include the following:
(i) The name of the ordering physician or other individual specified in paragraph (2)(ii).
(ii) The date and time the order was obtained.
(iii) The specific type of restraint ordered, including length of time for which the order authorized the restraint.
(iv) The reason the restraint was ordered.
(v) The frequency and duration that staff shall monitor the child's vital signs.
(7) The physician or other individual specified in paragraph (2)(ii) shall order the least restrictive restraint likely to be effective in resolving the emergency safety situation taking into account onsite-staff recommendations.
(8) An order to administer a drug used as a restraint must meet the following requirements:
(i) The drug is ordered by a licensed physician.
(ii) The drug is administered by a licensed, certified or registered medical professional.
(iii) The child is examined by a licensed physician immediately prior to each incidence of administering a drug and the licensed physician has given a written order to administer the drug immediately prior to each incidence of administering a drug.
(9) An order for restraint must:
(i) Be limited to no longer than the duration of the emergency safety situation. A standing or PRN order for restraint is prohibited.
(ii) Under no circumstances exceed 2 hours for a child between 18 and 21 years of age, 1 hour for a child between 9 and 18 years of age, and 30 minutes for a child under 9 years of age.
(10) If the restraint is discontinued before the original order expires, a new order shall be obtained prior to reapplying the restraint.
(g) Application of restraint.
(1) Only staff trained in the use of emergency safety interventions as specified in § 23.62 (relating to staff training) shall be permitted to apply a restraint.
(2) During a restraint, the trained staff shall:
(i) Continually access and monitor the physical and psychological well-being of the child.
(ii) Release the hold by changing the position of the physical restraint or the staff applying the restraint at least once every 10 consecutive minutes during the restraint.
(iii) Ensure the safe use of restraint throughout the duration of the restraint and assess both physical and psychological factors of the child.
(iv) Clearly identify for the child the criteria for discontinuation of the restraint.
(v) Discontinue a restraint when a child demonstrates the child has regained self-control.
(3) During a restraint, staff trained in the use of restraint, but who are not applying the restraint, shall continuously observe, monitor and document the physical and emotional condition of the child. Staff shall document the condition of the child at least every 10 minutes after the restraint begins in the child's record.
(4) The use of the restraint must be limited to the duration of the emergency safety situation and until the child's safety and the safety of others can be ensured, even if the order for restraint has not expired.
(5) If the emergency safety situation continues beyond the time specified in the order authorizing the restraint, an RN or other licensed staff, shall contact the individual specified in subsection (f)(2)(ii) to receive further instructions.
(6) During a restraint, a child's physical needs shall be met.
(7) During the use of a drug as a restraint, staff shall monitor the child's vital signs at least once an hour and in accordance with the frequency and duration recommended and documented by the prescribing physician, in addition to the requirements in paragraph (2).
(8) Within 1 hour of the initiation of the restraint, a physician, CRNP, RN or PA trained in the use of emergency safety interventions and permitted by the RTF to assess the physical and psychological well-being of children shall conduct a face-to-face assessment of the physical and psychological well-being of the child including:
(i) The child's physical and psychological status.
(ii) The child's behavior.
(iii) The appropriateness of the intervention measures.
(iv) Complications resulting from the intervention.
(h) Medical treatment for injuries. Medical treatment for injuries resulting from the use of restraint is as follows:
(1) Staff shall assess a child to determine the extent of any injuries and shall obtain medical treatment from qualified medical personnel for a child injured as a result of a restraint immediately after discovery of an injury. Staff that is medically trained to provide emergency first-aid care and cardiopulmonary resuscitation should be available during and after a restraint to provide emergency medical interventions until further follow-up care can be provided.
(2) Staff that applied or participated in a restraint that results in an injury to a child shall meet with supervisory staff and evaluate the circumstances that caused the injury, and the RTF shall develop a plan to prevent further injuries.
(i) Notification. Notification of parent and, when applicable, the guardian or custodian shall be as follows:
(1) An RTF shall notify a parent and, when applicable, the guardian or custodian, of a child who has been restrained as soon as possible, but no later than 5 hours after the initiation of the restraint.
(2) An RTF shall document in a child's record that the parent and, when applicable, the guardian or custodian, has been notified of the restraint, including the date and time of notification and the name of the staff providing the notification.
(j) Documentation of restraint.
(1) Documentation of a restraint shall be written in a child's medical record and include the following:
(i) A description of the emergency safety situation.
(ii) The order for restraint as specified in subsection (f)(7).
(iii) If an individual specified in subsection (f)(2)(ii) ordered the restraint, an explanation that other staff were unavailable, as specified in subsection (f)(2)(ii).
(iv) For verbal orders, the name and title of the individual ordering the restraint, the time the order was given, the type of restraint ordered and the maximum time for which the restraint was ordered. The licensed staff identified in subsection (f)(3) accepting the verbal order shall sign and date the orders received. The ordering individual shall counter sign the order within 1 business day of the restraint.
(v) The time the restraint actually began and ended.
(vi) The names and job titles of staff involved in the restraint.
(vii) The time and results of the 1 hour assessment, specified in subsection (g)(8).
(viii) The date and time the treatment team physician was contacted and informed about the use of restraint, if the restraint was ordered by someone other than the treatment team physician.
(ix) Other documentation in § 23.206(b) (relating to restrictive procedure records).
(x) The dates, times and methods of attempts to notify a child's parent and, when applicable, the guardian or custodian, and the date and time of successful notification signed by each individual that attempted to contact the parent and, when applicable, the guardian or custodian.
(xi) A summary of each postintervention debriefing.
(xii) A description of all injuries that occur as a result of the restraint, including injuries to staff resulting from restraint.
(2) An RTF shall maintain a record of each emergency safety situation, the restraints used, and their outcomes.
(k) Postintervention debriefings.
(1) Shortly after the restraint is discontinued, staff involved in the restraint and supervisory staff shall conduct an informal and brief postrelease debriefment with the child for the purpose of rebuilding trust, helping the child regain composure and briefly discussing how the restraint might have been avoided and can be avoided in the future. If a child requests that the child does not want a particular staff who was involved in the restraint to participate in the postrelease debriefment, that request shall be honored.
(2) Within 24 hours after the restraint is discontinued, staff involved in the restraint, except when the presence of particular staff may jeopardize the well-being of the child, shall meet face-to-face with the child to discuss the circumstances that resulted in the use of restraint and strategies to be used by the staff, the child, or others that could prevent the use of restraint in the future.
(i) Other RTF staff, the RTF Family Advocate, ISPT members, the child's parents and, when applicable, the guardian or custodian, shall be given the opportunity to participate in the meeting.
(ii) If the child's parents and, when applicable, the child's guardian or custodian, attends the meeting, the RTF must conduct the meeting in a language that is understood by the child's parent and, when applicable, the guardian or custodian.
(3) Within 24 hours after the restraint is discontinued, staff involved in the restraint, appropriate supervisory and administrative staff, and the RTF Family Advocate shall conduct a debriefing session that includes, at a minimum, a review and discussion of the following:
(i) The emergency safety situation that required the restraint, including discussion of the participating factors that led up to the restraint.
(ii) Alternative techniques that might have prevented the use of the restraint.
(iii) The procedures, if any that staff are to implement to prevent any recurrence of the use of restraint.
(iv) The outcome of the restraint, including any injuries that may have resulted from the use of restraint.
(4) Staff shall document in the child's record that all three debriefing sessions took place. The documentation must include the following:
(i) The name of staff present for the debriefings.
(ii) The name of staff that were excused from the debriefings.
(iii) Changes to the child's treatment plan that result from the debriefings.
§ 23.206. Restrictive procedure records.
(a) A central record of each use of restrictive procedure shall be kept and include the following:
(1) The specific behavior addressed.
(2) The methods of intervention used to address the behavior, including all less intrusive measures attempted, and the reasons these measures were not effective.
(3) The date and time the procedure was used.
(4) The specific procedure used.
(5) The staff that used the procedure.
(6) The duration of the procedure.
(7) The staff who observed the child during the procedure.
(8) The child's condition upon completion of the procedure.
(9) The order for restraint.
(10) The time and results of the required 1-hour assessment.
(11) The physician or other licensed practitioner who order the restraint shall sign the restraint order in the record as soon as possible.
(b) Documentation of compliance with this section shall be kept in the child's record.
SERVICES § 23.221. Description of services.
(a) An RTF shall operate its program and provide services in accordance with a written service description approved by the Department.
(b) The service description must include the following:
(1) The RTF location, legal ownership and administration table of organization.
(2) The vision and mission of the RTF.
(3) A detailed description of how the program will meet the requirements in this chapter and current clinical standards of care.
(4) The scope and a general description of the services provided by the RTF.
(5) The number, ages, needs and any special characteristics of the children the RTF serves.
(6) The specific activities and programs provided by the RTF.
(7) The staff qualifications and staffing ratios with explanations for those that exceed the minimum requirements.
(8) An explanation of the RTF's ability to support and maximize the quality of life and functional abilities of children with emotional and behavioral issues using gender-responsive approaches that include a continuum of out-of-home treatment options for children with behavioral health needs.
(9) A demonstration of the RTF's ability to address special characteristics of the children the RTF intends to serve including neurological disability such as ASD or a co-occurring disorder such as substance abuse or disability such as developmental delay, deafness and blindness.
(10) A written policy regarding staff filing legal charges against a child which includes the following:
(i) The nature of the emotional and behavioral needs of the children residing at the RTF.
(ii) The possibility for injury to staff because of the potential of aggressive behaviors to occur as a result of the clinical conditions of a child.
(iii) A procedure for staff that choose to press charges to inform RTF management and discuss the pros and cons of pressing charges with the RTF director, with documentation of the meeting and meeting outcomes prior to filing charges.
(11) Verification from the LEA of the school district in which the RTF is located stating the following:
(i) The RTF has consulted with the LEA and the LEA has acknowledged its obligation to educate a child who is in an RTF in the most integrated setting and in the public school, whenever appropriate.
(ii) The LEA will meet the education, special education and related service needs of the children in the RTF.
(iii) An RTF shall notify the LEA if the RTF plans to expand or make other changes that will impact the LEA's requirement to provide educational services.
(c) The service description and policies and procedures shall be approved by the Department before the RTF begins operation.
(d) A change to an approved service description, which includes a change in the number of children the RTF plans to serve and to any approved policy or procedure, shall be approved by the Department prior to implementation.
§ 23.222. Admission process.
(a) Prior to admitting a child, an RTF shall interview the child and determine if its services, activities and programs are appropriate for the age, needs and any special characteristics of the child. The RTF shall document its findings. If the RTF determines that its services, activities and programs are not appropriate for the child and the child should not be admitted to the RTF, the RTF shall explain to the referral source in writing the reason the child cannot be admitted to the RTF. The RTF shall maintain the documentation in the business office of the RTF for periodic review by the Department.
(b) The RTF shall have an admission process that assesses and documents the following for a child, prior to or upon admission:
(1) A child's diagnosis.
(2) The results from a structured screening or assessment.
(3) The service needs of a child.
(4) A child's legal status.
(5) The circumstances that make admission of a child necessary.
(6) The results of a trauma screen administered upon admission or within 7 days of admission with a summary of findings and a discussion of the clinical relevance of the findings to the child's presenting problems. If the RTF has a copy of a trauma screen administered to the child within the prior 4 months, then the RTF does not need to administer another screen, but must include a written discussion of the findings of the earlier trauma screen and the clinical relevance of those findings to the child's presenting problems as required.
(7) A summary of a strengths and culture discovery or assessment completed upon admission or within 7 days of admission.
(8) How the activities and services provided by the RTF will address the biopsychosocial needs of a child.
(c) An RTF shall retain documentation of the prior approval of the administrator of the Interstate Compact on the Placement of Children in the record of a child admitted from outside of this Commonwealth.
(d) If a child is readmitted to the same RTF within 5 days, the readmission will not be considered a new admission for MA program purposes, but rather a continuation of the original admission.
§ 23.223. Development of the ISP.
(a) A preliminary treatment plan addressing a child's behavioral health needs shall be completed within 24 hours of admission.
(b) An ISP shall be developed for a child within 14 calendar days of a child's admission and include the following:
(1) A comprehensive strengths-based treatment plan addressing the behavioral health needs of a child and based on a diagnostic evaluation and the information related to a child's trauma screen and history demonstrating that trauma-related factors are being addressed in clinical treatment.
(2) Medical needs of a child, including medications.
(3) Psychological, social, behavioral and developmental needs of a child that reflect the need for RTF admission.
(c) The ISP shall be developed by an ISPT, an independent team comprised of the following:
(1) The child.
(2) The child's parents and, when applicable, the child's guardian or custodian.
(3) A person invited by the child or the child's parent.
(4) A contracting agency representative.
(5) A representative of the county Mental Health/Mental Retardation Program.
(6) A prescribing or treating psychiatrist or other clinician who will be working with the child.
(7) A representative of the CCYA or JPO if the child is in the child welfare or juvenile justice system.
(8) A child's Behavioral Health MCO.
(9) A representative of the responsible school district if written parental consent has been obtained.
(10) A physician.
(d) The treatment plan portion of the ISP addressing a child's behavioral health needs shall be developed by the treatment team, which must be an interdisciplinary team of physicians and other personnel who are employed by, or provide services to children in, the RTF.
(1) The treatment team shall:
(i) Assess a child's immediate and long-range therapeutic needs, developmental priorities, and personal strengths and limitations.
(ii) Assess the potential resources of a child's family.
(iii) Set treatment objectives.
(iv) Prescribe therapeutic modalities to achieve a plans objective.
(2) The treatment team must include a board-eligible or board-certified psychiatrist and one of the following:
(i) A psychiatric social worker.
(ii) An RN with specialized training or 1 year of experience in treating children with a serious mental illness or emotional or behavioral disorder.
(iii) A licensed occupational therapist who has specialized training or one year of experience in treating children with a serious mental illness or behavioral disorder.
(iv) A psychologist who has a master's degree in clinical psychology or who has been licensed by the Commonwealth.
(e) At least 3 phone or written contacts shall be made at least 2 weeks in advance to invite the child and the child's parent and, when applicable, a guardian or custodian, to participate in the development of the ISP at a time and location convenient for the child and the child's parent, and when applicable, the child's guardian or custodian, and the RTF.
(f) Documentation of a contact made to involve a child's parent and, when applicable, guardian or custodian shall be kept in the child's record.
(g) Persons who participated in the development of the ISP shall sign and date the ISP, with the exception of the child, the child's parent and, when applicable, the child's guardian or custodian, who shall be given the opportunity to, but are not required to, sign the ISP. Disagreement with the ISP or refusal to sign the ISP shall be documented in the child's record.
§ 23.224. Content of the ISP.
An ISP should reflect the needs, strengths, culture and priorities of a child and the child's family, and include the following:
(1) A treatment plan that is written in language understandable to the child and the child's family, and includes the following:
(i) Developmentally appropriate, asset-building treatment goals and objectives, such as building functional competencies.
(ii) Biologic, psychological and social interventions.
(iii) The child's identified priorities.
(iv) The environments in which the child exhibits a behavioral health treatment need.
(v) An explanation of the appropriate settings and time allocations for an intervention.
(vi) A detailed description of changes or updates from previous treatment plans.
(vii) Documentation of the continued clinical need for the service.
(viii) Detailed information to assist the staff with a comprehensive understanding of the specific interventions and objectives with which the staff will be assisting a child in attaining goals.
(2) Evaluation of the child's skill level for a goal.
(3) Monthly documentation of the child's progress on each goal.
(4) Services and training that meet the child's needs, including the child's needs for safety, competency development and permanency.
(5) A component addressing family involvement including, when applicable, the collaborative efforts with a High-Fidelity Wraparound Team.
(6) A plan to teach the child health and safety skills including the following:
(i) Nutrition and food selection.
(ii) Exercise.
(iii) Physical self-care.
(iv) Sleep.
(v) Coping skills.
(vi) Relaxation approaches.
(vii) Personal interests for constructive use of leisure time.
(viii) Substance use and abuse.
(ix) Personal safety.
(x) Healthy interpersonal relationships.
(xi) Services to others.
(xii) Decision-making skills.
(7) A component addressing how a child's education needs will be met in accordance with applicable Federal and State laws and regulations.
(8) The anticipated duration of the stay at the RTF.
(9) Discharge and aftercare plan to be addressed during monthly treatment team meetings and during ISPT meetings to ensure continuity of care with a child's family, school and community upon discharge.
(10) Methods to be used to measure progress on the ISP, including who is to measure progress and the objective criteria to be used.
(11) The name of the person responsible for coordinating the implementation of the ISP.
(12) Medical needs, including medication.
§ 23.225. Review and revision of the ISP.
(a) A review of a child's progress on the ISP, and a revision of the ISP if needed, shall be completed at least every 30 days.
(b) A child's ISP shall be revised if one of the following occur:
(1) There has been no progress on a goal.
(2) A goal is no longer appropriate.
(3) A goal needs to be modified.
(4) A goal needs to be added.
(c) A review and revision of the ISP shall be completed in accordance with § 23.223(b)(1) (relating to development of the ISP.)
(d) An RTF shall notify and invite a child's parents and, when applicable, a guardian or custodian, to participate in the review of the ISP and consider making changes based on a child's clinical course. Parent, and when applicable, guardian or custodian involvement is also to be obtained for a change in type of psychotropic medication.
(e) A child and the child's parent and, when applicable, guardian or custodian, shall contribute to the development, review and revision of a child's ISP.
§ 23.226. Implementation of the ISP.
(a) An RTF shall implement an ISP as written.
(b) An RTF is responsible to assign sufficient staff responsible for the implementation of the ISP, including the treatment plan.
§ 23.227. Copies of the ISP.
(a) A copy of an ISP, revisions to an ISP and monthly documentation of progress shall be provided to the child if the child is over 14 years of age, the parent and, when applicable, the child's guardian or custodian, the contracting agency and a person who participated in the development of or revision to the ISP.
(b) A copy of an ISP, revisions to an ISP and monthly documentation of progress shall be kept in the child's record.
§ 23.228. Behavioral health treatment.
(a) An RTF shall provide behavioral health treatment that is built on the competencies of a child and the child's family, while addressing specific needs of the child including culture, treatment history and family relationships.
(b) Behavioral health treatment must include, at a minimum, the following, which shall be provided as needed:
(1) Individual psychotherapy, group psychotherapy, family therapy and other therapeutic interventions, using evidence-based approaches, when possible, as indicated in the treatment plan, which addresses both the child's presenting behaviors and underlying mental health issues and, when clinically indicated, co-occurring issues to include mental health and substance abuse.
(2) Alternative approaches for a child when individual or group psychotherapy modalities are not considered effective treatment approaches, such as with a child with ASD, alternative approaches must be used.
(3) Both resiliency-promoting therapeutic milieu and trauma-informed care, characterized by supporting dignity, respect and hope, as part of both individual and group programming that includes the following:
(i) Community meetings.
(ii) Prosocial peer groups.
(iii) Psychoeducation groups.
(4) Social skills consistent with a child's successful adaptation to both society norms and a child's individual community.
(5) Age-appropriate training about maintenance of good physical health including, with the permission of a parent and, when applicable, a guardian or custodian, the prevention of sexually transmitted diseases including HIV/AIDS.
(6) Special individualized activities, relevant to a child's medical or physical needs.
(7) Use of psychotropic medication, when indicated.
(8) Training in daily living skills and community access skills.
§ 23.229. Education.
(a) Under 22 Pa. Code Chapters 11, 14 and 15 (relating to student attendance; special education services and programs; and protected handicapped students), a child who is of compulsory school age shall participate in a school program approved by the Department of Education or an educational program under contract with the LEA.
(b) The decision regarding the education portion of a child's day is to be made on an individualized basis utilizing the most integrated setting, with input from members of the ISPT, local public education officials and the child's home school district.
§ 23.230. Discharge and aftercare planning.
(a) A child's discharge and aftercare planning shall occur at a treatment team meeting and must be child centered and incorporate the following:
(1) Short-term goals, such as participation in a sport, community activity or religious organizations.
(2) Long-term life goals, including attainment of independent living and vocational skills and other special skills, such as playing a musical instrument or attending postsecondary education.
(3) A psychiatric discharge summary or final evaluation for a child receiving or who has received psychotropic medication during the child's RTF stay.
(b) Prior to discharge, the RTF shall schedule an appointment with the community behavioral health agency that will provide aftercare and submit documents related to the child's care in the RTF to that behavioral health agency.
(c) Within 14 days prior to discharge, the RTF shall submit the discharge summary to the community behavioral health agency providing aftercare.
(d) For each child receiving or who has received psychotropic medication during the child's RTF stay, the clinical rational for psychotropic medication shall be clearly documented on the child's psychiatric discharge summary or final evaluation.
(e) Prior to the transfer or discharge of a child, the RTF shall inform, and discuss with the child's parent and, when applicable, the child's guardian or custodian, the recommended transfer or discharge. Documentation of the discussion or transmission of the information shall be kept in a child's record.
(f) No later than 10 days after discharge, if a child was placed in the RTF by another state, the RTF shall document in the child's record that the administrator of the Interstate Compact on the Placement of Children was notified of the discharge.
(g) An RTF shall follow up with a child and family by telephone, 15 and 30 days postdischarge to determine if the child is receiving community-based behavioral health services, as identified in the discharge and aftercare plan.
(h) If, as a result of the RTF telephonic contact at 15 or 30 days postdischarge with a child and family, the RTF learns that a child is not receiving community-based behavioral health services, the primary contact or other designated staff, with child and family consent, shall contact the community-based behavioral health provider, the county MH/MR office, or the CASSP Coordinator to facilitate the provision of the community-based behavioral health services. The outcome of this telephonic contact shall be documented in a child's record.
CHILD RECORDS § 23.241. Emergency information.
(a) Emergency information shall be easily accessible at an RTF and documented in a child's record.
(b) Emergency information for a child must include the following:
(1) The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.
(2) The name, address and telephone number of the child's physician or other source of health care, health insurance and MA information.
(3) The name, address and telephone number of the person able to give consent for medical treatment, if needed.
(4) A copy of the child's most recent health examination.
§ 23.242. Child records.
(a) A separate record shall be kept for a child.
(b) Entries in a child's record must be legible, dated and signed by the person making the entry. The record shall be maintained in an organized and competent manner.
§ 23.243. Content of child records.
A child's record must include the following:
(1) Personal information including:
(i) Name, sex, admission date, birth date and Social Security number.
(ii) Race, height, weight, color of hair, color of eyes and identifying marks.
(iii) Dated photograph of the child taken within the past year.
(iv) Language spoken or means of communication understood by a child and the primary language used by a child's family, if other than English.
(v) Religious affiliation.
(vi) Emergency information required under § 23.241(b) (relating to emergency information).
(2) Physical health records.
(3) Dental, vision and hearing records.
(4) Health and safety assessments.
(5) Behavioral health evaluations during the course of treatment, including psychiatric evaluations, psychological evaluations and psychological testing results, if obtained.
(6) ISP and ISP revisions and summaries of ISP reviews.
(7) Restrictive procedure records relating to the child as required under § 23.206 (relating to restrictive procedure records).
(8) Reports of reportable incidents, as specified in § 23.17 (relating to reportable incidents).
(9) Consent to treatment, as specified in § 23.20 (relating to consent to treatment).
(10) A court order, if applicable.
(11) Admission information specified in §§ 23.221 and 23.222 (relating to description of services; and admission process).
(12) Signed notification of rights, grievance procedures and applicable consent to treatment protections specified in § 23.31 (relating to notification of rights, grievance procedures and consent to treatment protections).
(13) Service records of the contracting agency.
(14) Education records.
(15) Current treatment plans.
(16) Past treatment plans.
(17) Special consultations or assessments completed or requested.
(18) Progress notes that document a child's participation in individual therapy, group therapy, family therapy and other therapeutic interventions.
(19) Documentation of a child's progress toward meeting treatment goals.
(20) Documentation of the family's participation in planning and treatment and ongoing efforts of the RTF to accommodate family schedules and encourage participation.
(21) Current psychotropic medication and documentation of regular medication reviews and the clinical rationale for the psychotropic medication including the following:
(i) A change in medication documented in a medication order.
(ii) Documentation of the administration of a prescribed medication, including dosage, route of administration, staff administering and signature of staff administering.
(22) Documentation of goals of therapeutic leave and the outcomes and reviews following therapeutic leave.
§ 23.244. Record retention.
(a) A child's record shall be kept in a locked location when unattended.
(b) Information in a child's record shall be kept for at least 6 years or until an audit is final or litigation is resolved.
(c) A child's record shall be kept for at least 6 years following a child's discharge or until an audit is final or litigation is resolved, whichever is later.
RTFs SERVING NINE OR MORE CHILDREN § 23.251. Additional requirements.
In addition to the other provisions of this chapter, this section and §§ 23.252—23.257 apply to an RTF serving nine or more children.
§ 23.252. Sewage system approval.
An RTF that is not connected to a public sewer system shall have a written sanitation approval for its sewage system by the sewage enforcement official of the municipality in which the RTF is located.
§ 23.253. Evacuation procedures.
Written emergency evacuation procedures and an evacuation diagram specifying directions for egress in the event of an emergency shall be posted in a conspicuous place.
§ 23.254. Exit signs.
(a) Signs bearing the word ''EXIT'' in plain legible letters shall be placed at an exit.
(b) If the exit or way to reach the exit is not immediately visible, access to an exit shall be marked with readily visible signs indicating the direction of travel.
(c) Exit sign letters must be at least 6 inches in height with the principle strokes of letters at least 3/4 inch wide.
§ 23.255. Laundry.
(a) There shall be a laundry area which is separate from kitchen, dining and other living areas.
(b) Soiled linen shall be covered while being transported through food preparation and food storage areas.
§ 23.256. Dishwashing.
(a) Utensils used for eating, drinking, preparation and serving of food or drink shall be washed, rinsed and sanitized after each use by a mechanical dishwasher or by a method approved by the Department of Agriculture.
(b) A mechanical dishwasher must use hot water temperatures exceeding 140° F in the wash cycle and 180° F in the final rinse cycle or shall be of a chemical sanitizing type approved by the National Sanitation Foundation.
(c) A mechanical dishwasher shall be operated in accordance with the manufacturer's instructions.
§ 23.257. Child bedrooms.
A child's bedroom may not be more than 200 feet from a bathtub or shower and toilet.
Subchapter C. PARTICIPATION REQUIREMENTS SCOPE OF BENEFITS
Sec.
23.281. Scope of benefits. CONDITIONS FOR MA PAYMENT
23.282.
Policy. PROVIDER PARTICIPATION
23.291. General participation requirements for an RTF. 23.292. Participation requirements for an out-of-State RTF. 23.293. Participation requirements for an RTF that treats children for drug and alcohol diagnosis in conjunction with a diagnosed mental illness or serious emotional or behavioral disorder. 23.294. Ongoing responsibilities of an RTF. 23.295. Changes of ownership or control.
SCOPE OF BENEFITS § 23.281. Scope of benefits.
(a) A child who is an MA recipient is eligible for medically necessary RTF services provided by an RTF enrolled in the MA Program.
(b) A child who is receiving services in an accredited RTF the day preceding the date of the child's 21st birthday continues to be eligible for RTF services until RTF services are no longer medically necessary or the individual is 22 years of age, whichever occurs first.
CONDITIONS FOR MA PAYMENT § 23.282. Policy.
(a) The Department pays for medically necessary services rendered to an eligible individual, as specified in § 23.281 (relating to scope of benefits), by an RTF enrolled in the MA Program.
(b) Payment in the fee-for-service delivery system is made for services provided by an RTF subject to the provisions of this chapter and Chapter 1101 (relating to general provisions).
(c) Payment in the managed care delivery system is made for services provided by an RTF subject to the provisions of this chapter and Chapter 1101, except that the Department may delegate responsibilities to the behavioral health managed care organizations as specified in § 23.319 (relating to Department delegation of responsibility to behavioral health managed care organizations).
(d) Payment for absence without authorization is as follows:
(1) The Department will make payment for up to 2 days of absence without authorization from an RTF when the following conditions are met:
(i) Upon determining that a child is absent without authorization, an RTF shall file a police report and notify the JPO if the child has one. The RTF shall also conduct a search of the RTF buildings, grounds and offsite areas where the staff believes the child might have gone.
(ii) If a child cannot be located within 2 hours of the initial determination that the child is missing, the RTF shall notify the following:
(A) The County MH/MR Office.
(B) The CCYA, if the child is in its custody.
(C) The supervising juvenile court, if the child is under the supervision of the juvenile court.
(D) The child's responsible family member or legal guardian, as appropriate.
(iii) An RTF shall search offsite for at least 4 hours during each 24-hour period that the child is absent without authorization.
(iv) When the child is found or returns voluntarily, the RTF shall notify previously notified parties that the child is no longer absent without authorization.
(v) An action taken to locate the child during the child's absence without authorization and the required notifications shall be documented in the child's medical record. Documentation of onsite and offsite searches must specify the date and hours of search, where the search was conducted, any pertinent findings and be signed by staff that conducted the search.
(2) If the child is readmitted to the same RTF within 5 days, the readmission will not be considered a new admission for program purposes but, rather, a continuation of the original admission.
PROVIDER PARTICIPATION § 23.291. General participation requirements for an RTF.
(a) The Department will regulate participation in the MA program and may refuse to allow an RTF to participate in the MA program. Before allowing enrollment, the Department will consider the MA Program's need for additional RTF services in the RTF's primary service area as the most important factor in determining whether to grant or deny a request for enrollment as an RTF.
(b) In addition to the participation requirements established in Chapter 1101 (relating to general provisions), to participate in the MA Program, an RTF shall:
(1) Be licensed by the Department as an RTF under this chapter.
(2) Have a service description approved by the Department.
(3) Provide the services described in the service description at the location stated in the service description.
(4) Have in effect a utilization review plan that meets the requirements set forth at 42 CFR Part 456, Subpart D (relating to utilization control: mental hospitals) and provide psychiatric services that meet the requirements of 42 CFR Part 441, Subpart D (relating to inpatient psychiatric services for individuals under age 21 in psychiatric facilities or programs).
(5) Be in compliance with Federal restraint and seclusion requirements and attest annually by July 21 of each year that the facility is in compliance with 42 CFR Part 483, Subpart G (relating to condition of participation for the use of restraint or seclusion in psychiatric residential treatment facilities providing inpatient psychiatric services for individuals under age 21) on a Department-specified form. A facility enrolling as a Medicaid provider shall meet this requirement at the time it executes a provider agreement with the Medicaid agency.
(6) Have a transfer agreement with an acute care hospital and inpatient psychiatric hospital.
(7) Receive and maintain accreditation as a child and adolescent RTF by CARF, COA, JCAHO or by another accrediting body approved by the Department as published in a notice in the Pennsylvania Bulletin.
(8) Provide services under the direction of a board-certified or board-eligible psychiatrist.
(9) Meet all ISP requirements as specified in § 23.223 (relating to development of the ISP).
(10) Meet all prior authorization and certification of need requirements as specified in § 23.314 (relating to evaluations and treatment plans).
§ 23.292. Participation requirements for an out-of-State RTF.
An out-of-State RTF shall meet the following requirements:
(1) Be licensed and participate in the Medicaid Program of the state in which the RTF is located, if that state recognizes facilities which provide equivalent services.
(2) Have a service description that meets the requirements in this chapter.
(3) Have a ban on prone restraint.
(4) Meet the requirements established in Chapter 1101 (relating to general provisions) and § 23.291(b)(2)—(8) (relating to general participation requirements for an RTF).
§ 23.293. Participation requirements for an RTF that treats children for drug and alcohol diagnosis in conjunction with a diagnosed mental illness or serious emotional or behavioral disorder.
An RTF that treats children for drug and alcohol conditions shall:
(1) Meet the requirements established in § 23.291 (relating to general participation requirements for an RTF).
(2) Be licensed by the Department of Health to provide drug and alcohol treatment services, unless the RTF contracts with a licensed drug and alcohol agency to provide substance abuse treatment services.
(3) Comply with the Department's current requirements for co-occurring competent service provision found at www.pa-co-occurring.org, including universal screening and assessment for co-occurring disorders, referral protocols for appropriate interventions, the employment of qualified professionals to treat co-occurring disorders and certification as a co-occurring competent RTF.
§ 23.294. Ongoing responsibilities of an RTF.
In addition to the ongoing responsibilities established in § 1101.51 (relating to ongoing responsibilities of providers), an RTF shall:
(1) Comply with State and Federal regulations, statutes, policies and procedures.
(2) Maintain current agreements with general and psychiatric hospitals, community-based mental health services, drug and alcohol services and, to the extent necessary, other RTFs for the prompt and appropriate transfer or referral of a child who requires or may be expected to require care in another setting.
(3) Furnish complete and accurate copies if requested of a child's records and the RTF's fiscal records to the Department or its designees, or Federal and State reviewers within 14 days of the request, unless a different timeframe is specified in the request.
(4) Retain complete, accurate, legible and auditable clinical, medical and fiscal records as specified in § 23.244(a) and (b) (relating to record retention).
(5) Notify the Department of a program site change.
(6) Submit a new attestation that the facility is in compliance with 42 CFR Part 483, Subpart G (relating to condition of participation for the use of restraint or seclusion in psychiatric residential treatment facilities providing inpatient psychiatric services for individuals under age 21) when RTF management changes.
(7) Notify the Department of the RTF's plans for the orderly transfer of children within 5 days of notification from the Department of Health that it has determined that the RTF is out of compliance with 42 CFR Part 483, Subpart G and must close.
§ 23.295. Changes of ownership or control.
(a) If an RTF changes ownership and the new owner wishes to participate in the MA program, the RTF shall submit a new application on the form provided by the Department for participation in the MA program.
(b) When an RTF changes ownership, the Department will approve participation in the MA Program by the new owner if the Department determines the new owner to be eligible to participate in the MA program as described under § 23.291 (relating to general participation requirements for an RTF). The new ownership shall meet Federal and State requirements prior to approving the change.
Subchapter D. PAYMENT PROVISIONS PAYMENT FOR RTF SERVICES
Sec.
23.301. Allowable costs. 23.302. Income and offsets to allowable costs. 23.303. Bed occupancy. 23.304. Cost allocation. 23.305. Related-party transactions. 23.306. Costs, limitations and services excluded from the RTF per diem rate. 23.307. General payment policy. 23.308. Third-party liability. 23.309. Payment for services in an out-of-State RTF. 23.310. Billing requirements. 23.311. Annual cost reporting. 23.312. General rate-setting policy. 23.313. Financial records. 23.314. Evaluations and treatment plans. 23.315. Information required to request admission or continued stay. 23.316. Admission authorization and continued stay authorization
request.23.317. Authorization determination. 23.318. Effective date of coverage. 23.319. Department delegation of responsibility to behavioral health managed care organizations. UTILIZATION CONTROL
23.321. Scope of claim review process. 23.322. RTF utilization review. 23.323. Adverse determinations. INSPECTION OF CARE REVIEWS
23.331. Inspection of care reviews: general. 23.332. Inspection of care reports. ADMINISTRATIVE SANCTIONS
23.341. Provider abuse. 23.342. Administrative sanctions. PROVIDER RIGHT OF APPEAL
23.351. Provider right of appeal.
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