65E-9.006. Program Standards

(1) Additional standards for therapeutic group homes. The primary mission of the therapeutic group home is to provide treatment of serious emotional disturbance. Distinguishing features of a therapeutic group home include the following:

(a) Meets the requirements of a single-family unit or community residential home as defined in Chapter 419, F.S.; the home is a non-secure or unlocked facility;

(b) The use of mechanical restraint or drugs used as restraint is prohibited;

(c) If physical restraint is used, the following conditions shall be met:

1. Physical restraint must be applied only during potential emergency or crisis situations for no more than 30 minutes;

2. If the use of physical restraint is required during the child’s stay, the treatment team shall formally review the child’s treatment plan, at least monthly, and revise at the time of the review if determined necessary, to actively address and eliminate its use. As part of its review, the treatment team will determine whether implementation of an individual behavior plan is necessary, considering such factors as the frequency and duration of the physical restraint incidents and the age and cognitive ability of the child; and

3. The guidelines in Rule 65E-9.013, F.A.C., related to physical restraint shall be met in addition to those listed above.

(d) The use of seclusion is prohibited. If time-out is used, the provider shall comply with the procedures outlined in subsection 65E-9.013(11), F.A.C.;

(e) Children or adolescents must be medically stable;

(f) Children or adolescents being served attend school in the community and engage in community recreational and social activities;

(g) Treatment plan includes treatment and support services, goals and objectives designed to enable children being served to transition to a less restrictive level of care or be reunited with their family; and

(h) Treatment and other mental health services are provided in a family-like setting, and the provider may employ professional parents to staff the home.

(2) Collocation.

(a) Upon written approval of the department and the agency, a provider may collocate other programs with programs serving children admitted under Chapter 394 or Section 39.407, F.S.

(b) The collocated programs may share administration and facility services, such as housekeeping, food preparation, and maintenance.

(c) Children admitted to these other programs shall be separated from the other children by staff supervision and shall not co-mingle or share a common space at the same time.

(3) Treatment and services.

(a) Treatment shall be individualized, child and family centered, culturally competent, and based on the child’s assessed strengths, needs, and presenting problems that precipitated admission to the program.

(b) Treatment services shall be provided as part of an individualized written treatment, plan that complies with Rule 65E-9.009, F.A.C., of this chapter.

(c) Treatment modalities and services shall be in accordance with the child’s psychiatric, behavioral, emotional and social needs and be incorporated into their individualized treatment plan and discharge plan.

(d) The provider shall ensure that all staff caring for or providing treatment or services for the child:

1. Have current information about the child’s treatment plan and goals, including the child’s permanency goals if admitted pursuant to Section 39.407, F.S.; and

2. Direct all aspects of the child’s treatment, services and daily activities toward meeting the child’s specific treatment goals.

(e) The provider shall ensure that all staff providing a treatment modality to the child are qualified to provide that treatment modality.

(f) Discussions are held on an on-going basis with the individuals involved in implementing treatment.

(g) Treatment shall not be aversive, coercive, or experimental.

(h) Treatment provided, including behavior analysis services, shall be consistent with nationally recognized standards.

(i) When multiple modalities of treatment are provided, such as psychotherapy, behavior management, and medication, the treatment shall be coordinated among the treatment professionals.

(j) Treatment progress shall be monitored on a continuous basis and the treatment adjusted as needed to meet the child’s individual treatment goals.

(4) Activities.

(a) Basic routines shall be outlined in writing and made available to staff and children on a continuing basis.

(b) The daily program shall be planned to provide a framework for daily living and periodically reviewed and revised as the needs of the individual child or the living group change.

(c) Daily routines shall be adjusted as needed to meet special requirements of the child’s treatment plan.

(d) The facility shall have a written plan for a range of age-appropriate indoor and outdoor recreational and leisure activities provided for children, including activities for evenings and weekends. Such activities shall be based on the group and individual interests and developmental needs of the children in care.

(e) Books, magazines, newspapers, arts and crafts materials, radios and televisions shall be available in accordance with children’s recreational, cultural and educational backgrounds and needs.

(f) Provisions shall be made for each child to have daily time for privacy and pursuit of individual interests.

(g) The facility shall have a written policy addressing the involvement of children in community activities and services, which includes how the appropriate level of community involvement is determined for each child.

(5) Education. The provider shall arrange for or provide an educational program for children, that complies with the State Board of Education, Rule 6A-6.0361, F.A.C., effective date 2-18-93, hereby incorporated by reference.

(6) Food and nutrition.

(a) If the provider serves meals to staff members, they shall serve staff and children substantially the same food, except when age or special dietary requirements dictate differences.

(b) The provider shall serve three well-balanced meals a day in the morning, noon, and evening and provide snacks. If a child is admitted between meals, snacks will be provided. When children are attending school or are not present in the facility during mealtime, the provider shall make arrangements for the children’s meals.

(c) The provider shall retain menus, with substitutions, for a 12-month period, which shall be available for review. Menus shall be posted 24 hours before serving of the meal. Any change shall be noted. Menus shall be evaluated by a consultant dietitian for nutritional adequacy at least annually. The provider shall maintain records of the dietician’s reviews.

(d) The provider shall plan and prepare special diets as needed (e.g., diabetic, bland, high calorie). No more than fourteen hours shall elapse between the end of the evening meal and the beginning of the morning meal where a protein is served. Meals shall meet general requirements for nutrition published by the department or currently found in the Recommended Daily Diet Allowances, Food and Nutrition Board; or by the Florida Dietetic Association.

(7) Health, medical, and emergency medical and psychiatric services.

(a) The provider shall develop and implement on an ongoing basis written procedures for health, medical, and emergency medical and psychiatric services describing how the provider obtains or provides general and specialized medical, psychiatric, nursing, pharmaceutical and dental services.

(b) The procedure shall clearly specify which staff are available and authorized to provide necessary emergency psychiatric or medical care, or to arrange for referral or transfer to another facility including ambulance arrangements, when necessary. The procedure shall include:

1. Handling and reporting of emergencies. Such procedures shall be reviewed at least yearly by all staff and updated as needed;

2. Obtaining emergency diagnoses and treatment of dental problems;

3. Facilitating emergency hospitalization in a licensed medical facility;

4. Providing emergency medical and psychiatric care; and

5. Notifying and obtaining consent from the parent or legal guardian in emergency situations. This procedure shall be discussed with the child’s parent or guardian upon admission. The discussion shall be documented in the child’s file.

(c) The provider shall have a staff member on duty at all times, when children are present in the facility, who is trained and currently certified to administer first aid and CPR.

(d) The provider shall immediately notify the child's parent or guardian and the placing organization or the department of any serious illness, any incident involving serious bodily injury, or any severe psychiatric episode requiring the hospitalization of a child.

(e) The provider shall have available, either within the provider organization or by written agreement with health care providers, a full range of services for treatment of illnesses and maintenance of general health. Agreements shall include provisions for on-site visits, office visits, and hospitalization.

(f) Children who are physically ill shall be cared for in surroundings familiar to them, if medically feasible, as determined by a physician. If medical isolation is necessary, it shall be provided. There shall be a sufficient number of qualified staff available to give care and attention within a setting designed for such care.

(g) A complete physical examination shall be provided for each child in the provider's care every 12 months and more frequently, if indicated.

(h) Immunization of all children shall be kept current in accordance with the American Academy of Pediatrics guidelines.

(i) Each staff member shall be required to report to the program’s physician and note in the child’s record any illnesses or marked physical dysfunction of the child.

(j) All staff shall have training in the handling of emergency medical situations.

(k) Emergency medical services shall be available within 45 minutes, 24 hours a day, seven days a week.

(l) The program physician's name and telephone number shall be clearly posted in areas accessible by staff and others within the facility.

(m) There shall be a first aid kit available to staff for each unit or building for facilities with multiple units or buildings and one per facility for single unit or building facilities. Contents of the first-aid kits shall be selected by the medical staff.

(n) The provider shall have a written agreement with a licensed hospital verifying that routine and emergency hospitalization will be available.

(8) Administration of medication.

(a) Pharmaceutical services, if provided, shall be maintained and delivered as described in the applicable sections of Chapters 465 and 893, F.S., and the Board of Pharmacy rules.

(b) All medicines and drugs shall be kept in a double locked location. Prescription medications shall be prescribed only by a duly licensed physician or an ARNP or physician’s assistant working under the direction of a licensed physician.

(c) An accurate log shall be kept of the administration of all medication including the following:

1. Name of the child for whom it is prescribed;

2. Physician’s name, and reason for medication;

3. Quantity of medication in container when received;

4. Method of administration of medication (i.e., orally, topically, or injected);

5. Amount and dosage of medication administered;

6. Time of day and date medication is to be administered or self-administered and time of day and date medication was taken by the child; and

7. Signature of staff member who administered or supervised self-administration of the medication.

(d) The provider shall not permit medication prescribed for one child to be given to another child.

(e) Children capable of self-medication shall be supervised by a staff person who has been trained in medication supervision.

(f) For children not capable of self-medication, only a licensed nurse or unlicensed staff who has received training as required by this rule shall administer medications.

(9) Religious and ethnic heritage. The provider shall offer opportunities for children to participate in religious services and other religious and ethnic activities within the framework of their individual and family interests, treatment modality and provider setting. The option to celebrate holidays in the child’s traditional manner shall be provided and encouraged.

(10) Interpreters, translators and language options. The provider shall establish procedures for identifying and assessing the language needs of each child and providing:

(a) A range of oral and written language assistance options, including American Sign Language;

(b) Written materials in languages that are spoken by the child other than English; and

(c) Oral language interpretation for children identified with limited English proficiency.

(11) Clothing and personal needs.

(a) The provider shall complete a written inventory of personal belongings of each child upon admission and account for all personal belongings upon discharge. This written inventory shall be maintained in the child’s case file and a copy given to the parent or guardian at admission and discharge.

(b) The provider shall ensure each child has individual personal hygiene and grooming items readily available and has training in personal care, hygiene, and grooming appropriate to the child’s age, gender, race, culture and development.

(c) The provider shall involve the child in the selection, care and maintenance of personal clothing as appropriate to the child’s age and ability. Clothing shall be maintained in good repair, sized to fit the child and suited to the climate and season.

(d) The provider shall allow a child to possess personal belongings. The provider may limit or supervise the use of these items while the child is in care.

(e) When needed, protection from the weather or insects shall be provided, such as rain gear and insect repellent.

(f) The provider shall return all of the child’s personal clothing and belongings to the parent or guardian when the child is discharged from the facility.

(12) Child’s record.

(a) The provider shall have written procedures regarding children’s records, including provisions to ensure that clinical records are maintained in accordance with Section 394.4615, F.S.

(b) The provider shall develop an individualized record for each child. The form and detail of the records may vary but shall, at a minimum, include:

1. Identification and contact information, including the child’s name, date of birth, Social Security number, gender, race, school and grade, date of admission, and the parent or guardian’s name, address, home and work telephone numbers;

2. Source of referral;

3. Reason for referral to residential treatment, e.g., chief complaint, presenting problem(s);

4. Record of the complete assessment;

5. DSM diagnosis;

6. Treatment plan;

7. Medication history;

8. Record of medication administered by program staff, including type of medication, dosages, frequency of administration, persons who administered each dose, and method of administration;

9. Documentation of course of treatment and all evaluations and examinations, including those from other facilities, such as emergency rooms or general hospitals;

10. Progress notes;

11. Treatment summaries;

12. Consultation reports;

13. Informed consent forms;

14. A chronological listing of previous placements, including the dates of admission and discharge, and dependency and delinquency actions affecting the minor’s legal status;

15. Written individual education plan for the child, when applicable;

16. The discharge summary, which shall include the initial diagnosis, clinical summary, treatment outcomes, assessment of child’s treatment needs at discharge, the name, address and phone number of the person to whom the child was discharged and follow-up plans. In the event of death, a summary shall be added to the record and shall include circumstances leading to the death. All discharge summaries shall be signed by the clinical or medical director;

17. For out of state children, copies of completed interstate compact ICPC 100A and ICPC 100B forms (February 2002) and a copy of each Interstate Compact Transmittal Memorandum and any attachments thereto that were sent to the Residential Treatment Center by the department’s Interstate Compact on the Placement of Children Office;

18. Documentation of any use of restraint, seclusion or time out;

19. A copy of each incident report that includes a clear description of each incident; the time, place, and names of individuals involved; witnesses; nature of injuries, if any; cause, if known; action(s) taken; a description of medical services provided, if any; by whom such services were provided; and any steps taken to prevent a recurrence. Incident reports shall be completed by the individual having first hand knowledge of the incident, including paid and volunteer staff, emergency or temporary staff, and student interns; and

20. Documentation that all of the various notices and copies required by these rules were properly given.

(c) Records of discharged children shall be completed within 15 business days following discharge.

(d) Recording. Entries in the child’s record shall be made by staff having pertinent information regarding the child. Staff shall legibly sign and date each entry. Symbols and abbreviations shall be used only when there is an explanatory notation. Final diagnosis, both psychiatric and physical, shall be recorded in full without the use of symbols or abbreviations.

(e) Maintenance of records.

1. Each provider shall maintain a master filing system, including a comprehensive record of each child’s involvement in the program.

2. Records for children currently receiving services shall be kept in the unit where the child is being treated or be directly and readily accessible to the clinical staff caring for the child.

3. The program shall maintain a system of identification and coding to facilitate prompt location and ongoing updating of the child’s clinical records.

4. Records may be removed from the program’s jurisdiction and safekeeping only as required by law or rule.

5. The provider shall establish procedures regarding the storage, disposal, or destruction of clinical records, which are compatible with the protection of rights.

6. Records for each child shall be kept for at least five years after discharge.

7. The provider shall maintain a permanent admission and discharge register of all children served, including name of the child, the child’s parent or guardian, address, date of admission and discharge, child’'s date of birth, custody status, person to which the child was discharged, and address to which discharged.

(13) Quality assurance program. The provider shall develop and follow a written procedure for a systematic approach to assessing, monitoring and evaluating its quality of care and treatment, improving its performance, ensuring compliance with standards, and disseminating results. The quality assurance program shall address and include:

(a) Appropriateness of service assignment, intensity and duration, appropriateness of resources utilized, and adequacy and clinical soundness of care and treatment given;

(b) Utilization review;

(c) Identification of current and potential problems in service delivery and strategies for addressing the problems;

(d) A written system for quality improvement, approved by the provider’s governing board that includes:

1. A written delineation of responsibilities for key staff;

2. A policy for peer reviews;

3. A confidentiality policy complying with all statutory confidentiality requirements, state and federal; and

4. Written, measurable criteria and norms assessing, evaluating, and monitoring quality of care and treatment.

(e) A description of the methods used for identifying and analyzing problems, determining priorities for investigation, resolving problems, and monitoring to assure desired results are achieved and sustained;

(f) A systematic process to collect and analyze data from reports, including, but not limited to, incident reports, grievance reports, department and agency monitoring or inspection reports and self-inspection reports;

(g) A systematic process to collect and analyze data on process outcomes, client outcomes, priority issues chosen for improvement, and satisfaction of clients;

(h) A process to establish the level of performance, priorities for improvement, and actions to improve performance;

(i) A process to incorporate quality assurance activities in existing programs, processes and procedures;

(j) A process for collecting and analyzing data on the use of restraint and seclusion to monitor and improve performance in preventing situations that involve risks to children and staff. The provider shall:

1. Collect and regularly analyze, at least quarterly, restraint and seclusion data to ascertain that restraint and seclusion are used only as emergency interventions, to identify opportunities for reducing the rate and improving the safety of restraint and seclusion use, and to identify any need to redesign procedures;

2. Aggregate quarterly restraint and seclusion data by all settings, units or locations, including:

a. Shift;

b. Staff who initiated the procedure;

c. Details of the interactions prior to the event;

d. Details of the interactions during the event;

e. The duration of each episode;

f. Details of the interactions immediately following the event;

g. Date and time each episode was initiated and concluded;

h. Day of the week each episode was initiated;

i. The type of restraint used;

j. Whether injuries were sustained by the child or staff; and

k. Age and gender of each child for which emergency safety interventions had been found necessary.

3. Prepare and submit a report quarterly to the district/region mental health program office, including the aggregate data and:

a. Number and duration of each instance of restraint or seclusion experienced by a child within a 12-hour timeframe;

b. The number of instances of restraint or seclusion experienced by each child; and

c. Use of psychoactive medications as an alternative for or to enable discontinuation of restraint or seclusion.

(k) Analysis of the use of time-out shall be conducted quarterly by the treatment team and shall include:

1. Patterns and trends, for example, by shift, staff present, or day of the week;

2. Multiple instances of time-out within a 12-hour timeframe;

3. Number of episodes per child; and

4. Instances of extending time-out beyond 30 minutes.

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