65E-9.007. Staffing

(1) Personnel procedures. The provider shall have written personnel procedures that, at a minimum, address the following items:

(a) The recruitment, retention, training and effective performance of qualified staff;

(b) The types and numbers of clinical, managerial and direct care staff needed to provide children with care and treatment in a safe and therapeutic environment;

(c) The requirement of the provider, as a mandated reporter, to report all suspected cases of child abuse, neglect and exploitation involving any employee, volunteer, or student to the Abuse Registry and the department, in accordance with Chapter 39 and Section 394.459, F.S.

(2) Staff communication. The provider’s personnel procedures shall ensure and require the inter-communication among staff of information regarding children necessary to the performance of each staff responsibility, including between working shifts, staff changes and consultations with professional staff. Where one staff member or one program group relies upon information provided through this required free interchange of information, these interactions shall be documented in writing and maintained in the respective children’s case files.

(3) Staff composition. The provider shall have the following staffing, any of which may be part-time, if the required equivalent full-time coverage is provided, except for those positions with a required specified staffing ratio:

(a) Psychiatrist.

1. For residential treatment centers, the provider shall have on staff or under contract a psychiatrist, licensed under Chapter 458, F.S., who is board certified or board eligible in child and adolescent psychiatry to serve as medical director for the program and such position shall oversee the development and revision of the treatment plan and the provision of mental health services provided to children. A similarly qualified psychiatrist who consults with the board certified psychiatrist may provide back-up coverage. A psychiatrist shall be on call “24 hours-a-day”, seven “days-a-week”, and shall participate in staffings. For children committed under Section 985.19, F.S., a psychologist as defined in paragraph 65E-9.007(3)(d), F.A.C., may be used in lieu of the medical director to oversee the development and revision of the treatment plan and the provision of mental health services provided to children.

2. For therapeutic group homes, the provider shall have on staff or under contract a board certified or board eligible psychiatrist or have a definitive written agreement with a board certified or board eligible psychiatrist or an organization to provide psychiatric services to children in the home, including participation in staffings.

(b) Medical doctor. The provider shall have an agreement with a pediatrician, family care physician, medical group or prepaid health plan to provide primary medical coverage to children in the facility.

(c) Registered nurse.

1. A registered nurse shall supervise the nursing staff during the times that the children are present in the facility and normally awake, the nursing staff to child ratio shall be no less than 1:30, and during normal sleeping hours, the nursing staff to child ratio shall be no less than 1:40.

2. For therapeutic group homes that do not use restraint or seclusion in their program, the provider is not required to have a registered nurse or other nursing staff on duty, but shall have definitive written agreements for obtaining necessary nursing services.

(d) Psychologist. Each provider shall have on staff or under contract, at a minimum, one licensed psychologist or have definitive written agreements with an individual psychologist or psychological organization to provide such services as needed.

(e) Direct care staff. At a minimum, two (2) direct care staff shall be awake and on duty at all times. In addition, the following direct care staff-to-child ratios shall be provided and maintained:

1. During hours when children are present in the facility and normally awake, the direct care staff to child ratio shall be no less than 1:4; and

2. During hours when the children are normally asleep, the direct care staff to child ratio shall be no less than 1:6; and

3. While residents are away from the facility, the staffing ratio for those residents shall be no less than 1:4. The need for more intensive staffing will be determined by the child's physician; and

4. Direct care staff shall not divide time on their shift between programs located in other areas of the facility or other buildings; and

5. While transporting residents of residential treatment centers other than group homes, the driver shall not be counted as the direct care staff providing care, assistance or supervision of the child. For therapeutic group home residents, prior to a single staff person transporting one or more children in a motor vehicle, children must be assessed to ensure the safety of the children and staff.

(f) If the provider’s program includes behavior analysis services, a certified behavior analyst, a master’s level practitioner, or professionals licensed under Chapter 490 or 491, F.S., with documented training and experience in behavior management program design and implementation shall be employed on staff or under contract, either full-or part-time, to provide ongoing staff training and quality assurance in the use of the behavior management techniques, which may include, but are not limited to those listed in sub-subparagraph 65E-9.007(5)(e)4.c., F.A.C.

(g) The provider shall be able to demonstrate and provide as necessary, upon request, the ability to acquire and the past uses of the consultation services of dieticians, speech, hearing and language specialists, recreation therapists, and other specialists, when same will be or has been needed.

(4) Staff qualifications.

(a) The administrator shall have a master’s degree in administration or be of a professional discipline such as social work, psychology, counseling, or special education and have at least two years administrative experience. The administrator may be a corporate administrator, who is not located on site. If the administrator is not routinely located on site, an individual qualified by training and experience who is routinely located on site must be appointed in writing to act as the administrator’s designee. A person with a baccalaureate degree may also qualify for administrator with seven years experience of child and adolescent mental health care and three years administrative experience. Persons occupying this position upon promulgation of this rule may be allowed to continue in this position.

(b) The medical director shall have experience in the diagnosis and treatment of child and adolescent mental health and be board certified or board eligible in psychiatry with the American Board of Psychiatry.

(c) The clinical director shall have a minimum of a master’s degree and at least two years of “specialty” experience in a clinical capacity with severely emotionally disturbed children. If the clinical director is not full-time, there shall be a full-time service coordinator who is a master’s level practitioner.

(d) Individual, group and family therapy shall be provided by a licensed practitioner, pursuant to Florida Statutes, that includes a psychiatric advanced registered nurse practitioner, psychologist, psychiatrist, clinical social worker, mental health counselor or a master’s level individual working under the direct supervision of a licensed practitioner, as listed above.

(e) Staff responsible for treatment and discharge planning shall have a minimum of a bachelor’s degree in psychology, counseling, social work, special education, health education or related human services field with at least two years of experience working with children with emotional disturbance. These staff shall be supervised by a master’s level clinician.

(f) Direct care staff employed to work directly with children shall be at least 18 years of age and have a high school diploma or general education development (GED) certificate. Persons occupying this position upon promulgation of this rule may be allowed to continue in this position.

(5) Staff orientation and training.

(a) The provider shall have, and implement on an ongoing basis, a written plan for the orientation, ongoing training, and professional development of staff.

(b) The provider shall implement orientation and training programs for all new employees and ongoing staff training to increase knowledge and skills and improve quality of care and treatment services.

(c) The provider shall conduct orientation for each new employee during the first 2 months of employment. The orientation shall include specific job responsibilities, policies and procedures, care and supervision of children, and competency-based first aid and CPR.

(d) The provider shall document training received by staff, including staff name and position, training subject, date completed and signature of instructor. The documented training shall be filed in the staff member’s personnel record and be available for review by the department and the agency.

(e) The provider shall implement a minimum of 40 hours of in-service training annually for all staff and volunteers who work directly with children. Continuing education for professional licenses and certifications may count towards training hours if the training covers the appropriate areas. This training shall cover all policies and procedures relevant to each position and shall, at a minimum, include each of the following:

1. Administrative:

a. Administrative policies and procedures and overall program goals;

b. Federal and state laws and rules governing the program;

c. Identification and reporting of child abuse and neglect;

d. Protection of children’s rights; and

e. Confidentiality.

2. Safety:

a. Disaster preparedness and evacuation procedures;

b. Fire safety;

c. Emergency procedures;

d. Violence prevention and suicide precautions; and

e. First aid and CPR, with competency demonstrated annually.

3. Child development:

a. Child supervision skills;

b. Children’s physical and emotional needs;

c. Developmental stages of childhood and adolescence;

d. Family relationships and the impact of separation;

e. Substance abuse recognition and prevention; and

f. Principles and practices of child care.

4. Treatment services:

a. Individualized treatment that is culturally competent;

b. Treatment that addresses issues the child may have involving sexual or physical abuse, abandonment, domestic violence, separation, divorce, or adoption;

c. Behavior management techniques include, but are not limited to: preventing problem behavior, defining and teaching expectations, teaching and encouraging the child’s long-term use of new skills as alternative behaviors, contingency management, teaching and promoting choice making and self-management skills, time-out, point systems or level systems, de-escalation procedures, and crisis prevention and intervention;

d. Treatment plan development and implementation;

e. Treatment that supports the child’s permanency goals; and

f. The provider shall ensure ongoing training and be able to produce documentation of such training on the use of restraint and seclusion, physical escort, time-out, de-escalation procedures and crisis prevention and intervention.

(I) Before staff may participate in any use of restraint or seclusion, staff shall be competency trained to minimize the use of restraint and seclusion, to use alternative, non-physical, non-intrusive behavioral intervention techniques to handle agitated or potentially violent children, and to use restraints and seclusion safely.

(II) Staff shall complete a training course in the safe and appropriate use of seclusion and restraint and in the use of alternative non-intrusive behavior management techniques. The training course shall be provided by individuals qualified by education, training, and experience to provide such training. Competencies shall be demonstrated on a semiannual basis. Training requirements for all staff who participate in the use of restraint and seclusion shall include:

(A) An understanding of the underlying causes, e.g., medical, behavioral and environmental, of consequential behaviors exhibited by the children being served;

(B) How staff behaviors can affect the behaviors of others, especially children with a history of trauma;

(C) The use of non-physical interventions, such as de-escalation, mediation, active listening, self-protection and other techniques, such as time-out for the purpose of preventing potential and intervening in emergency safety situations;

(D) Recognizing signs of respiratory and cardiac distress in children;

(E) Recognizing signs of depression and potential suicidal behaviors;

(F) Certification in the use of cardiopulmonary resuscitation (CPR). Competency based re-certification in CPR is required annually;

(G) How to monitor children in restraint or seclusion; and

(H) The safe use of approved restraint techniques, including physical holding techniques, take-down procedures, and the proper application, monitoring and removal of restraints.

(III) Training requirements for staff who are authorized to monitor a child’s condition and perform assessments while the child is in seclusion or restraint shall include:

(A) Taking vital signs and interpreting their relevance to the physical safety of the child;

(B) Tending to nutritional and hydration needs;

(C) Checking circulation and range of motion in the extremities;

(D) Addressing hydration, hygiene and elimination;

(E) Addressing physical and psychological status and comfort;

(F) Assisting children to de-escalate to a point that would allow for the discontinuation of restraint or seclusion;

(G) Recognizing when the emergency safety situation has ended and the safety of the child and others can be ensured so the restraint or seclusion can be discontinued; and

(H) Recognizing the need for and when to contact a medically trained licensed practitioner or emergency medical services in order to evaluate and treat the child’s physical status.

(6) Volunteers and students.

(a) A provider that uses volunteers to work directly with children shall:

1. Screen the volunteers in accordance with Section 394.4572, F.S.;

2. Develop descriptions of duties and specific responsibilities expected of each volunteer;

3. Provide orientation and training, including policies and procedures, the needs of children in care, and the needs of their families;

4. Ensure that volunteers who perform any services for children have the same qualifications and training as a paid employee for the position and receive the same supervision and evaluation as a paid employee; and

5. Keep records on the hours and activities of volunteers.

(b) A provider that accepts students who will have direct contact with residents shall:

1. Screen the students in accordance with Section 394.4572, F.S.;

2. Develop, implement, and maintain on an ongoing basis a written plan describing student tasks and functions. Copies of the plan shall be provided to each student and his or her school;

3. Designate a staff member to supervise and evaluate the students and conduct orientation and training, including policies and procedures, the needs of children in care and the needs of their families;

4. Ensure that students do not assume the total responsibilities of any paid staff member (students shall not be counted in the staff to client ratio).

Specific Authority 394.875(8) FS. Law Implemented 394.875 FS. History–New 7-25-06, Amended 9-24-08.