Riders on the Storm Rule 31 compliance in the first nine months.

Riders on the Storm

Rule 31 compliance in the first nine months

• Presented by Rick Moldenhauer, MS, LADC, ICADC, LPC

Treatment Services Consultant/State Methadone Authority

P: (651) 431 2474F: (651) 431 7449Chemical Health Division, DHSPO Box 64977St Paul, Minnesota [email protected]

RULE 31 TABLE OF CONTENTS

Part Number Title

9530.6405 Definitions

9530.6410 Applicability

9530.6415 Licensing Requirements

9530.6420 Initial Service Plans

9530.6422 Comprehensive Assessment

9530.6425 Individual Treatment Plans

9530.6430 Treatment Services

9530.6435 Health Care Services

9530.6440 Client Records

9530.6445 Staffing Requirements

9530.6450 Staff Qualifications

9530.6455 Provider Policies and Procedures

9530.6460 Personnel Policies and Procedures

9530.6465 Service Initiation and Termination Policies

9530.6470 Policies and Procedures/Client Rights

9530.6475 Emergency Procedures

9530.6480 Evaluation

9530.6485 Additional Requirements/Adolescents

9530.6490 Additional Requirements/Clients with Children

9530.6495 Additional Requirements/Co-occurring Mental Health

9530.6500 Additional Requirements/Methadone

9530.6505 Additional Requirements/Room and Board

Rule 31 Programs as of 09/30/05

• # of programs: 280• # serving adolescents:

133• # serving clients with

children: 1

• # serving co-occurring: 4

• # serving methadone: 7

• # providing room and board: 89

Rule 31 Program surveys released as of 9/30/05

• # of programs: 44• # total citations 1338• Mean: 30.41• Range 1-117

Generally Speaking• Six stated they had not

prepared for Rule 31• Three were given

Conditional Licenses• 1338 total citations to date

(09/29/05)

• 44 released 1/1/05-9/30/05• Jan 05: none• Feb 05: 7• March 05: 6• April 05: 7• May 05: 4• June 05: 8• July 05: 4• August 05: 7• Sept 05: 1

Analysis by section• 1) Postings/Physical plant• 2) Policies, Procedures and Practices• 3) Vulnerable Adult• 4) Client Recordkeeping• 5) Personnel Policies• 6) Staffing Requirements• 7) Personnel Files• 8) Client Records

Citations by month

• Jan:• Feb:

11,12,10,12,34,30,28• Mar: 35, 19, 99, 111,

30• Apr: 26, 5, 9, 25, 21,

113, 9• May: 8, 26, 22, 15

• June: 25, 27, 20, 18, 22, 1, 18, 15,

• July: 23, 19, 19, 1• Aug: 1, 1, 21, 117,

117, 117, 24 1, • Sept: 18

CORRECTIVE ACTION ORDERED FOR VIOLATIONS

For those violation(s) that were not corrected during the licensing review, corrective action for each violation is required by Minnesota Statutes, section 245A.06, and is hereby ordered by the Commissioner of Human Services. Beginning immediately, and on a continuing basis, you must ensure compliance with all applicable laws and rules. Evidence of correction must be submitted to DHS Licensing by _______________________ only for those violations that are identified by a check in the seventh column entitled "Submission Required." All documentation and other evidence of compliance required by this correction order must be submitted to the Department of Human Services, Division of Licensing, 444 Lafayette Road, St. Paul, Minnesota 55155-3842. Failure to correct the violations within the prescribed amount of time may result in fines and/or action against your license, as provided for in Minnesota Statutes, sections 245A.06 and 245A.07.

Announced Visit Unannounced Visit

VIOLATIONS AND CORRECTION ORDERS

At the time of the licensing review on ______________________________________________, the following _______ violation(s) of state and (or) federal laws and rules were observed. Each violation is identified in numerical order in the first column titled “Violation Number.”

Violations that were corrected during the licensing review are indicated in the sixth column titled "Corr. on Site." During the licensing review, ________ violation(s) were corrected and no further corrective action is necessary. These violations are listed to assist in ensuring ongoing compliance with all applicable rule requirements.

Violations that were included in the Order from the last licensing review, and any subsequent Order(s) issued by DHS Licensing, are identified by a check in the third column, titled “Prev. Cited.”

Compliance with licensing requirements are indicated in the fifth column, titled “Item met or not met” using the following codes: (+) denotes that there was no violation of the applicable law or rule; (-) denotes a violation of the applicable law or rule; (NR) denotes the applicable law or rule was not reviewed and (NA) denotes the law or rule was not applicable.

Program Name: ________________________________ Address: _________________________________________________________

License Number: _______________ Type of License: _______________ Licensor(s): __________________________________________

Initial Licensing Review Full Review Modified Review

LICENSING REVIEW REPORT AND CORRECTION ORDER

Date Correction Order Issued: _________________ License Holder Representative who received this report: __________________________

Postings

Maltreatment of MinorsMALTREATMENT OF MINORS REPORTING POLICY

Who Should Report Child Abuse and Neglect Any person may voluntarily report abuse or neglect. If you work with children in a licensed facility, you are legally required or mandated to report and cannot shift

the responsibility of reporting to your supervisor or to anyone else at your licensed facility. If you know or have reason to believe a child is being or has been neglected or physically or sexually abused within the preceding three years you must immediately (within 24 hours) make a report to an outside agency.

Where to Report If you know or suspect that a child is in immediate danger, call 911.

All reports concerning suspected abuse or neglect of children occurring in a licensed facility should be made t o the Department of Human Services, Licensing Division’s Maltreatment Intake line at (651) 297 -4123.

Reports regarding incidents of suspected abuse or neglect of children occurring within a family or in the

community should be made to the local county social services agency at ________________ or local law enforcement at _______________.

If your report does not involve possible abuse or neglect, but does involve possible violations of Minnesota Statutes or Rules that govern the facility, you should call the Department of Human Services, Licensing Division at (651) 296-3971.

What to Report

A report to any of the above agencies should contain enough information to identify the child involved, any persons responsible for the abuse or neglect (if known), and the nature and extent of the maltreatment and/or possible licensing violations. For reports concerning suspected abuse or neglect occurring within a licensed facility, the report should include any actions taken by the facility in response to the incident .

An oral report of suspected abuse or neglect made to one of the above agencies by a mandated reporter must be followed by a written report to the same agency within 72 hours, exclusive of weekends and holidays.

Retaliation Prohibited

An employer of any mandated reporter shall not retaliate against the mandated reporter for reports made in good faith or against a child with respect to whom the report is made. The Reporting of Maltreatment of Minors Act contains specific provisions regarding civil actions that can be initiated by mandated reporters who believe that retaliation has occurred.

Failure to Report

A mandated reporter who knows or has reason to believe a child is or has been neglected or physically or sexually abused and fails to report is guilty of a misdemeanor. In addition, a mandated reporter who fails to report maltreatment that is found to be serious or recurring maltreatment may be disqualified from employment in positions allowing direct contact with persons receiving services from programs licensed by the Department of Human Services and by the Minnesota Department of Health, and unlicensed Personal Care Provider Organizations. THIS REPORTING POLICY SHOULD BE POSTED IN A PROMINENT LOCATION AND BE MADE AVAILABLE UPON REQUEST.

Vulnerable AdultMALTREATMENT OF VULNERABLE ADULTS REPORTING POLICIES

In Chemical Dependency Rehabilitation Programs federal law specifically prohibits a person from disclosing patient identifying information in connection with a report of suspected maltreatment, unless the vulnerable adult, or the vulnerable adult's guardian, conservator, or legal representative, has consented to disclosure in a manner which conforms to federal requirements. All residents are covered by this federal law. Verify that upon the resident's admission to the facility the resident , or a guardian, conservator, or legal representative has given written consent to the disclosure of suspected maltreatment. If no written consent is in the client’s file, you must immediately seek consent to make a report and are prohibited by federal law from reporting the incident of suspected maltreatment without that consent.

If you know or suspect that a vulnerable adult has been maltreated, you must report it

immediately (within 24 hours). You can report to the Common Entry Point at _______________________ (phone number). Or, you can report internally to (name or position) _________________________________.

If the individual listed above is involved in the alleged or suspected maltreatment, you must report to ___________________________________ (name or position).

When an internal report is received, _____________________________ (name or position) is responsible for deciding if the report must be forwarded to the Common Entry Point. If that person is involved in the suspected maltreatment, __________________________ (name or position) will assume responsibility for deciding if the report must be forwarded to the Common Entry Point. The report must be forwarded within 24 hours. If you have reported internally, you will receive, within two working days, a written notice that

tells you whether or not your report has been forwarded to the Common Entry Point. The notice will be given to you in a manner that protects your identity. It will inform you that, if you are not satisfied with the facility’s decision on whether or not to report externally, you may still make the external report to the Common Entry Point yourself. It will also inform you that you are protected against any retaliation if you decide to make a good faith report to the Common Entry Point.

An internal review of the report must be completed if the facility has reason to know that an

internal or external report of alleged or suspected maltreatment has been made. The review will be completed by _________________________________ (name or position). If this individual is involved in the alleged or suspected maltreatment, _____________________ (name or position) will be responsible for completing the internal review.

The internal review must include: whether related policies and procedures were followed;

whether the policies and procedures were adequate; whether there is a need for additional staff training; and whether further action is necessary to protect the health and safety of vulnerable adults.

The internal review must be documented, and made available to the Commissioner of the

Department of Human Services upon request. THIS REPORTING POLICY MUST BE POSTED IN A PROMINENT LOCATION, AND BE MADE AVAILABLE UPON REQUEST.

4747.1500

http://www.revisor.leg.state.mn.us/arule/4747/1500.html

626.556

http://www.revisor.leg.state.mn.us/stats/626/556.html

626.557


626.5572


144.651


Policies, Procedures and Practices

Polices, Procedures and Practices

Polices, Procedures and PracticesViolation Number

Applicable Law or Rule

Pre

v. C

ited

Requirement Item metor notmet

Cor

r. on

site

Sub

mis

sion

R

equi

red

Notes

9530.6505, subpart 3, items A-D (continuted)

Client Property Management (continued)D. The license holder returned all property held in trust to the client upon service termination regardless of the client's service termination status, except: . (1) drugs, drug paraphernalia, and drug containers that are forfeited under Minnesota Statutes, section 609.5316, were destroyed by staff or given over to the custody of a local law enforcement agency, according to Code of Federal Regulations, title 42, chapter 1, part 2, subpart B, sections 2.1 to 2.67-1; . (2) weapons, explosives, and other property which can cause serious harm to self or others were given over to the custody of a local law enforcement agency, and the client was notified of the transfer and the right to reclaim any lawful property transferred; and . (3) medications that were determined by a physician to be harmful after examining the client, except when the client's personal physician approved the medication for continued use.

ADDITIONAL CLIENT RIGHTS POLICIES AND PROCEDURES RESIDENTIAL PROGRAMS (continued)

Comments:

Polices, Procedures and Practices

Vulnerable Adult Maltreatment Prevention and Reporting Policies

Vulnerable Adult Maltreatment

Policies, Procedures and Practices-Client Recordkeeping

Client Recordkeeping

Personnel Policies, Procedures and Practices


Violation Number


Pre

v. C

ited

Requirement Item metor notmet

Cor

r. on

site

S

ubm

issi

on

Req

uire

d

Notes

9530.6460, subpart 1, items A-G (continued)

* D. described behavior that constitutes grounds for disciplinary action, suspension or dismissal, including: policies that address chemical use problems and that stated the timeline requirements for freedom from chemical use problems described in part 9530.6450, subpart 1. (Two years for treatment directors, supervisors, nurses, counselors, and other professionals. One year for paraprofessionals and all other staff with direct client contact. The time period begins to run on the date the employee begins receiving treatment services or the date of the last incident.)

policies prohibiting personal involvement (sexual contact) with clients or former clients within two years of receiving psychotherapy, in violation of Minnesota Statutes, chapter 148A.

policies prohibiting client abuse as specified under Minnesota Statutes, sections 245A.65, 626.556, 626.557, and 626.5572;

E. listed behaviors or incidents that are considered chemical use problems that included: 1. receiving treatment for chemical use within the period specified for the position in the staff qualification requirements; 2. chemical use that has a negative impact on the staff member's job performance; 3. chemical use that affects the credibility of treatment services with clients, referal sources, or other members of the community; and (4) symptoms of intoxication or withdrawal on the job.

PERSONNEL POLICIES, PROCEDURES and PRACTICESALL PROGRAMS - continued

Staffing Requirements

Personnel Files

Personnel FilesALCOHOL AND DRUG COUNSELOR

QUALIFICATIONSALL PROGRAMS continued

File A File B File C File D File E

* B. The personnel file of alcohol and drug counselor exempt under Minnesota Statutes, chapter 148C, contained documentation of competence, as evidenced by one of the following: (1) completion of at least a baccalaureate degree with a major or concentration in social work, nursing, sociology, human services, or psychology, or licensure as a registered nurse; successful completion of a minimum of 120 hours of classroom instruction in which each of the core functions listed in Minnesota Statutes, chapter 148C, is covered; and successful completion of 440 hours of supervised experience as an alcohol and drug counselor, either as a student or as a staff member;

(2) completion of 270 hours of alcohol and drug counselor training in which each of the core functions listed in Minnesota Statutes, chapter 148C, is covered, and successful completion of 880 hours of supervised experience as an alcohol and drug counselor, either as a student, or as a staff member;

(3) current certification as an alcohol and drug counselor or alcohol and drug counselor reciprocal, through the evaluation process established by the International Certification and Reciprocity Consortium Alcohol and Other Drug Abuse, Inc., and published in the Case Presentation Method Trainer's Manual, copyright 1993;

(4) completion of a bachelor's degree including 480 hours of alcohol and drug counseling education from an accredited school or educational program and 880 hours of alcohol and drug counseling practicum; or

Violation Number


Pre

v. C

ited

Requirement

Cor

r. on

site

Sub

mis

sion

R

equi

red

Notes

Personnel Files

9530.6450,subpart 5, item B

Personnel Files

Client Record Contents

Client Record ContentsViolation Number


Pre

v. C

ited

Requirement

Cor

r on

site

Sub

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R

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Notes

COMPREHENSIVE ASSESSMENTALL PROGRAMS (continued)

File 1 File 2 File 3 File 4 File 5

D. chemical use history including amounts and types of chemicals used, frequency of use, and period of abstinence;

E. specific problem behaviors exhibited by the client when under the influence of chemicals;

F. current family status, family history, including history or presence of physical or sexual abuse, level of family support, and chemical use, abuse, or dependency among family members and significant others;

G. physical concerns or diagnoses that may influence the treatment plan;

H. mental health history and current psychiatric status, including symptoms, disability, current treatment supports, and psychotropic medications needed to maintain stability;

I. Arrests and legal interventions related to chemical use;

J. Ability to function appropriately in a work and educational setting;

K. ability to understand written treatment materials, including rules and client rights;

L. risk-taking behavior, including behavior that puts the client at risk of exposure to blood borne or sexually transmitted diseases;

M. social network in relation to expected support for recovery and leisure time activities that have been associated with chemical use; and

N. a determination whether a client is a vulnerable adult as defined in Minnesota Statutes, section 626.5572, subdivision 21. An individual abuse prevention plan was required for all clients who met the definition of "vulnerable adult."

Client Files

Client Record Contents

RECOMMENDATIONS

The following recommendations are not requirements of Minnesota Rules or laws governing your services or facility. These recommendations are provided to call your attention to areas where your facility or service is in minimum compliance with the requirements of rules or laws, but it would be advisable to strengthen your efforts in these areas.

Failure to follow these recommendations will not result in a fine or action against your license at this time. However, should failure to follow recommendations result in a violation of rules or laws at a future date, you will be cited for noncompliance and may be subject to fines or action against your license.

http://www.leg.state.mn.us/leg/statutes.asp

Riders on the Storm Rule 31 compliance in the first nine months.

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