HB2667 HH&HR AM 3-11
The Committee on Health and Human Resources moves to amend the
bill on page two, section one, line seven, after the word
"authorized", by striking out the period and inserting in lieu
thereof the following:
"with the following amendment:
On page one by striking everything after the series title and
inserting in lieu thereof the following:
1.1. Scope. -- This rule establishes standards and
procedures for the licensure of residential child care and
treatment facilities under the provisions of W. Va. Code §§49-2B-1
et seq., 27-17-1 et seq., and related federal and state codes
except as set forth in section
s 2.3 of this rule (relating to
exemptions). The W. Va. Code is available in public libraries and
on the Legislature's web page, http://www.legis.state.wv.us/. This
rule should be read in conjunction with the provisions of W. Va.
Code §§49-2B-1 et seq., 27-9-1, and 27-17-1 et seq.
1.2. Authority. -- W. Va. Code §§49-2B, 27-17-3, 27-1A-
4(g), 27-1A-6(6) and 27-1A-7.
1.3. Filing Date. --
May 2, 2007 July 1, 2012. 1.4. Effective Date. --
July 1, 2007 July 1, 2013.1.5. Review and Revision - This legislative rule will be
reviewed at a minimum of every 5 years for content and
applicability, with revisions and additions made as needed.
1.5. Repeal and Replacement of Former Rule -- This
legislative rule repeals and replaces "Minimum Licensing
Requirements for Group Residential Facilities in West
Virginia",78CSR3, effective June 1, 1982 July. The organizations
covered in this rule are exempt from the requirements for
"Licensure of Behavioral Health Centers," 64CSR11, effective July
1, 2000. Organizations within this rule (excluding ICF-MR and PRTF)
are exempt from the requirements for "Licensure of Behavioral
Health Centers," 64CSR11, effective July 1, 2000.
1.6. Purpose -- These standards are the basis for the
licensing and approval of residential child care and treatment
facilities in West Virginia. Licenses or certificates of approval
are issued if the standards and applicable rules and regulations
are met. The purpose is to protect the health, safety and well-
being of children receiving care in residential facilities and to
regulate the provision of out of home behavioral health treatment
for children with behavioral, emotional and/or developmental
challenges, placed in congregate treatment settings, through the
formulation, application and enforcement of minimum licensing
requirements. Nothing in these standards are intended to interfere with any requirements relating to funding streams.
§78-3-2. Application and Enforcement.
2.1. The core requirements, Sections 1 through 16.4.a, apply
to all residential child care settings and congregate treatment
settings, both public and private, that offer residential services
to children and transitioning adults who have been separated from
their family for the purpose of care and/or behavioral health
treatment, except where otherwise indicated within this rule.
Organizations classified as providing foster family care by the
Department of Health and Human Resources are exempt from this rule
and are governed by the Department's rule "Child Placing Agencies
Licensure", 78CSR2, effective July 1,
2001 2007. Each
organization included in this rule shall comply with core
requirements in addition to specialized modules as applicable to
2.1.a. This rule contains the minimum requirements to
obtain a license or certificate of approval to provide residential
child care and treatment for children in West Virginia.
2.1.b. This rule applies equally to for- profit, not-
non-profit, publicly-funded and privately-funded facilities.
2.1.c. This rule applies to the following congregate
living facilities serving children and transitioning adults:
2.1.c.1. Psychiatric residential treatment
facilities for persons
under age less than 21 years of age;
2.1.c.2. Residential crisis support or emergency
2.1.c.3. Residential maternity and parenting
2.1.c.4. Group residential child care settings;
2.1.c.5. Outdoor therapeutic educational programs;
2.1.c.6. Intermediate care facilities for persons
mental retardation intellectual disabilities; and,
2.1.c.7. Therapeutic residential schools.
This rule is enforced by the Secretary of the Department of
Health and Human Resources.
This rule does not apply to the following:
2.3.a. A program exempted by the state or federal
2.3.b. A program providing solely academic services
accredited or operated by the state Department of Education;
2.3.c. Seasonal camps operated for children with a
primary purpose of recreation, in which children are attending
sessions for periods not exceeding thirty days;
2.3.d. Juvenile detention centers or juvenile correction
facilities operated or contracted through the Department of Military Affairs and Public Safety;
2.3.e. Adoption and foster family care facilities
recognized as such by the Department of Health and Human Resources;
2.3.f. Hospitals or other medical facilities which are
primarily used for temporary residential care of children for
treatment, convalescence or testing.
3.1. Administrator -- The designated person responsible for
carrying out the governing body's policies and the day-to-day
operation of the organization.
3.2. Advisory Council -- An association of persons that
makes recommendations regarding the policies and procedures of an
organization to the governing body of that organization, but having
no proprietary interest in the organization or actual management or
3.3. Advocate -- A person or organization acting in the
best interest of the child to establish, expand, protect and
enforce the child's human, legal and civil rights.
3.4. Aftercare -- Services to be provided subsequent to a
child's discharge from placement as identified in the discharge
3.5. Appropriate State or Governmental Authority -- A state or local governmental agency that has responsibility for or
authority over an aspect of the operation of an organization.
3.6. Adult Protective Services/Child Protective Services
(APS/CPS) Background Check - an authorized disclosure of an
individual's history with the Department as an identified adult or
child abuse maltreator.
3.6. 3.7. Aversive Conditioning -- The application of
startling, painful or noxious stimuli to a child for the purpose of
3.7. 3.8. Aversive Procedures -- Restrictive procedures
that impose undesirable consequences for inappropriate behaviors.
Aversive procedures include, but are not limited to, physical
restraint, chemical restraint, seclusion, fines or loss of
3.8. 3.9. Behavior Support Plan. -- A written plan designed
to teach adaptive behaviors and reduce or eliminate maladaptive
3.9. 3.10 Behavioral Health Services and Treatment --
Services designed to improve the adaptive functioning (including
but not limited to emotional, behavioral, interpersonal, and age-
appropriate independent functioning) of children with mental
illness; developmental disabilities; behavioral challenges;
traumatic brain injuries expressed as emotional or behavioral
difficulties; or substance abuse.
3.10. 3.11 Care Plan/Plan of Care -- A document describing
the services to be provided to a child while in residential care
and treatment. The plan of care shall describe the purpose and
objectives of each service provided and shall address the needs of
the child and family, as appropriate and as identified in the
initial assessment and subsequent assessments. Synonymous with
3.11. 3.12. Case Record/Clinical Record -- A comprehensive
collection of information about a child in the care of an
organization providing residential treatment. A unified
description and documentation of the evaluation, present and
prospective services and treatment provided for the child while in
the care of the organization.
3.12. 3.13. Case Record Review -- The review of case records
for accuracy, consistency, quality and compliance by an individual
or group of individuals.
3.13. 3.14. Child -- Any person under less than eighteen
years of age or who is a transitioning adult as defined in sub-
section 3.96 of this rule. (W. Va. Code §49-2B-2(e))
3.14. 3.15. Child Abuse -- The threat to a child's health
or welfare by a person who knowingly or intentionally inflicts,
attempts to inflict or knowingly allows another person to inflict
physical injury or mental or emotional injury upon the child; or sexual abuse or sexual exploitation (W. Va. Code §49-1-3).
3.15. 3.16. Child Neglect -- The failure to provide
adequate nutrition, clothing, shelter, supervision, medical care or
education; or abandonment.
3.16. 3.17. Child's Case Plan -- A comprehensive document
prepared by the Department pursuant to the requirements of W. Va.
Code §49-6-5 following an adjudication by the court that the child
is an abused and/or neglected child, that directs the provision of
services, including the services provided to the child and the
provision of a permanent placement for the child.
3.17. 3.18. Child-Specific Training -- Training provided to
respond to the specialized needs of a particular child.
3.18. 3.19. Civil Rights -- The rights of personal liberty
guaranteed by the Constitutions of the United States and the State
of West Virginia, by federal, and state laws.
3. 19. 3.20. Consequences -- Logical and natural
consequences are part of a disciplinary or educational plan to
teach children appropriate behavior and the effects of their
behavior. Logical consequences are intentionally planned and
designed to be similar to what would happen to an adult in a
similar situation. Natural consequences are Outcomes that happen as
a result of behaviors that are not planned or controlled.
Consequences are relevant to the infraction. , respectful and
3.20. 3.21. Continuous Quality Improvement -- A well defined
process for assessing and improving the overall performance of the
organization by identifying standards that will promote quality
outcomes for persons served and modifying the organization's
practices and services to meet those outcomes.
3.21. 3.22. Corporal Punishment -- The intentional
inflicting of pain or discomfort to the body. through actions such
as, but not limited to, striking or hitting with any part of the
body or with an implement, or pinching, pulling or shaking.
3.22. 3.23. Corrective Action Plan -- A written agreement
between the Department and an organization, approved prior to
implementation, that outlines the steps an organization shall take
to correct areas of non-compliances identified by the Department
through an inspection or the investigation of a complaint.
3.23. 3.24. Criminal Identification Bureau (CIB) Record Check
-- A fingerprinting process that identifies a person who has been
arrested or convicted of criminal behavior.
3.24. 3.25. Crisis Intervention Skills and Techniques --
Methods used to de-escalate situations that could result in harm to
persons or property.
3.25. 3.26. Critical Incident -- The alleged, suspected, or
actual occurrence, including but not limited to any of the
following involving a child in residential treatment: abuse, neglect, death due to any cause, attempted suicide, behavior that
will likely lead to serious injury or significant property damage,
fire resulting in injury, relocation or an interruption of
services, any major involvement with law enforcement authorities,
injury that requires hospitalization or results in permanent
physical damage, life-threatening reaction because of a drug or
food, a serious consequence resulting from an apparent error in
medication or dietary administration, extended and unauthorized
absence of a child that exceeds his or her plan of care provision
for community access, or the unplanned removal of a child, against
his or her wishes, from either residential or program services.
3.26. 3.27. Department -- The West Virginia Department of
Health and Human Resources.
3.27. 3.28. Detoxification -- The process of eliminating
the toxic effects of drugs and alcohol from the body.
3.28. 3.29. Direct Service Worker -- Any employee of an
organization who works directly with children as a major function
of his or her job.
3.29. 3.30. Discharge -- The termination of a child's
affiliation with an organization.
3.30. 3.31. Discharge Planning -- The organized process of
identifying the approximate length of stay and the criteria for
exit of a child from the current service, and less restrictive alternatives for a later date. Discharge planning begins upon
admission and includes provision for appropriate follow-up
3.31. 3.32. Discipline -- A system of rules governing
conduct in an organization which usually prescribes consequences
for the violation of particular rules.
3.32. 3.33. Documentation -- A record in compliance with
3.33. 3.34. Early Periodic Screening, Diagnosis and Treatment
(EPSDT), also known as "Healthcheck" -- The child health
component of the Medicaid program which establishes standards of
medical care for children. The EPSDT shall be completed within 72
hours of when a child enters departmental custody and annually
3.34. 3.35. Family -- A group of one (1) or more adults and
one or more children. The adults shall have a long-term commitment
to caring for and rearing children.
3.35. 3.36. Goal -- An expected result or condition that
takes time to achieve, is specified in a statement of relatively
broad scope, and provides guidance in establishing intermediate
objectives directed toward its attainment.
3.36. 3.37. Governing Body -- A person or persons with the
administrative control and legal authority to set policy and
oversee operations of an organization.
3.37. 3.38. Group Residential Treatment -- Provision of
supervision, room, board and psychosocial or habilitative treatment
for children who are in need of out-of-home care and may be
considered emotionally, developmentally and or behaviorally
challenging. The definition does not include any organization
more narrowly defined elsewhere in this rule, nor does it include
children placed in a private residence classified as a foster
family or foster home by the Department.
3.39. Health Screen - A physical examination that is
administered by a Qualified Health Practitioner (i.e., Medical or
osteopathic physician; registered nurse; physician's assistant)
that occurs within 72 hours of placement into a new milieu.
3.38. 3.40. Human Resources -- All persons providing
services within an organization including all employees,
volunteers, student interns and consulting professionals.
3.39. 3.41. Incident -- An act or series of acts which
violates reasonable expectations for behavior and has the potential
to place a child or others at risk.
3.42. Independent Contractor - Individuals who perform paid
services for youth and are not employed by the residential
facility. This individual performs services as specified in a
contract or formal agreement as needed or required.
3.40. 3.43. Individualized Education Program -- An
individualized education program required by Federal and State law for educationally handicapped children; the plan for such a
3.41. 3.44. Informed Consent -- Written verification that a
child and his or her parent or guardian have been informed of the
nature of the treatment provided to the child and that they agree
to the proposed treatment.
3.42. 3.45. Institutional Investigative Unit -- A unit of
the Department authorized by the Secretary to investigate
complaints of child abuse or neglect.
3.43. 3.46. Interdisciplinary Team -- A group including a
child, legal representatives, and representatives from the
organization whose responsibility is to design and review a child's
plan of care.
3.44. 3.47. Intermediate Care Facility for Persons with
Mental Retardation Intellectual Disability -- A facility which
provides appropriate supervision, medical and habilitation services
for individuals with intellectual disabilities mental retardation
and/or developmental disabilities as defined in 42 CFR §440.150.
3.45. 3.48. Intervention -- The actions of the health
care/organizational staff employees designed to help the child
complete the objectives contained within his or her care plan.
3.46. 3.49. Life Skills -- Tasks, abilities, or knowledge
required to perform the activities of daily living.
3.47. 3.50. Maternity and Parenting Facility -- Provision of supervision, room, board and psychosocial or habilitative care for
young women who are pregnant or parenting.
3.48. 3.51. Medication Error -- The failure to administer
a drug ordered by a physician, or the administration of a drug
without a physician's order, in the wrong dosage, in the incorrect
form, by the incorrect method, or that is incorrect itself in a
manner as instructed or indicated in the Six Rights of Medication
Administration as defined in section 3.91 of this rule.
3.49. 3.52. Multidisciplinary Treatment Team -- A legally
identified team as defined in W. Va. Code §49-1-3-(g), designated
to review and approve the child's placement and plan of care as
appropriate. The team shall consist of the child's custodial parent
or parents, guardian or guardians, other immediate family members,
the attorney or attorneys representing the child, the parent or
parents of the child, the child's attorney, the guardian ad litem,
if any, the prosecuting attorney or his or her designee and where
appropriate to the particular case under consideration and
available, a court-appointed special advocate, an appropriate
school official and any other person or an organization
representative who may assist in providing recommendations for the
particular needs of the child and family.
3.53. Non-critical Incidents - Events occurring to a child
that need to be recorded and briefly investigated or reviewed by
the organizations and tracked for risk management or quality improvement purposes. These incidents would not include behaviors
for which there is a behavior support plan and data tracking
mechanism in place.
3.50. 3.54. Objective -- Desired measurable outcomes
related to a goal stated in terms understandable to the child and
his or her parent or guardian and agreed upon by the
3.51. 3.55. On-ground Educational Program -- An educational
program conducted on the property of an organization.
3.52. 3.56. Organization -- A facility or other entity
which provides residential services on a twenty-four (24) hour per
day basis and may provide a therapeutic treatment program for
children or transitioning adults.
3.53. 3.57. Outdoor Therapeutic Educational Program -- Any
entity that provides care, supervision and treatment for older
children and transitioning youth and adults aged 12 to 21 in an
outdoor setting where routine and specially planned activities are
provided in an outdoor milieu and designed to improve the child's
social, emotional, behavioral and educational functioning.
3.54. 3.58. Parents or Guardian -- A person or persons with
an ongoing, legally identified and recognized responsibility for
caring for a child. ; usually the child's mother and/or father, the
Department, or the Division of Juvenile Services.
3.55. 3.59. Physical Escort -- The temporary touching or holding of the hand, wrist, arm, shoulder or back for the purpose
of inducing a child who is acting out to walk to a safe location.
Using a light grasp to escort a child to a desired location. If the
youth can easily remove or escape the grasp, it is not a physical
restraint. If the patient cannot easily remove or escape the grasp,
it would be a physical restraint.
3.56. 3.60. Placement -- A change of living arrangement, or
the ongoing care of a child in an adoptive or foster home, group
facility, or other approved living situation.
3.57. 3.61. Placement Agreement -- A written document signed
by the child's parent or guardian and a representative of the
organization, which specifies the terms of the child's placement.
3.58. 3.62. Placing Agency -- An organization either
publicly or privately operated, legally authorized to place a child
or transitioning adult in the care of an organization.
3.59. 3.63. Policy -- A statement of the principles that
guide and govern the activities, procedures and operations of a
3.64. Principles of Normalization - The action of making
available to all people with disabilities patterns and conditions
of living which are as close as possible to the regular
circumstances of society.
3.60. 3.65. Procedures -- The specific methods by which policies are implemented.
Staff Employees- Individuals who meet the
criteria set forth by the licensing boards governing their specific
scope of practice as found in Chapter 30 of the West Virginia Code.
3.61. 3.67. Program -- A system of services provided to
those persons who are clients of an organization.
3.62. 3.68. Protective Device -- Any appliance, such as a
brace, pad, helmet, covering, or bandage, that is used to aid in
the healing of an injury or to prevent injury to the child.
3.63. 3.69. Protective Services Check -- A review of Adult
and Child Protective Services records maintained by the Department
of Health and Human Resource to determine whether a person has a
documented history of abusing or neglecting vulnerable adults or
3.64. 3.70. Punishment -- The infliction of a negative
penalty for wrongdoing, which may decrease the future rate and/or
probability of the behavior.
3.65. 3.71. Psychiatric Emergency -- An incident during
which a child loses control and behaves in a manner that poses
substantial likelihood of physical harm to himself or herself, or
3.66. 3.72. Psychiatric Residential Treatment Facility for
Persons under Twenty-One -- A free-standing program or physically
distinct part of a psychiatric inpatient facility that provides intensive, coordinated, and medically supervised behavioral health
services in a residential setting to children and adolescents that
do not need acute care as defined in 42 CFR §483.350 and §441.151.
3.67. 3.73. Psychotropic Medication -- Drugs designed to
affect the mind, mood, behavior, or other mental processes.
3.68. 3.74. Public Funds -- Money provided to an
organization by any governmental body.
3.69. 3.75. Quality Committee/Officer -- An individual or
group of individuals whose responsibility is to develop and
implement quality control processes which monitor programmatic and
clinical efforts of the organization and identifies methods to
improve services and resolve problems.
3.70. 3.76. Regulatory Body -- A governmental agency with
the ongoing responsibility for the formal authorization and
oversight of the operation of an organization.
3.71. 3.77. Requirement -- The specific minimal condition
or standard that shall be met by an organization as a condition of
licensure and/or approval to operate.
3.72. 3.78. Residential Child Care and Treatment Facility --
A congregate program which provides room, board, supervision and
may provide behavioral health treatment to children or
transitioning adults with behavioral, developmental and/or
3.73. 3.79. Residential Crisis Support/Shelter Care -- A form of short-term residential care for children which temporarily
provides food, shelter, clothing and other necessary crisis
intervention and stabilization services for children experiencing
emotional, familial or behavioral crises.
3.74. 3.80. Residential Maternity and Parenting Facilities.
-- A facility that primarily offers care and behavioral health
services to young women who are either pregnant or parenting and
3.75. 3.81. Respite Care -- Alternative short-term care.
3.76 3.82. Restraints -- (1) Any physical restraint that
is a mechanical or personal restriction that immobilizes or reduces
the ability of an individual to move his or her arms, legs or head
freely, not including devices, such as orthopedically prescribed
devices, surgical dressings or bandages, protective helmets, or any
other method that involves the physical holding of a child for the
purpose of conducting routine physical examinations or tests or to
protect the child from falling out of bed or to permit the child to
participate in activities without the risk of physical harm to the
child. This term does not include a physical escort; and (2) a
drug or medication that is used as a restraint to control behavior
or restrict the child's freedom of movement that is not a standard
treatment for the child's medical or psychiatric condition.
3.77. 3.83. Responsible Agency -- An agency with continuing overall responsibility for the child during placement.
3.78. 3.84. Residential Living Unit -- Living quarters used
by a particular group of children in care, consisting of separate
cottages or units in a residential building, and include including
a common room, dining or snack area, facilities for bathing,
toileting and personal hygiene and bedrooms.
3.79. 3.85. Rules -- A set of requirements issued by the
Secretary describing a standard or a set of standards of care to
apply in the oversight of an organization.
3.80. 3.86. Safety Committee/Officer -- An individual or
group of individuals whose responsibility is to review service
modalities or other organizational practices that limit freedom of
choice or involve risk. The committee/officer shall review the
organization's facilities and buildings on a quarterly basis for
safety, cleanliness and proper maintenance.
3.81. 3.87. Seclusion -- A behavioral control technique
involving locked isolation or the isolation separation of a child
in an isolated a physical space from which he or she is prevented
from leaving. The term does not include a time out.
3.82. 3.88. Secretary -- The Secretary of the Department of
Health and Human Resources or his or her designee.
3.83. 3.89. Secure Care -- A form of residential treatment
which employs, on a regular basis, locked doors or any other
physical means to prevent children in care from leaving the facility.
3.84. 3.90. Service -- A functional division of a program
or the delivery of care.
3.91. Six Rights of Medication Administration - A best-
practice criteria for medication administration recognized by the
West Virginia Board of Examiners for Registered Professional
Nurses. These criteria are used to assure that each resident
receives the specific medication prescribed for the person, in the
ordered amount, at the scheduled time, by the designated route-
both as prescribed and prepared, which is accurately recorded in
the resident's record: (1) the right resident; (2) the right drug;
(3) the right dosage; (4) the right time; (5) the right route; and
(6) the right record or documentation .
3.85. 3.92. Standards -- A measure of comparison for
3.86. 3.93. Supervision -- The observation, oversight, and
guidance of the child or group of children by the staff members
employees assigned to their care.
3.87. 3.94. Therapeutic Residential School -- A long-term
residential, educational facility providing post-secondary
education preparation, room, board, and supervision while providing
a structured environment and therapeutic support to older children
and transitioning adults who may need emotional, behavioral,
familial, social, intellectual, and/or academic development.
3.88. 3.95. Time-Out -- A behavior management technique that
is part of an approved treatment program and may involve the
separation of the child from the group, in a non-locked setting,
for the purpose of calming. Time out is not seclusion and is not
physically enforced or coerced in any way.
3.89. 3.96. Transitioning Adult -- An individual with a
transfer plan to move to an adult setting who meets one of the
(1) Is eighteen years of age but under twenty-one years
of age, was in departmental custody upon reaching eighteen years of
age, remains under the jurisdiction of the juvenile court, and/or
requires supervision and care to complete an education and or
which was initiated prior to the eighteenth
(2) Is eighteen years of age but under twenty-one years
of age, was adjudicated abused, neglected, or in departmental
custody upon reaching eighteen years of age and enters into a
contract with the Department to continue in an educational,
training, and/or treatment program.
which was initiated prior to
the eighteenth birthday._____3.97. Transitioning Youth - A youth, aged 16 or 17, in the
Department's custody and engaged in a program to enhance skills to
assist the transition into adulthood.
3.90. 3.98. Treatment -- A broad range of planned habilitative and/or rehabilitative services, including diagnostic
evaluation, counseling, medical, psychiatric, psychological,
training and social service care, that are provided to enable a
child to meet identified goals and objectives. This definition
does not supersede definitions related to funding streams.
3.91. 3.99. Treatment Strategy -- An orientation or set of
clinical techniques used in a particular therapeutic model to meet
a diagnosed need of a child in care over and above the provision of
3.92. 3.100. Universal Precautions -- A collection of
medically related behaviors, procedures, and protocols designed to
minimize the risk of disease transmission and contamination.
3.93. 3.101. Variance -- A written declaration by the
Secretary that a certain requirement of this rule may be satisfied
in a manner different from the manner set forth in the rule.
3.94. 3.102. Volunteer -- A person who provides services
without direct financial remuneration, and who meets the
organization's employment qualifications for health, safety and
3.95. 3.103 Waiver -- A written declaration by the Secretary
that a certain requirement may be treated as inapplicable in a
§78-3-4. State Administrative Procedures.
4.1. General Licensure Provisions.
4.1.a.. Before establishing, operating, maintaining or
advertising a residential child care and treatment program within
the State of West Virginia, an organization shall first obtain from
the Secretary a license authorizing the operation.
4.1.b. A license is valid for the organization named in
the application and is not transferable.
4.1.c. The organization shall surrender an invalid
license to the Secretary on written demand.
4.1.d. Applications for licenses or approvals are made
on forms prescribed by the Secretary.
4.1.e The organization shall apply for a new license
when the ownership of an organization changes. The new owner may
not operate until a license is issued.
4.1.f. An organization shall demonstrate a need for the
proposed service by obtaining a current certificate of need from
the Health Care Authority.
4.1.g. The Secretary shall make a decision on each
application within sixty days of its receipt and shall provide to
unsuccessful applicants written reasons for the decision.
4.1.h. The Secretary shall perform an on-site inspection
prior to issuing initial, renewal or provisional licenses.
4.2. License Application
4.2.a. The organization shall submit an application for
a license or certificate of approval for:
4.2.a.1. Establishment of a new facility;
4.2.a.2. A change in location;
4.2.a.3. A change in ownership;
4.2.a.4. A change in the population served,
including but not limited to gender, age and capacity;
4.2.a.5. Upon expiration of existing license; or
_______________4.2.a.6. A significant change in services provided.
4.2.b. The organization shall submit the completed
application at least 60 days in advance of the planned opening
date, change of location, change of ownership, change in program or
expiration of existing license.
4.2.c. The organization shall provide all required
information or the application is invalid.
4.2.d. The application shall be accompanied by
4.2.e. A member of the governing body and the
executive officer administrator shall sign the application. In
appropriate instances, this may be the same person.
4.2.f. The application shall be accompanied by a current
fire inspection report by the State Fire Marshal's Office and a
current food service and environmental inspection by the local
4.2.g. The governing body or its designated authority shall ensure adequate resources to support the organization's
services. If a new organization or an expansion of an existing
organization, the governing body shall demonstrate sufficient
operating funds for at least six months. The demonstration may
include reserves, lines of credit or history of adequate cash flow
from an existing program to support a new program for six months.
4.2.h. Existing organizations shall demonstrate
financial stability. The organization shall submit a statement
from an independent certified public accountant
(CPA) that proper
accounting procedures, including an annual audit from a CPA, are in
place for the organization.
4.3. Types of Licenses
4.3.a. Following application review, on-site inspection
and approved corrective action, if necessary, and if there is
compliance with the requirements of this rule, the Secretary shall
issue a license in one of three categories
. , if there is
compliance with this rule. A license may be amended at any time
during the cycle to reflect changes in the program, structure or
4.3.b. The Secretary shall issue an initial license to
organizations establishing a new service found to be in compliance
with regard to policy, procedure, organization, record keeping and
service environment rules.
It The initial license shall expire s
not more than six 6 months from date of issuance and may not be re-issued.
4.3.c. The Secretary shall issue a provisional license
to an organization seeking
a renewal license and is not in
compliance with this rule, but does not pose a significant risk to
the rights, well-being, health and safety of a child. to renew a
previously issued license but which is not in substantial
compliance with this rule. The non-compliant organization must
not, however, pose a significant risk to the rights, well-being,
health and safety of a child.
It expires not more than six months from date of issuance and may
not be re-issued. 4.3.d. The Secretary shall issue a regular license to
organizations complying with this rule.
It A regular license shall
expire not more than two years from the date of issuance.
4.4. Construction and Renovation
4.4.a. Before construction or extensive renovation
begins, an organization shall submit to the Secretary for approval
a copy of the site drawings and specifications for the
architectural structure and mechanical work.
4.4.b. All extensively renovated and new structures
meet comply with current standards of the Americans with
Disabilities Act (ADA) standards.
4.4.c. The Secretary may provide consultation and
technical assistance in obtaining compliance with this rule.
4.5.a. An organization shall permit the Secretary
unrestricted access to the facility to conduct announced and
unannounced inspections of all aspects of its operation and
4.5.b. An organization shall permit review of
agency's the organization's case records, corporate and financial
records, board minutes and employment records as requested by the
4.5.c. An organization shall permit access to employees,
members of the governing board and children receiving services from
the organization as requested by the Secretary.
4.5.d. If an organization is accredited by an
accreditation body, it shall supply copies of all relevant
accreditation reports to the regulatory body within ten days of
4.5.e. The Secretary shall inspect a licensed
organization thirty to ninety days prior to the expiration of its
4.5.f. The Secretary shall issue a report within ten
working days of completion of an inspection.
4.6. Complaint Investigation
4.6.a. Any person may file a complaint with the
Secretary alleging violation of applicable laws or rules by an organization. A complaint shall state the nature of the complaint
and the organization by name.
4.6.b. The Secretary may conduct unannounced inspections
of organizations involved in a complaint and any other
investigations necessary to determine the validity of a complaint.
4.6.c. At the time of the investigation, the
investigator shall notify the administrative officer of the alleged
reason for the complaint.
4.6.d. The Secretary shall provide to the organization
a written report of the results of the investigation along with any
4.6.e. The Secretary may provide to the complainant a
description of the corrective action the organization is required
to take and of any disciplinary action the Secretary
will may take.
4.6.f. The Secretary shall keep the names of a
complainant and of any child involved in the complaint or
investigation and any information that could reasonably lead to
their identification confidential.
4.6.g. If a complaint becomes the subject of a judicial
proceeding, nothing in this rule prohibits the disclosure of
information that would otherwise be disclosed in judicial
4.6.h. The organization shall not discharge or discriminate in any way against a child or guardian, or employee
who has been a complainant, on whose behalf a complaint has been
submitted, or who has participated in an investigation process.
4.7. Reports and Records
4.7.a. The Secretary shall keep on file a report of any
inspection or investigation.
4.7.b. The report shall specify the areas of non-
compliance with the rule it violates, and describe the precise
data, observation or interview to support the deficiency.
4.7.c. Information in reports or records is available to
the public except:
4.7.c.1. As specified in this section regarding
4.7.c.2. Information of a personal nature from a
staffs employee's file; and
4.7.c.3. Information required to be kept
confidential by state or federal law.
4.7.d. The Secretary shall not make a report public
until the organization has the opportunity to review the report and
submit a Corrective Action Plan, if necessary.
4.8. Corrective Action Plans
4.8.a. Within ten working days after receipt of the
licensing report, the organization shall submit to the Secretary
for approval a written plan to correct all areas of non-compliance
s that are in violation of this rule. , unless a variance is
requested by the organization and granted by the Secretary. The
plan shall specify:
4.8.a.1. Any action taken or procedures proposed to
correct the areas of non-compliance and prevent their reoccurrence;
4.8.a.2. The date or projected date of completion
of each action taken or to be taken; and
4.8.a.3. The signature of the
officer administrator or his or her designee.
4.8.b. The Secretary shall approve, modify or reject the
proposed corrective action plan in writing. The organization may
make modifications in conjunction with the Secretary.
4.8.c. The Secretary shall state the reasons for
rejection or modification of any corrective action plan.
4.8.d. The organization shall submit a revised
corrective action plan within ten working days whenever the
Secretary rejects a Corrective Action Plan.
4.8.e. The organization shall immediately correct an
area of non-compliance that risks the health or safety of child or
4.8.f. The Secretary
may shall determine if corrections
have been made.
4.9. Waivers and Variances
4.9.a. An organization shall comply with all relevant requirements unless a waiver or variance for a specific requirement
has been granted through a prior written agreement. This agreement
shall specify the specific requirement to be waived, the duration
of the waiver, and the terms under which the waiver is granted.
4.9.b. Waiver of specific requirements shall be granted
only when the organization has documented and demonstrated that it
complies with the intent of the particular requirement in a manner
not permitted by
the requirement this rule.
4.9.c. The waiver shall contain provisions for a regular
review of the waiver.
4.9.d. When an organization fails to comply with the
waiver agreement, the agreement is subject to immediate
cancellation. The Secretary shall determine compliance with the
4.10.a. The Secretary may deny the organization's
application for licensure or licensure renewal; revoke or modify a
license; and/or prohibit admissions or reduce child census for one
or more of the following reasons:
4.10.a.1. The Secretary makes a determination that
fraud or other illegal action has been committed;
4.10.a.2. The organization violates federal, state
or local law relating to building, health, fire protection, safety,
sanitation or zoning, or payment of worker's compensation or employment security taxes.
4.10.a.3. The organization conducts practices that
jeopardize the health, safety, well-being or clinical treatment of
4.10.a.4. The organization fails or refuses to
submit reports or make records available as requested by the
4.10.a.5. The organization refuses to provide
access to its location or records as requested by the Secretary.
4.10.b. Where a violation of this rule may result in
serious harm to children under care, the Secretary may seek
injunctive relief against any person, corporation, child welfare
organization or government official through proceedings instituted
by the attorney general, or the appropriate county prosecuting
attorney, in the circuit court of Kanawha County, or in the circuit
court of any county where the children are residing or may be
4.10.c. Where the operation of a residential child care
and treatment facility constitutes an immediate danger of serious
harm to children served by the facility, the Secretary shall issue
an order of closure terminating operation of the facility. A
facility closed by the Secretary may not operate pending
administrative or judicial review without court order.
4.11. Annual Time Study
An organization is subject to an annual time study regarding
the quantification of
staff employee supervision time upon the
request of the Department.
4.12. Administrative and Judicial Review
Any person, corporation, governmental official or child
welfare organization, aggrieved by a decision of the Secretary made
pursuant to this rule may contest the decision upon making a
request for a hearing by the Secretary within thirty days of
receipt of notice of the decision. Administrative and judicial
review shall be made in accordance with the provisions of article
five, chapter twenty-nine-a of the State Code of West Virginia.
Any decision issued by the Secretary may be made effective from the
date of issuance. Immediate relief there may be obtained upon a
showing of good cause made by a verified petition to the circuit
court of Kanawha County or the circuit court of any county where
the affected organization of child welfare organization may be
located. The pendency of administrative or judicial review shall
not prevent the Secretary from obtaining injunctive relief as
provided for in 4.10.b. of this rule.
§78-3-5. Ethical Practice, Rights and Responsibilities.
5.1. Rights and Responsibilities
5.1.a. The organization shall inform all children and
their family and/or guardians of their rights and responsibilities.
Information on rights and responsibilities shall be tailored for each of the organization's services as appropriate, and shall
reflect the consequences of areas of non-compliance with
programmatic rules, as well as limitation on individual rights
occasioned by involuntary placement or court orders.
5.1.b. All persons served and/or their guardians as
appropriate shall receive information about their rights and
responsibilities that is:
5.1.b.1. Posted in a public area (as appropriate);
5.1.b.2. Provided in writing;
5.1.b.3. Distributed during their initial contact
with the organization during admission; and
5.1.b.4. Effectively and appropriately communicated
to persons with special needs and/or in an age-appropriate manner.
5.1.c. Each child's record shall contain documentation
that the individual received an explanation of his or her rights
and responsibilities, initialed by the child and/or parent or
5.1.d. Written rights shall include, but are not limited
5.1.d.1. Rules and behavioral expectations;
5.1.d.2. Factors that could result in discharge and
termination unless clinically contra-indicated;
5.1.d.3. Basic information about how to file
complaints, grievances or appeals; and
5.1.d.4. Rights of persons in residential child
care and treatment facilities as specified in subsection 5.4 of
5.1.e. The organization's policy and procedures shall
5.1.e.1. The parent or guardian may refuse any
service, treatment or medication unless mandated by law or court
5.1.e.2. If the parent or guardian or
transitioning youth or transitioning adult refuses a recommended
service, treatment or medication the organization informs the
person of the consequences of the refusal, which may include
termination or discharge.
5.2. Access and Eligibility
5.2.a. The organization shall define its service
population and the eligibility criteria for each of its services.
5.2.b. Organizational policy shall state that the
organization does not discriminate by race, color, age, national
origin or disability unless it is part of an individualized
determination that the facts and circumstances of a particular case
require the consideration of race, color, age, national origin or
disability in order to advance the best interests of the child.
5.2.c. The organization shall have in place a policy detailing admissions procedures for each service and the procedures
5.2.c.1. Minimize barriers to timely initiation of
5.2.c.2. Provide for initial screening or placement
on a waiting list;
5.2.c.3. Allow the organization to give priority to
children and families with urgent needs or in emergency situations
as appropriate; and
5.2.c.4. Ensure that all persons are treated
5.3. Culturally Competent Practice
5.3.a. The organization's policies, procedures and
practices shall recognize, respect and respond to the unique,
culturally defined needs of persons and families within its service
5.4. Rights of Persons in Residential Child Care and
5.4.a. A child or transitioning adult receiving services
from the organization shall have basic rights including, but not
5.4.a.1. Adequate food, clothing and shelter;
5.4.a.2. Adult guidance, support and supervision;
5.4.a.3. Freedom from abuse, neglect, corporal
punishment and exploitation;
5.4.a.5. Services necessary to promote safety,
permanency and well-being;
5.4.a.6. Clean and safe surroundings;
5.4.a.7. Adequate medical care;
5.4.a.8. Visitation with family and significant
others as specified in the plan of care and/or the child's case
plan, unless clinically contra-indicated or otherwise described in
5.4.a.9. Communication with family and significant
others by telephone, e-mail, texting or other means of
communication as specified in the plan of care and/or the child's
case plan or under conditions described in policy;
5.4.a.10. Uncensored mail, unless there is reason
to suspect it may contain unauthorized, dangerous or illegal
substances or materials or is clinically contra-indicated, or
unless consent has been given by parent or guardian to inspect
5.4.a.11. Freedom of thought, conscience and
5.4.a.12. Reasonable access to a legal representative, clergy or spiritual advisor and representative of
the placing organization, if applicable;
5.4.a.13. Reasonable access to personal funds, if
managed by the organization, unless clinically contra-indicated;
5.4.a.14. Privacy, as reasonable for the child's
age and functioning, unless clinically contra-indicated; and,
5.4.a.15. Participation in decisions regarding the
services provided, unless clinically contra-indicated.
5.5. Confidentiality and Privacy Protections
5.5.a. The organization shall conform to all federal and
state requirements with regards to the confidentiality of children
and families served (42 CFR Part 2, Public Law 104-191, Health
Insurance Portability and Accountability Act of 1996, as amended,
and W. Va. Code §49-7-1, as amended).
5.5.b. The organization shall have clearly stated
procedures regarding the disclosure of information about children
that are in compliance with state and federal code. Policy
The policies shall be in compliance with all applicable state and
federal laws and rules and regulations and shall include procedures
for instances in which the child may be dangerous to him or herself
5.5.c. The organization shall assure that
a any needed
release of information is are completed in full prior to obtaining
the guardian's signature, for it to be valid for each instance where information is needed. A copy of the all signed form
releases of information shall be placed in the case record.
5.5.d. The organization shall have a written policy
regarding searches of children rooms or property which shall be
respectful of privacy rights. The organization shall document any
carefully. stating the reason for the search and the outcome
of the search.
5.5.e. The organization shall require employees to make
every effort to preserve the child's right to privacy and personal
dignity according to the age and functioning of the child;
5.5.f. The organization shall not use surveillance
cameras or listening devices for routine observation of children in
their rooms unless required by judicial order or contract;
5.5.g. The organization shall provide a secure area or
locker for a child's possessions if requested by the child; and
5.5.h. The organization shall prohibit:
5.5.h.1. Involuntary participation in public
of by children served by the organization. in public
performances. without the informed consent of the parent or legal
guardian; 5.5.h.2. Required or coerced use of public
statements by persons served that express gratitude to the
5.5.h.3. Use of photographs, videotapes, audio-
taped interviews, artwork or creative writing for public relations
or fund raising purposes without the informed written consent of
the parent or guardian or the child if he or she has reached
majority or has been adjudicated an emancipated adult.
5.6. Access to Case Records and Information Management
Children, their attorney or their parent or
guardian shall have access to their case records to the extent
permitted by state and federal law. (Public Law 104-191 and W.Va.
Code §49-7-1). Every child, his or her attorney and the child's
parents or guardian shall have access to the child's case records
to the extent permitted by state and federal law.
5.6.b. The organization may require that sensitive
psychological, psychiatric or other information be reviewed with
the support of clinical
staffs employees. The organization shall
document the reason for the requirement.
5.6.c. The organization shall have policy and procedures
that protect electronically maintained data in compliance with
(Public Law 104-191).
5.7. Research Protections
5.7.a. The organization shall have written policies
regarding the participation of children and transitioning adults in
5.7.b. Organizational policy shall clearly state whether
or not the organization conducts, participates in, or permits
research involving persons served.
5.7.c. If an organization does research, it shall have
a human subjects committee or an internal review board that reports
chief executive officer administrator or a designated
authority with policymaking functions; and
5.7.c.1. Reviews research proposals that involve
5.7.c.2. Makes recommendations regarding the ethics
of proposed or existing research;
5.7.c.3. Makes recommendations as to whether or not
to approve research proposals; and
5.7.c.4. Establishes a minimum frequency for
monitoring of ongoing research activities.
5.7.d. Participation in research by children or their
families is voluntary. The organization may not threaten to
withdraw services or otherwise coerce persons or their guardians
into participating and shall prohibit the use of financial
incentives for recruiting research participants.
5.7.e. Each research participant or when appropriate his
or her parent or guardian shall sign a consent form that includes:
5.7.e.1. A statement that he or she voluntarily
agrees to participate in the research project;
5.7.e.2. A statement that the organization will continue to provide services regardless of whether
or not he or she
agrees to participate in the research project;
5.7.e.3. An explanation of the nature and purpose
of the research project;
5.7.e.4. A clear description of possible risks or
discomfort associated with the research project;
5.7.e.5. A guarantee of confidentiality; and,
5.7.e.6. The signature of the parent or guardian or
5.7.f. The organization shall safeguard the identity and
privacy of persons served in all phases of research conducted by or
with the cooperation of the organization.
5.8. Grievance Procedures
Written policy and procedures shall provide
child and their his or her parent or guardian with a formal
mechanism for expressing and resolving complaints and grievances.
These procedures shall be explained and distributed to children
each child and their his or her parent or guardian. The recipient
shall acknowledge receipt of the procedures in writing. The
5.8.a. Be given to all persons served and their parents
or guardians upon intake into service, and thereafter upon request
or at the initiation of a grievance;
5.8.b. Include an internal appeal procedure and options
for external appeal which shall include the regulatory body and/or
the Federal Office of Civil Rights;
5.8.c. Provide for a timely resolution of the matter and
require a written response to the aggrieved that includes
documentation of the response in the case record or in a separate
file, with reference to the separate file to be noted in case
record; and in the administrative file; and
5.8.d. Indicate that grievances may be filed either
orally or in writing and that all
staff employees of the
organization are responsible for assisting any person who wishes to
file a grievance.
5.9. Ethical Conduct
5.9.a. The organization shall develop and implement
written standards of ethical conduct for its governing board and
5.9.b. The organization shall not misrepresent or
operate a service or program in any way that is misleading,
deceptive or illegal.
5.9.c. The organization shall require its s
employees to know and comply with policies and procedures
established by the organization.
5.9.d. When a child's third-party benefits or payments
end or when a child reaches his or her majority while in service, the organization shall have a procedure to discontinue services to
the child and family in an orderly, ethical fashion.
5.10. Protection of Health and Safety
In its daily operations, the organization shall protect the
health and safety of the
each recipient of service in its care.§78-3-6. Continuous Quality Improvement.
6.1. The organization shall describe in policy and procedure
a well-defined process for assessing and improving its overall
performance and shall identify standards that will promote quality
outcomes for persons served.
6.1.a. The policy or procedure shall:
6.1.a.1. Describe the organization's continuous
quality improvement activities;
6.1.a.2. Assign responsibility for conducting and
coordinating continuous quality improvement activities;
6.1.a.3. Specify time frames;
6.1.a.4. Define methods for monitoring and
reporting results; and
6.1.a.5. Describe feedback mechanisms and
6.1.b. The continuous quality improvement procedure
shall be annually reviewed and updated by senior management and the
6.1.c. The continuous quality improvement process shall include at a minimum three basic components:
6.1.c.2. Case review and compliance; and,
6.1.d. Organizations may designate committees and/or
individuals to carry out the continuous quality improvement
6.2.a. The organization shall conduct a quarterly review
of the use of service modalities or other organizational practices
that involve risk or limit freedom of choice including but not
6.2.a.1. The use of restrictive behavior management
interventions such as restraints (physical, mechanical or chemical)
and seclusion to manage inappropriate and/or aggressive behavior;
6.2.a.2. Aversive procedures used by the
organization as consequences to inappropriate behavior;
6.2.a.3. Critical incidents and non-critical
incidents, including trends and patterns;
6.2.a.4. Reports and allegations of neglect and/or
abuse, both internal and external;
6.2.a.5. Restrictions of privacy including mail,
phone and visitation restrictions;
6.2.a.6. Internal investigations; and
6.2.b. The organization shall conduct a documented,
quarterly safety review of all facilities and buildings to ensure
the safety, cleanliness and appropriateness of each service
environment. Outdoor facilities shall have a monitoring procedure
which shall review at least quarterly all program environments and
processes for safety and sanitation.
6.3. Case Review
6.3.a. The organization shall conduct a quarterly case
review consisting of at least 10% of all open cases and of cases
closed that quarter, chosen using a generally accepted standardized
sampling methodology. Records from all program or unit sites shall
Staffs Employees who conduct case reviews shall
evaluate quality and the presence or absence of required documents,
and the clarity and continuity of the documents, which shall
include but not be limited to:
6.3.c.2. Care plans;
6.3.c.3. Appropriate consents;
6.3.c.4. Custody or guardianship documents;
6.3.c.5. Individualized educational plans as
6.3.c.6. Progress notes, case notes and summaries;
6.3.c.7. Relevant signatures; and
6.3.c.8. Aftercare, discharge and transition plans.
6.3.d. Written procedures for case review shall ensure
that workers do not review cases in which they have been directly
6.3.e. Based on the case record review, the reviewer
shall prepare a document summarizing case record areas of non-
compliance. The organization is responsible for documenting follow-
up on areas of non-compliances.
6.3.f. The organization shall document efforts to
remediate identified patterns of non- compliance through re-
training or increased supervision efforts.
6.4.a. The organization shall have a process that
establishes standards and measures outcomes relative to those
standards for each of its facilities on an ongoing basis.
6.4.b. The organization shall analyze outcome data at
least annually as part of a self-assessment in order to determine
program effectiveness. Results of findings shall be presented to
the governing body.
6.4.c. The organization shall have a systematic,
documented method of assessing child satisfaction.
6.5. Feedback Mechanisms
6.5.a. The organization shall submit annual summary
results of the safety, case review and quality evaluation processes
to the governing body and any advisory councils.
6.5.b. The organization shall annually provide the
results of all reviews including annual financial audits,
accreditation reviews and licensing reviews to the governing body.
6.5.c. The organization shall use the findings of its
continuous quality improvement processes to:
6.5.c.1. Identify problems or service deficits;
6.5.c.2. Determine possible causes when data reveal
issues of concern;
6.5.c.3. Problem solve and develop plans to correct
areas of concern or deficit;
6.5.c.4. Implement and monitor the effectiveness of
corrective plans; and
6.5.c.5. Modify the corrective plans as necessary.
§78-3-7. Governing Body and Organization.
7.1. The organization shall have a clearly identified group
of people (or person or partnership when applicable) which
exercises authority over and has responsibility for its operation,
policies and practices.
The governing body shall be one of the following:
7.1.a. A Board of Directors in the case of a non-profit or for-profit corporation;
7.1.b. Appointed officials of a governmental unit;
7.1.c. A proprietor in case of a sole proprietorship;
7.1.d. Partners, in case of a partnership; or,
7.1.e. A body meeting the criteria established by the
Secretary of State.
7.2. The governing body shall include
no fewer than six
members, including men and women with varying abilities,
experiences, and cultural backgrounds representative of the
community. The governing body may establish an advisory council
including men and women with varying abilities, experiences, and
cultural backgrounds representative of the community if it can not
meet the requirement.
7.3. An advisory council shall provide feedback, information
and recommendations to the governing body on program policy and
procedures, incident reports and quality assurance data.
7.4. An employee or member of the immediate family of an
employee of any public organization which regulates or purchases or
arranges the services of a privately run organization may not be a
member of the governing body of the organization.
7.5. All members of the governing body or advisory council
shall be provided:
7.5.a. A formal orientation to the organization and
responsibilities of membership of the governing body or advisory council, which shall be documented;
7.5.b. Written information that specifies the member's
fiduciary and/or other responsibilities of the organization;
7.5.c. Annual reports of the activities of the
7.5.d. Reports from all regulatory bodies.
7.6. The Governing Body shall:
7.6.a. Identify in writing the mission of the
organization and develop a plan to meet that mission;
7.6.b. Ensure that all planned or provided services are
consistent with the organization's mission and plan;
7.6.c. Oversee the organization's operations and
7.6.d. Determine whether services are within the
organization's capabilities and resources;
7.6.e. Adopt administrative,
staffs employees, and
program policies which are reviewed at least every two years;
7.6.f. Review and approve a budget prior to the
beginning of the fiscal year;
7.6.g. Annually review and formally accept the financial
a chief executive officer an administrator
and delegate authority to that person to employ and dismiss staff
employees, implement board policies, and manage day-to-day operation of the organization;
7.6.i. Permit the
chief executive officer administrator
or his or her designee to attend all meetings of the governing body
and committee, with the exception of those held for the purpose of
reviewing the performance, status or compensation of the chief
executive officer administrator.
7.6.j. Annually evaluate and document the
executive officer's administrator performance through specific
criteria and objectives;
7.6.k. Initiate a continuous quality improvement Program
and direct needed changes based on the results;
7.6.l. Annually review facility needs related to risk
7.6.m. Maintain a long-range plan and review it
7.6.n. Maintain minutes and records generated from all
meetings, including members who were present or absent;
7.6.o. Annually visit each organizational site;
7.6.p. Annually review facility needs related to capital
7.6.q. Meet at least twice annually.
. Chief Executive Officer Administrator
chief executive officer is administrator shall be responsible for the organization's daily operations.
chief executive officer administrator shall:
7.7.b.1. Plan and coordinate the development of
policies governing the organization's program of services with the
7.7.b.2. Work with the governing body to develop
and implement facilities which serve to meet the mission of the
7.7.b.3. Provide written comprehensive reports to
the governing body at least annually regarding the operation of
present facilities and their compliance with organizational policy;
7.7.b.4. Provide written reports on the
organization's finances to the governing body at least annually
regarding present financial status, anticipated problems, financial
planning and funding alternatives; and
7.7.b.5. Ensure that human resources management
complies with federal and state employment law.
7.8. Conflicts of Interest
7.8.a. The organization shall have a policy which
defines and limits conflicts of interest.
Staffs All persons employed by or volunteering
for the organization, the governing body, advisory council members
and consultants shall follow the policy.
7.9. Administrative File for the Organization
7.9.a. An organization shall assemble an administrative
file, which shall be made available upon request of the appropriate
governmental organization. It shall contain the following
information and documents:
7.9.a.1. The governing structure including the charter
and articles of incorporation as appropriate;
b a.2. A mission statement and long term plan;
c a.3. The most recent audit and financial
d a.4. The by-laws or other legal basis for its
e a.5. The organizational structure and the overall
administrative lines of authority and organization staff employees
f a.6. The name and position of persons authorized
to sign agreements and submit official documentation to the
appropriate government organization;
g a.7. The governing body structure and its
composition with names and addresses and terms of membership as
h a.8. Existing purchase of service agreements;
i a.9. Insurance coverage (all types) including
bonding documents if appropriate;
j a.10. A master list of all clinical and social
service professionals used by the organization, either as employees
or contractors, and
k a.11. A description and the membership of any
§78-3-8. Risk Management.
8.1. The organization shall purchase appropriate types of
insurance including as appropriate, but not limited to: general
liability, worker's compensation, disability, fire and theft,
medical, indemnification, professional liability, officer's or
director's liability, automobile liability and malpractice.
8.2. The organization shall ensure that all
who sign checks, handle cash or contributions or manage funds,
including children's funds, are bonded at the organization's
expense or that the organization maintains appropriate insurance
coverage to cover potential losses.
8.3. An organization that provides transportation for persons
served as part of a service shall maintain adequate insurance
Staffs Employees and volunteers transporting children
residents in their own vehicles as part of their duties shall
provide the organization with evidence that they are properly
insured in case of automobile accident. That evidence shall be
updated annually. Copies of the individual's license to drive shall be maintained in the individual's personnel file and shall be
updated at an interval to be specified in organizational policy.
8.4. All insurance policies shall be at a financial level
adequate to cover the organization in case of an accident or suit.
All bonding policies shall be adequate to replace the aggregate of
funds managed by the organization.
8.5. Legal Compliance
The organization shall comply with all applicable federal,
state, and local laws, rules and regulations associated with all
aspects of service delivery and operations and shall possess all
relevant and appropriate licenses.
8.6. Security of Information
8.6.a. The organization shall have policies and
procedures regulating access to records of
staff employees and
persons served which are in compliance with all federal (Public Law
104-191 and 42 CFR Part 2) and state requirements. Regulatory
agencies shall be allowed access to all information as necessary to
fulfill their statutory duties.
8.6.b. The organization shall ensure that records,
whether paper or electronic, can be located at any time.
8.6.c. The organization shall have procedures to protect
service and organizational records, whether in electronic or paper
form, from destruction by fire, water, loss or other damage and
from other unauthorized access, which include:
Daily Backup of all electronic records;
8.6.c.2. Storage of paper records and preserved
data in locked cabinets.
8.6.d. Written operational procedures shall govern the
retention, maintenance and destruction of records of former service
8.6.e. The organization shall retain children's records
for a minimum of five years following the child's eighteenth
8.6.f. The organization shall have a policy regarding
disposal of records which respects confidentiality and security of
8.6.g. The organization shall ensure that all computers
have up-to-date anti-virus protection and procedures for protecting
the confidentiality and integrity of internal databases and
8.6.h. The format of electronically transmitted data
shall comply with all applicable legal standards and requirements.
(Public Law 104-191). 8.7. Contractual Relationships
8.7.a. The organization shall use written purchase of
service agreements or written contracts with both general
contractors or vendors and professional contractors of clinical services.
8.7.b. Purchase of non-clinical service or material
contracts shall describe all significant terms and conditions
including as appropriate:
8.7.b.1. Roles and responsibilities of
8.7.b.2. Services to be provided;
8.7.b.3. Provisions for training and technical
support as necessary;
8.7.b.4. Duration of the contract, including
delineation of follow up services;
8.7.b.5. Methods for resolving disputes;
8.7.b.6. A plan and procedure for timely payment;
8.7.b.7. Consequences for failure to pay;
8.7.b.8. Documentation necessary for, and means of
reporting to, funding or oversight bodies;
8.7.b.9. Conditions for termination; and
8.7.b.10. Expected outcomes as appropriate.
8.7.c. If the organization arranges externally or
contractually for the provision of clinical services, the
organization shall have a written agreement which specifies:
8.7.c.1. Roles and responsibilities of the
organization and the contracting party;
8.7.c.2. Documentation required of the contracting
individual or service with time lines for provision of the
8.7.c.3. Services to be provided;
8.7.c.4. Provision of appropriate liability or
malpractice insurance either by the contractor or contracting
8.7.c.5. Procedures for exchange of information;
8.7.c.6. Definition of the clients to be served and
the services to be provided;
8.7.c.7. Time lines for provision of service;
8.7.c.8. Terms of payment;
8.7.c.9. Assurances that the contracting party
shall adhere to state and federal requirements of confidentiality;
8.7.c.10. Expected outcomes as appropriate.
8.7.d. The organization shall ensure a complete
personnel file on each contracted clinical employee and consultant
who provides direct services to children on site, including:
8.7.d.1. Evidence of clinical training;
8.7.d.2. Evidence of appropriate licensure or
8.7.d.3. Evidence of malpractice or liability
insurance as specified in the contract;
8.7.d.4. Evidence of ability to conduct business in
the State of West Virginia;
8.7.d.5. Evidence of a criminal background check.
8.7.e. If the organization contracts for professional
services with a licensed practitioner who serves children in his or
her own location, the organization shall have a personnel file
containing the following:
8.7.e.1. Evidence of clinical training;
8.7.e.2. Evidence of licensure;
8.7.e.3. Evidence of liability insurance; or
8.7.e.4. Evidence of a license to operate a
business in the state of West Virginia;
8.7.e.5. Evidence that the practitioner is the
employee of a licensed behavioral health center and therefore in
compliance with regulatory requirements. 8.7.f. The organization shall ensure that contractual
vendors are oriented to and adhere to the organization's policies
and procedures regarding professional practices and
§78-3-9. Financial Management System.
9.1. The organization shall have a written budget, approved
by the governing body, that shall serve as a plan for managing its
financial resources for the fiscal year.
9.2. The organization shall have established financial management policies and procedures that follow generally accepted
accounting principles (GAAP).
9.3. The organization shall have annual financial statements
prepared in accordance with generally accepted accounting
9.4. Financial Accountability
9.4.a. The organization shall make available an annual
report of fiscal, statistical and service data that includes
summary information regarding its financial position.
9.4.b. The organization shall ensure that an
administratively independent auditor conducts an annual audit.
9.4.c. An organization that assumes fiduciary
responsibility for client funds or disburses other child funds,
such as maintenance or allowance funds, shall have written
operational procedures that ensure:
9.4.c.1. Separate individual accounting of funds
with monthly statements to the child and his or her parent or
guardian. Funds managed on behalf of clients shall not be
commingled with organizational funds;
9.4.c.2. Protection of child assets, including a
bond sufficient to cover all child accounts, unless the aggregate
value of the child accounts is less than $500; and
9.4.c.3. Compliance with applicable legislative,
judicial and governmental requirements, including those applying to payment of benefits allotted by the state or federal government.
§78-3-10. Management of Human Resources.
10.1. Deployment of
10.1.a. The organization shall retain sufficient numbers
of qualified individuals to:
10.1.a.1. Efficiently and effectively meet the
demand for all services it provides; and
10.1.a.2. Provide and coordinate the services that
are within the organization's scope and mission.
10.1.b. The organization shall ensure that sufficient,
licensed or certified professional clinical
staffs employees are
employed or available on a consistent basis to provide, at a
10.1.b.1. All intakes and diagnostic assessments
are completed by suitably trained and experienced professional
staff employees are is
available and mandated to provide direct supervision and
consultation to direct care staff employees, professional interns
and paraprofessionals at a ratio appropriate to the number of
employees or interns supervised and the demands of the population
staff employees or staff employees under supervision for licensure or certification
according to state law is available and mandated to provide direct
service to children and transitioning adults for those
organizations providing therapy services (individual, group and
family) and/or medical services; and
Staff is Employees are available in
sufficient quantity and with sufficient credentials to address the
needs of the child as identified by the assessment and
interdisciplinary team process.
10.1.c. The organization shall identify an individual at
each program site responsible for overall administration of the
program at that site.
10.2. Personnel Practices
10.2.a. Upon employment of services, the organization
shall provide each employee
s with written policies and procedures
regarding wages, benefits, promotions, insurance protections,
staffs employee training and development opportunities as
10.2.b. The organization shall have policies which
compliant comply with all federal and state statutes, rules and
regulations regarding employment practices.
10.2.c. The minimum age of any person serving as an
employment for organizations serving children aged 13 and
greater older shall be 20 years of age.
10.2.d. If the age of the population served at an
organization is uniformly 12 years and under, the minimum age of
staff employees serving the population shall be a minimum of 18
10.2.e. If the program serves transitioning adults up to
age 21, the ages of the
staff employees providing direct care
shall be at least 3 three years older than the age of the eldest
10.2.f. The organization shall interview each qualified
applicant personally prior to employment. The organization shall
document contact with at least three unrelated references by
telephone, in writing or in person for each
person applicant being
actively considered for employment. At least one reference shall be
a professional reference. If the person has never been employed,
school references may be used.
10.2.g. The organization shall review with the applicant
a comprehensive job description at the time of the interview and
provide a copy of a detailed written job description upon
employment engagement and upon significant changes in job
assignment or responsibilities.
10.2.h. The organization shall submit a request for a
Criminal Identification Bureau (CIB) records check and a Protective
Services records check to the Department
on for each potential employee or independent contractor prior to permitting that
employee or independent contractor working to work with children.
An organization may submit CIB records check directly to the West
Virginia State Police. The organization shall document that it has
pursued the completion of the records check vigorously. The
organization is responsible for following policies and procedures
with regard to researching possible criminal and protective
services backgrounds as established and disseminated by the
Secretary. If the potential applicant has lived outside the State
of West Virginia since turning 18, a records check with the Federal
Bureau of Investigation National Crime Information Center (NCIC)
is also required.
__________10.2.i. If the applicant has a disfigurement or
disability that prevents a clear fingerprint after three attempts,
a name-based criminal background check may be substituted for the
finger-print based check.
__________10.2.j. The organization shall submit a request for a
Protective Services (Adult and Child) background check on each
applicant to the Department. Documentation of the results of the
check shall be maintained with the personnel file of the applicant.
__________10.2.k. The organization shall document that it has
pursued the completion of both record checks. The organization is
responsible for following any other policies and procedures with
regard to researching possible criminal and protective services backgrounds as established and disseminated by the Secretary.
10.2.h.1. 10.2.k.1. The organization may use permit
applicants for employment to work as an employee or independent
contractor prior to receiving the result of the CIB/NCIC records
check under the following conditions:
10.2.h.1.a. 10.2.k.1.a. A delay in offering or
beginning an applicant's employment engagement would seriously
disrupt staff employee scheduling and/or impact staff employee to
10.2.k.1.b. A Statement of Criminal Record has been
completed by the applicant, detailing his or her own words any
criminal history and the history does not reflect in any criminal
history that would otherwise preclude engagement at the
10.2.h.1.B. 10.2.k.1.c. The applicant's fingerprints
have been submitted to the State Police;
10.2.h.1.C. 10.2.k.1.d The employee applicant is
informed in writing that final approval for the applicant to become
an employee or independent contractor employment is contingent upon
the receipt of a clear Protective Services and NCIC/CIB checks; and
10.2.h.1.D. 10.2.k.1.e. A written safety plan is
implemented which ensures that the newly hired staff employee works
under direct supervision and is not left alone with a child until
the CIB record check results are received.
10.2.l A Statement of Criminal Record shall be completed
yearly for each employee, volunteer or independent contractor;
__________10.2.m. Both CIB and Protective Services record checks
are to be repeated every five years;
__________10.2.n. Organizational policy shall prohibit the
engagement of any employee, volunteer or independent contractor who
has a history of substantiated adult or child abuse or neglect.
10.2.i. 10.2.o. Organizational policy shall prohibit
employment engagement or retention of either staffs employees, or
contractors, or volunteers who have a history of convictions for;
10.2.i.1. 10.2.o.1. Abduction;
10.2.i.2. 10.2.o.2. Any violent felony crime;
included by not limited to rape, sexual assault, homicide,
felonious physical assault or felonious battery;
10.2.i.3. 10.2.o.3. Child or adult abuse or neglect;
10.2.i.4. 10.2.o.4. Crimes which involve the
exploitation of a child or an incapacitated adult;
10.2.i.5. 10.2.o.5. Domestic battery or domestic
10.2.i.6. 10.2.o.6. Felony arson;
10.2.i.7. 10.2.o.7. Felony or misdemeanor crime
against a child or incapacitated adult which causes harm;
10.2.i.8. 10.2.o.8. Felony drug related offenses
within the last ten (10)years;
10.2.i.9. 10.2.o.9. Felony DUI within the last ten
10.2.i.10. 10.2.o.10. Hate crimes;
10.2.i.11. 10.2.o.11. Kidnapping;
10.2.i.12 10.2.o.12. Murder or homicide;
10.2.i.13. 10.2.o.13. Neglect or abuse by a
10.2.i.14. 10.2.o.14. Pornography crimes; involving
children or incapacitated adults including but not limited to, use
of minors in filming sexually explicit conduct, distribution and
exhibition of material depicting minors in sexually explicit
conduct or sending, distributing, exhibiting, possessing,
displaying or transporting material by a parent, guardian or
custodian, depicting a child engaged in sexually explicit conduct.
10.2.i.15. 10.2.o.15. Purchase or sale of a child;
10.2.i.16. 10.2.o.16. Sexual offenses. including
but not limited to incest, sexual abuse, or indecent exposure.
10.2.j. 10.2.p. The organization shall have a policy and
mandatory training process for all employees for compliance with
mandatory reporting requirements regarding allegations of abuse or
neglect of children as described in W. Va. Code §49-6A-1 et seq.
10.2.k. 10.2.q. The organization shall have a written
job description and selection criteria for each position or group of similar positions that includes the qualifications, expectations
and responsibilities required of staffs employees. Job
descriptions shall be readily available to staff employees.
10.2.l. 10.2.r. The job description shall detail the
supervisory chain of command for each position.
10.2.m. 10.2.s. The organization shall designate a
supervisor for each separate service or program.
10.2.n. 10.2.t. The organization shall employ persons who
are qualified according to the job description and selection
criteria for the positions they occupy. An organization employing
any person who does not possess the usual qualifications for the
position in which he or she is employed shall have a written
statement justifying reasons for employing this person. Licensure
or certification requirements for a position may only be waived or
altered by the Secretary.
10.2.o. 10.2.u. The organization shall verify the
credentials of all organization staff employees and individuals,
who are contract employees of the organization, including:
10.2.o.1. 10.2.u.1. Education and training;
10.2.o.2. 10.2.u.2. Relevant experience; and
10.2.o.3. 10.2.u.3. State licensing or
certification requirements for their respective disciplines, if
10.2.p. 10.2.v. If the job description allows less than full licensure for individuals eligible for professional licensure
or certification, the organization shall demonstrate that:
10.2.p.1. 10.2.v.1. A person with requisite
credentials provides appropriate supervision to the staff
10.2.p.2. 10.2.v.2 The staffs employees are
actively working toward licensure and/or certification.
10.2.p.3. 10.2.v.3. This requirement shall not be
construed to apply to individuals performing job duties which would
not normally require licensure or certification.
10.3.a. Volunteers included in this rule are defined as
those individuals involved in direct contact with the
organization's children on a regular basis. 10.3.
b a. The organization shall have a policy which
specifies the roles and responsibilities that volunteers may
c b. The organization shall ensure that volunteers
receive regular supervision to provide assistance, directions for
activity and support.
d c. Any documentation provided by volunteers to be
placed in a clinical record shall include the date and signature of
the volunteer's on-site supervisor prior to being placed in the record.
e d. The organization shall ensure that volunteers
understand the responsibilities of the position and the time
commitments required prior to formal assignment.
.f e. The organization shall formally train
volunteers in confidentiality prior to beginning their duties and
shall maintain documentation of the training.
g f. The organization shall have a policy requiring
volunteer screening, which shall include the same criminal and
protective services background checks as required for employees and
independent contractors. on all volunteers, as required by
10.3.g. The organization shall not use any volunteer who
would not pass the background or security requirements as an
employee or independent contractor.
10.4. Students and Student Interns or Residents
10.4.a. Students covered by this rule are those
individuals serving an academic placement of more than thirty hours
on site per three month quarter. Students serving less than thirty
hours per quarter shall be continually supervised by
employee and may not work alone with children.
10.4.b. The organization shall have a policy which
specifies the roles and responsibilities that students may assume.
10.4.c. The organization shall ensure that students receive regular documented supervision to provide assistance,
directions for activity and support.
10.4.d. Any documentation provided by students to be
placed in a clinical record shall include the date and signature of
the student's on-site supervisor prior to being placed in the
10.4.e. The organization shall formally train students
in confidentiality prior to beginning their duties and shall
maintain documentation of the training.
10.5. Employee, Volunteer, and Student Records
10.5.a. The organization shall maintain personnel
records for all employees,
contracted clinical employees, students
and volunteers. These records shall be reviewed annually and
updated as necessary, and contain, as appropriate:
10.5.a.1. Identifying information and emergency
10.5.a.2. An application for employment, volunteer
or student service
or resume (excepting contracted clinical
employees); 10.5.a.3. A job description or contract;
10.5.a.4. Reference verification;
10.5.a.5. Documentation of education and/or
licensure or certification;
10.5.a.6. Documentation of relevant training as
10.5.a.7. Documentation of employee orientation
including training in confidentiality;
10.5.a.8. Documentation of criminal and protective
services background checks ; and
10.5.a.9. Performance evaluations (except
contracted clinical employees students and volunteers) and
documentation relating to performance, including disciplinary
actions and termination summaries, as appropriate.
employee organization shall have a record,
stored separately, containing medical information of on each the
employee, 's volunteer or student. medical information to include
The medical records shall include:
10.5.b.1. An initial tuberculosis screening before
assumption of duties and
annual a screening every 5 years
10.5.b.2. A physician's statement of lack of a
communicable disease; and
10.5.b.3. 10.5.b.2. Results of random drug screens
if required by organization policy.
10.5.c. The files shall be secured in a confidential
manner with limited access.
10.6. Performance Review
10.6.a. The organization shall conduct annual
performance reviews between each employee and the supervisor or
person to whom he or she is accountable.
10.6.b. The organization shall develop performance
expectations for each position which are discussed with each
10.6.c. The organization shall give the employee
opportunity to sign the written performance review and provide
written comments before the report is entered into their personnel
10.6.d. The organization shall have a policy which
clearly delineates procedures governing disciplinary actions and
non-voluntary termination of
§78-3-11. Training and Supervision of
11.1. Orientation of New
11.1.a. The organization shall ensure that
all each new
employee, volunteer, student and contracted clinical staffs receive
an orientation within the first ten days of employment and shall
document that orientation in the individual's personnel record.
11.1.b. The organization shall orient all new
employees, and contracted clinicians to:
11.1.b.1. Its mission, philosophy and goals;
11.1.b.2. Its services, policies and procedures;
11.1.b.3. An organizational chart that delineates lines of accountability and authority at all levels of the
11.1.b.4. The objectives and process of the
organization's continuous quality improvement program;
11.1.b.5. The organization's policies and
procedures on confidentiality and disclosure of information on
persons served, including penalties for violation of these policies
and procedures and an orientation to federal confidentiality
requirements as they apply to the organization;
11.1.b.6. The legal rights of persons served;
11.1.b.7. Mandatory reporting procedures for
suspected abuse and neglect;
11.1.b.8. Appropriate identification and
documentation of incidents;
11.1.b.9. The responsibility to abide by
organizational and professional ethics;
11.1.b.10. Fire drills; and
11.1.b.11. Procedures regarding medical and
psychiatric emergencies, including necessary notification of
guardians and others.
11.1.c. Additionally, program
direct care responsibilities shall be trained as soon as possible
upon within 90 days of employment on the following:
11.1.c.1. The establishment of rapport and responsive behaviors with persons served;
11.1.c.2. 11.1.c.1 Sensitivity to differences in
cultural norms and values as appropriate;
11.1.c.2. Management of children attempting to
escape supervision or who are away from supervision;
11.1.c.3. Sensitivity to sexual identity including
lesbian, gay, bisexual, transgender and questioning youth;
11.1.c.3. 11.1.c.4. Family dynamics, including
human growth and development;
11.1.c.4. 11.1.c.5. Proper documentation techniques;
11.1.c.5. Psychiatric emergency procedures and
management; and 11.1.c.6. Basic therapeutic or behavior management
that may include principles of behavior modification
and analysis, including antecedents and consequences, functionality
of behavior, principles of reinforcements and alternative methods
of reducing and/or replacing inappropriate behaviors. 11.1.d. Until the training is completed, the
person employee may not work unless accompanied at all times by a
staff member employee who is experienced and knowledgeable in these
Staff Employee Training and Content
11.2.a. The organization shall provide training to clinical and direct care
staffs employees in the following health
related topics within thirty days of employment:
11.2.a.1. Basic medical needs and problems of the
population served, including management of sick children and
symptoms of common medical problems, such as allergy reactions,
diabetes and asthma;
11.2.a.2. Basic first aid (completed according to
OSHA-approved pediatric first aid requirements and adult
requirements as appropriate) and medication reactions (including
desired and undesired effects). This training must be updated
every three years;
Adult Pulmonary Resuscitation (CPR),
unless the organization serves an infant population, in which case
both adult and infant cardiopulmonary resuscitation training is
required. This training must be updated every two years Cardio-
Pulmonary Resuscitation (CPR) Adult Certification is required every
two years and First Aid certification every three years, specific
to population served (adult, child and/or infant);
11.2.a.4. Supervision of self-administration of
medication as applicable including typical medications prescribed,
appropriate dosages and schedules and common side effects. This
must shall be updated annually;
11.2.a.5. Basic de-escalation techniques and
passive restraints. This training must be updated annually;
11.2.a.6. The organization's protocols for
universal disease precautions and providing services to children
with contagious and infectious diseases including positive HIV,
AIDS, hepatitis, tuberculosis, or other air and blood borne
pathogens. This training must be updated annually;
11.2.a.7. Recognizing the symptoms of common
medical problems such as asthma and diabetes;
11.2.a.8. 11.2.a.7 The organization's procedures
regarding the duty to warn others of impending harm by a child due
to threats made by a resident of the organization's program. The
procedures shall include, at a minimum, the requirement that verbal
communication of the treatment to the potential victim occur
11.2.a.9. 11.2.a.8. Appropriate management of
suicidal threats or behaviors;
11.2.a.9. Children's trauma stress
experiences, to include:
_________________________11.2.a.9.A. impact on development,
behavior and relationships;
11.2.a.9.B. understanding the types of
_________________________11.2.a.9.C. understanding the influence of
11.2.a.9.D. recognizing how on-going stressors impact child traumatic stress;
11.2.a.9.E. responding to crises with
_________________________11.2.a.9.F. strategies and interventions
to promote resiliency and health;
11.2.a.10. Appropriate management of aggressive or
out of control behavior;
11.2.a.11. Procedures for notifying family members,
parents or guardians or other contacts in the case of emergencies;
11.2.a.12. Management of children attempting to
11.2.a.13. 11.2.a.10. Food handlers certification
as necessary and appropriate. and
11.2.a.14. Heimlich's maneuver or abdominal thrust
or any other life-saving technique for choking/obstructed airway as
recognized by the American Red Cross or equivalent.
11.2.b. The organization shall provide a minimum of
twelve hours of annual internal continuing education for all
program staffs providing direct services to children. Objectives
for internal continuing education should be based on required items
as listed within this rule and an analysis of systemic weaknesses
as identified by the continuous quality improvement process.
11.2.c. 11.2.b. The organization shall inform all staffs
employees in writing of its policy defining and prohibiting corporal and degrading punishment.
11.2.d. 11.2.c. The organization shall train appropriate
staffs employees on procedures for maintaining a safe, hygienic,
and sanitary environment. Procedures shall address:
11.2.d.1. 11.2.c.1. Steps to retard the spread of
infection in bathrooms, bedding and food; and
11.2.d.2. 11.2.c.2. Proper storage of cleaning
supplies and hazardous materials.
11.2.d.3. Handling of sick children.
11.2.e. 11.2.d. Staff Employees shall be trained at the
time of admission to serve any child with special needs such as
dietary restrictions, use of epipen an epinephrine auto-injector,
rescue inhalers, diabetic monitoring mechanisms, etc.
11.2.f. 11.2.e. The organization shall document all staff
employee training provided to employees.
11.3.a. The organization shall have a system of
employee supervision that is tailored to the organization's model
of service delivery and uses individual and/or group supervision on
a regularly scheduled basis.
11.3.b. Supervisory ratios for program
shall be adequate and adjusted according to the following criteria:
11.3.b.1. Educational background and skill level of those supervised;
11.3.b.2. Skills of the supervisor;
11.3.b.3. Workload size and complexity;
11.3.b.4. Newness of the assignment;
11.3.b.5. Variance due to turnover, vacation and
other factors; and
11.3.b.6. Mode of supervision (group, individual,
on-going, scheduled, etc.).
11.3.c. The organization shall ensure that supervisory
staffs employees have sufficient time to hold supervisory
conferences and conduct evaluation and training activities.
11.3.d. The organization shall adjust supervisory
assignments, frequency and duration in response to the findings and
recommendation of the continuous quality improvement processes.
§78-3-12. Service Environment.
12.1. Environmental Quality
12.1.a. The organization shall provide services in an
environment (buildings, grounds and equipment) that meets all
applicable federal, state and local health, building, safety and
12.1.b. All structures on the grounds and equipment of
the organization shall be maintained in good repair and free from
danger to health and safety.
12.1.b.1. Broken, rundown or defective furnishings and equipment shall be replaced or repaired promptly.
12.1.b.2. Outside doors, windows and other features
of the structure necessary for security from weather shall be
repaired within 24 (twenty-four) hours of being found to be in a
state of disrepair.
12.1.c. The organization shall operate facilities in an
environment that is safe, accessible, and appropriate for the needs
of the child.
12.1.d. The organization shall provide adequate
housekeeping, laundry, maintenance, storage and other
administrative support functions required to carry out its
12.1.e. The organization shall post by the telephone in
all direct care and residential service locations, emergency
telephone numbers for the fire department, poison control hot-line,
local police, and child abuse hot line.
and on-call staff. Each
child capable of using them shall be oriented to their presence and
use of the telephone system in emergencies.
12.1.f. Buildings owned or leased by the organization
shall be in compliance with Title III of the Americans with
Disabilities Act. Existing organizations shall make any
modifications readily achievable within the resources of the
organization. Where the building's age or excessive cost prevents
change to the facility or grounds, the organization shall have on file a plan that can be readily implemented to accommodate the
needs of persons with physical disabilities when served. The
organization may be compliant with the requirements of this section
by adapting its program to serve individuals with disabilities in
other equally effective ways.
12.1.g. All residential buildings shall conform to the
current Life Safety Code of the National Fire Protection
Association, unless exempted by the State Fire Marshal.
12.1.h. The organization shall have documentation that
the facilities owned or leased by the organization and used for
services are in full compliance with the State Fire Code. That
evidence shall be renewed as required by the State Fire Marshal.
12.1.i. All water supply systems in buildings owned or
leased by the organization shall comply with applicable Public
12.1.j. All drinking water facilities in buildings shall
be sanitary and accessible.
12.1.k. All buildings owned or leased by the
organization shall be served by an approved public sewage system or
by a sewage disposal system that has been approved by the
12.1.l. All rooms in buildings used by the organization
shall provide adequate heating, illumination and ventilation. The
following shall be prohibited:
12.1.l.1. Unvented, fume-producing heating devices;
12.1.l.2. Unprotected open heaters.
12.1.m. The organization shall have appropriate and as
necessary, secure storage areas for items such as food, utensils,
work materials, cleaning supplies, clothing, linens, medicines and
toxic materials. Food and medicines shall be stored separately
from all other materials and from each other.
12.1.n. Poisons and other potentially hazardous items
shall be kept in a locked place.
12.1.o. Solid waste storage shall be sufficient to
contain all solid waste in a safe and sanitary manner.
12.1.p. Garbage and rubbish which is stored outside
shall be stored securely in non-combustible, covered containers and
shall be removed on a regular basis not less than once every week.
Garbage containers shall be watertight and vermin proof, kept clean
and stored on a concrete or metal platform. Trash collection
receptacles and incinerators shall be separate from play areas and
be so located as to avoid being a nuisance to neighbors.
12.1.q. All plumbing in buildings owned or leased by the
organization shall meet the requirements of local plumbing codes or
the National Plumbing Code if no local codes apply.
12.1.r. Structures shall be maintained free of insects
and rodents of public health significance.
12.1.s. A routine maintenance and cleaning program shall
be maintained by the organization in all areas of the facility,
including interior and exterior spaces.
12.2. Food Services
12.2.a. Food shall be stored, prepared and served in a
12.2.b. Food services shall:
12.2.b.1. Meet or exceed national nutritional
12.2.b.2. Be planned with the documented assistance
of a dietitian; and
12.2.b.3. Meet general and prescribed dietary needs
of persons served.
12.2.c. Use of paper and/or throw-away plates, beverage
containers and utensils are to be limited and not used in day-to-
day meal service. Outdoor therapeutic educational programs are
exempt from this requirement when operating in the field.
12.3. Compliance with Legal, Health and Regulatory
12.3.a. The organization shall have current
authorization or licensure for facilities that require
authorization or licensure.
12.3.b. Current licenses or certificates shall be
prominently displayed in an area visible to the public.
12.3.c. The organization shall maintain in the
administrative file reports regarding:
12.3.c.1. Certification of occupancy requirements;
12.3.c.2. Zoning and building codes;
12.3.c.3. Occupational safety and health
12.3.c.4. Health, sanitation and fire codes;
12.3.c.5. Records of maintenance and safety
inspections performed internally (e.g., by the Safety
Committee/Officer of the continuous quality improvement process);
12.3.c.6. All other applicable safety codes; and
12.3.c.7. Any and all corrective action plans or
12.4.a. An organization that provides transportation in
its vehicles for children as part of a service shall have
procedures for ensuring:
12.4.a.1. The use of age-appropriate passenger
12.4.a.2. Adequate passenger supervision relative
to the ages, sexes, behavioral challenges and disabilities of the
12.4.a.3. Proper and timely licensure and
inspection of the vehicles;
12.4.a.4. First aid kits in each organizational
12.4.a.5. Proper and timely maintenance of
12.4.a.6. That the number of persons in any vehicle
used to transport children shall not exceed the number of available
safety restraint systems;
12.4.a.7. Sufficient liability insurance;
12.4.a.8. Adequate aisle space in vans transporting
12.4.a.9. Secure anchoring for wheelchairs except
in automobiles; and
12.4.a.10. Annual validation of driver licenses.
12.4.b. An organization that permits the transportation
of persons served in vehicles that belong to
staff employees shall
12.4.b.1. Passenger insurance coverage either
through the organization's insurance or the driver's automobile
12.4.b.2. Proof of insurance;
12.4.b.3. Age-appropriate passenger restraints for
12.4.b.4. Annual validation of the driver's
12.4.b.5. Current registration and inspection
12.5. Organization Safety and Security
12.5.a. The organization shall have a schedule of
regular inspection and maintenance activity to ensure the safety of
its premises, equipment and fixtures.
12.5.b. The organization shall have fire extinguishers
reviewed by a qualified professional annually.
12.5.c. The organization shall not maintain any firearm
or chemical weapon on the grounds or within the structures of the
12.5.d. All power driven equipment used by a facility
shall be kept in safe and good repair. The equipment shall be used
by children only under the supervision of a
staff member employee
and according to state code. Lawn mowers shall be stored in areas
separated with one hour fire rated material.
12.5.e. The organization shall have a Safety Committee
or designated safety and maintenance officer whose function is to
perform regular documented inspections for identification of
potentially hazardous conditions (e.g., harmful water temperatures,
improper use of small appliances, stairs without handrails, etc.)
and items in need of repair or maintenance. At no time shall those
inspections be less than quarterly.
12.6. Emergency Response
12.6.a. The organization shall have procedures in place
for responding to accidents, serious illness, fire, medical
emergencies, floods, natural disasters and other life threatening
12.6.a.1. Address the needs of any special
population served by the organization;
12.6.a.2. Specify evacuation procedures including
an evacuation site, parties to notify, and emergency items to take
12.6.a.3. Describe relocation plans for the service
and/or program if it becomes necessary;
12.6.a.4. Specify appropriate responses to medical
12.6.a.5. Require notification of the child's
parent or guardian and other appropriate authorities at the
12.6.b. Residential facilities shall conduct monthly
fire drills rotating all shifts at least once per quarter and shall
meet legal requirements for fire drills as specified by the State
Fire Marshal. Participation shall be mandatory for all
employees and children. Organizations which do not operate by
shifts (e.g., outdoor therapeutic educational programs) shall have
monthly fire drills at various times of the day and night.
12.6.c. The organization shall have procedures for dealing with injuries, accidents and illnesses. The organization
shall ensure that a communication device and first aid supplies are
readily available in all organization buildings.
12.6.d. The organization shall have procedures in place
for dealing with:
12.6.d.1. Persons who are injured, lost or absent
from care without permission; and
12.6.d.2. Persons who threaten violence or harm to
staffs employees providing care and/ or supervision.
12.6.e. The organization shall assign a
employee to orient each newly arrived child to organization
emergency procedures and the location of emergency exits as
appropriate during the first full day of the child's stay at the
organization. The staff member employee shall file a written
confirmation in the child's case record that the orientation has
12.6.f. The organization shall ensure that all
employee have immediate access to current poison control
information or procedures for referral for emergency medical
12.7. Contagious and Infectious Diseases
12.7.a. The organization shall have a procedure in place
for minimizing the risk of exposure to airborne and blood-borne
pathogens. Procedures shall comply with related standards of the Centers for Disease Control and the Occupational Safety and Health
12.7.b. The organization shall develop policies and
procedures to prevent and control the spread of HIV/AIDS,
hepatitis, tuberculosis, and other contagious or infectious
diseases and shall review and update those policies as necessary or
every two years at a minimum.
12.7.c. The organization shall have policies which
staffs staff members employees with direct contact with
12.7.c.1. Receive a tuberculosis risk assessment or
test prior to
initial assignment assumption of duties and at least
every five years thereafter, as well as after incidents of exposure
or manifestation of symptoms of TB; and
12.7.c.2. Demonstrate completion of an approved
treatment when test results are positive.
12.7.d. The organization that prepares food for children
shall have policies and procedures to ensure clean and safe food
preparation and prevent the exchange of communicable diseases. The
12.7.d.1. Require that food service employees do
not prepare and/or serve food if they have symptoms of acute
illness or an open, untreated wound;
12.7.d.2. Set forth minimum dishwashing and laundry
water temperatures to kill bacteria; and
12.7.d.3. Conform with the requirements for food
service as specified by the Department's rule, "Food
Establishments", 64CSR17, including as appropriate, current food
12.7.e. No child or employee, while affected with any
disease in a communicable form, or while a carrier of such disease,
or while affected with infected wounds, sores or a respiratory
infection shall work in any capacity in which there is a likelihood
of that person transmitting disease to other persons.
f e. The organization shall immediately notify the
health officer of the county in which it is located of any known or
suspected cases of unusual communicable disease , as required by law
which are required by law to be reported.
12.8. Building Exteriors and Grounds
12.8.a. An organization shall ensure that buildings,
grounds and recreational areas owned or leased by the organization
are maintained in good repair and free from reasonable danger to
health or safety.
12.8.b. Children and transitioning adults shall have
access to outdoor recreational space and suitable recreational
equipment that is in good repair and free from defects.
12.8.c. Areas determined to be unsafe, including steep
grades, cliffs, open pits, swimming pools, high voltage boosters,
high speed roads, or elevated walkways or stairs shall be fenced
off or have natural barriers to protect children. 12.9. Interior Space
12.9.a. Each living unit of an organization shall
contain space for the free and informal use of children in care.
12.9.b. Dining areas shall be arranged so as to allow
staff employees and guests to eat together in small
12.9.c. Dining areas shall be well-lighted, ventilated
and appropriately furnished.
12.9.d. Except for outdoor therapeutic educational
programs, there shall be a minimum of sixty square feet per
occupant in bedrooms. Bedrooms for single occupants shall have a
minimum of eighty square feet.
12.9.e. No more than four children may occupy a
designated bedroom space.
12.9.f. The bedroom space shall have a direct source of
12.9.g. Except for outdoor therapeutic educational
programs, each child shall have his or her own bed with sufficient
linens and covers. Linen shall be changed at least weekly, but
more frequently if necessary. Cots or other portable beds are not to be used on a routine basis. The uppermost mattress of any bunk
bed in use shall be far enough from the ceiling to allow the
occupant to sit up in bed.
12.9.h. Each child shall have his or her own dresser or
other storage space for private use, and/or a designated space for
hanging clothes and placing possessions.
12.9.i. Bathrooms and plumbing fixtures shall be kept
clean and maintained in good repair.
12.9.j. Water temperatures in sinks, showers and
bathtubs shall not exceed one hundred twenty (120) degrees
Fahrenheit. There shall be a safe and adequate supply of hot and
cold running water which shall be potable. Water from any source
other than a public water supply shall be tested annually by the
appropriate state or local authority in accordance with state or
12.9.k. Fixtures in bathrooms shall be situated so as to
be accessible to the average sized child of the household. If the
organization serves individuals with physical challenges,
accessible and/or adapted equipment shall be provided and there
shall be sufficient space in the bathroom to permit
assistance if necessary.
12.9.l. A facility shall have one toilet, one lavatory
and one bathtub or shower for every six children, at a minimum.
12.9.1.A. Bathrooms shall be clean and maintained in good repair.
12.9.1.B. 12.9.1.A. Bathroom floors and walls shall
be moisture resistant and non-absorbent.
12.9.l. 12.9.m. There shall be no open flame heaters in
any facility operated by the organization and used by children.
12.9.m. 12.9.n. Bathroom and bedroom facilities shall
allow individual privacy unless there is a clear, clinical
justification otherwise, which shall be documented on the plan of
care. There shall be doors on sleeping areas and bathrooms that can
be readily opened from both sides.
12.9.o. No locks shall be placed on any door that hinders
the exit of a person from that area. Locks may be used to restrict
access to certain areas, but must not require a key to exit.
12.9.n. 12.9.p. Kitchens used for meal preparation shall
be provided with the necessary equipment for the preparation,
storage, serving and cleanup of all meals for all the children and
staff employees regularly served by the kitchen. All equipment
shall be maintained in working order. Kitchens serving more than
eleven children shall meet all applicable provisions of the
Department's rule, "Food Establishments", 64CSR17. Kitchens
serving less than twelve may use a family-type kitchen provided
12.9.n.1. 12.9.p.1. Food shall be protected from
contamination during storage, preparation and service;
12.9.n.2. 12.9.p.2. Food contact utensils and
equipment shall be of appropriate material, easily cleaned and
maintained in good repair;
12.9.n.3. 12.9.p.3. Refrigeration equipment shall
assure the maintenance of food at or below 45 degrees Fahrenheit;
12.9.n.4. 12.9.p.4. Kitchen sinks shall have at
least two bowls. If a dishwasher is used, the temperature shall
reach a level sufficient to sanitize dishes. If no dishwasher is
used, proper sanitation treatments in the washing process shall be
12.9.o. 12.9.q. An organization using live-in staff
employees or house parents shall provide adequate, separate living
space for these staff employees.
12.9.o.1. 12.9.q.1. A bed shall be provided in
staff employee quarters for live-in staff employees or house
12.9.o.2. 12.9.q.2. Staff Employees shall not share
bedrooms with children.
12.9.p. 12.9.r. Furniture provided for children shall be
appropriately designed to meet the size and capabilities of the
children. Furnishings shall be maintained in good repair.
12.9.q. 12.9.s. An organization shall have securely
locked storage spaces for all potentially harmful materials. Poisonous or toxic materials shall be stored in locked storage
spaces not used for any other purpose.
12.9.r. 12.9.t. Drugs, staffs employee files and case
records are to be kept in locked storage spaces with authorized
12.9.s. 12.9.u. Any room, corridor or stairway within a
facility shall be sufficiently illuminated. Corridors in sleeping
areas shall be illuminated at night.
12.9.t. 12.9.v. Each separate living unit within an
organization shall have telephone service.
12.9.u. 12.9.w. Every access and exit to the building
shall be continuously maintained free of all obstruction or
impediments to immediate use.
12.9.v. 12.9.x. The use of candles is prohibited.
12.9.w. 12.9. y. Children shall swim only in areas which
are supervised by a certified individual. A certified individual
shall have a current water safety instructor certificate or senior
lifesaving certificate from the Red Cross.
12.9.x. 12.9.Z. On ground s pools shall be in a secured
area and shall comply with the Department's rule, Recreational
Water Facilities, 64CSR16.
12.9.y. 12.9.z.1. Windows shall have insect screening
unless the facility is centrally air-conditioned. The screening
should be readily removable in emergencies and shall be in good repair. All exterior doors shall be close fitting and self
§78-3-13. Initial Assessment and Plan of Care.
13.1. Multidisciplinary Team
In all instances in which there is a legally designated
Multidisciplinary Team (MDT), the organization's assessments and
care plans shall be copied to the designated "chair" or DHHR
representative of the MDT for the purpose of maintaining
consistency in assessment, treatment and placement planning. The
MDT is responsible by statute for overseeing the assessment and
case planning process for all children who are in the custody of
the Department. The organization shall supply a representative to
the MDT who is familiar with the child, his or her current status
and his or her
the progress in treatment. The Department of Health
and Human Resources designee assigned as the child's representative
to the MDT is responsible for approving plans of care designed by
the organization. This approval shall include permissions for
treatment including permission to administer specific medications.
13.2. Initial Assessment
Each child or transitioning adult that enters residential
treatment shall have a thorough assessment and a subsequent plan of
care, if considered appropriate by a health care professional.
13.2.a. For children and transitioning adults who have
comprehensive assessments completed within six months prior to admission, further assessments are not required, unless
circumstances have significantly changed or the assessments are
13.2.b. The organization shall have a comprehensive
assessment procedure for children entering the organization's care.
Clinical assessments shall be completed by an appropriately
licensed or certified clinical professional or an individual under
supervision for the licensure
or supervision. Other assessments may
be completed by employees meeting the requirements of their scope
of practice. The assessment All assessments comprising the
comprehensive assessment shall be completed prior to the
development of the plan of care and shall include as appropriate
13.2.b.1. Demographic information including custody
13.2.b.2. Presenting problems and
/ or reason for
13.2.b.3. A history of treatment;
13.2.b.4. A medical history;
13.2.b.5. A social history;
13.2.b.6. The potential need for use of restrictive
behavior management interventions;
13.2.b.6. 13.2.b.7. A developmental history;
13.2.b.7. 13.2.b.8. An educational or vocational history;
13.2.b.8. 13.2.b.9. A legal history;
13.2.b.9. 13.2.b.10. A substance abuse history;
13.2.b.10. 13.2.b.11. A mental status examination;
13.2.b.11. 13.2.b.12. An assessment of independent
living and adaptive living skills;
13.2.b.12. 13.2.b.13. A summary of the child's
13.2.b.13. 13.2.b.14. A summary of family strengths
and weaknesses; and
13.2.b.14. 13.2.b.15. A summary of presenting
problems or potential foci for treatment as identified through the
13.2.c. When appropriate to the needs of the person
served, the assessment shall include:
13.2.c.1. A review of adaptive behavior and/or a
13.2.c.2. A review of the need for assistive
technology, auxiliary aids and services and other special
13.2.c.3. Nutritional and dietary needs;
13.2.c.4. Special or unique behavioral issues; and
13.2.c.5. Academic, cognitive and/or vocational
testing or assessments.
13.2.d. Each assessment shall consider any unique
aspects of the person's racial, ethnic and cultural background, and
the need for any special service approaches resulting from that
13.2.e. The assessment shall result in a written
integrated summary of findings and recommendations which shall
guide the organization's treatment efforts. The integrated summary
of findings shall include:
13.2.e.1. Recommendations for dental, visual and
other health screenings or treatment;
13.2.e.2. A diagnosis, stated in terms approved by
the American Psychiatric Association, if applicable;
13.2.e.3. Recommendations for further assessment as
13.2.e.4. Recommendations for clinical behavioral
health treatment, if applicable;
13.2.e.5. Recommendations for interventions to be
made in the home environment, as necessary and appropriate;
13.2.e.6. Preliminary recommendations for placement
and aftercare upon discharge;
13.2.e.7. Recommendations for family visitation
unless contraindicated clinically or legally; and
13.2.e.8. Any recommendations for rights
13.2.f. The organization shall have a policy
establishing time lines for completion of a full assessment which
shall take into account urgency of child need, expected duration of
treatment, and time lines for plan of care. The time lines shall
facilitate provision of an appropriate range of services at the
earliest opportunity depending on the unique needs of the
individual and the expected duration of services. Exceptions to
those time lines shall be fully documented and justified in the
13.2.g. When the organization is required to accept
assessments from another organization or subcontracting entity, it
shall review each assessment for sufficiency and conduct additional
assessments if the product does not meet the standard.
13.2.h. The organization shall have a policy that
addresses the need to incorporate families into the assessment and
service-planning process unless clinically or legally contra-
13.3. Initial Plan of Care
13.3.a. The organization shall develop a short term or
initial plan of care within seventy-two hours of placement that
includes the following:
13.3.a.1. Justification for continuation of
medications prescribed prior to admission and continued until the
assessment process is completed or justification for medications prescribed by the admitting physician;
13.3.a.2. A summary of assessments needed for the
development of a full diagnostic and treatment perspective and
13.3.a.3. A description of specific, short-term
individual or group interventions to be provided prior to discharge
or the development of a plan of care, if any;
13.3.a.4. A description of educational services to
be provided prior to the development of an extended plan of care,
13.3.a.5. A description of any behavioral
interventions or protocols considered likely to be necessary prior
to the completion of the full assessment process; and
13.3.a.6. A description of acute or chronic medical
problems that may require treatment prior to the completion of the
13.3.b. The short term or initial plan of care shall be
developed whenever possible by a team representative of the
professionals performing the assessments, the child (if cognitively
capable of participating), the guardian, and the parents of the
child if practicable and not forbidden by the court. The plan
shall include a written description of the services to be provided.
The short term or initial plan of care shall be approved in writing
by the parent or legal guardian and the individual served, if that individual is considered sufficiently mature to understand the
document. The organization shall document every effort to obtain
guardian consent for treatment if the guardian is not present for
the development of the initial or short term plan of care.
13.3.c. If the expected length of stay is thirty (30)
days or less, the short term plan of care shall guide the team's
efforts throughout the child's stay with the organization and shall
be modified as necessary and appropriate. If, however, the expected
length of stay is to be greater than 30 days, the team shall meet
prior to the end of that time period to develop an extended plan of
13.3.d. Prior to discharge, the team shall meet to
review and document the child's progress in treatment, describe
continuing problems and issues and develop specific recommendations
for aftercare and follow-up. The aftercare and follow-up plans
and/or recommendations shall be provided to the child and his or
her parent and guardian upon discharge.
13.3.e. If a child requires a specific therapeutic
support plan or a protocol for
staff employees to use in dealing
with an inappropriate behavior, the plan or protocol shall be in
writing, shall be in terms which make it clear to direct care staff
employees and shall have the consent of the parent or guardian.
The plan shall include:
13.3.e.1. the behaviors to be monitored and modified;
13.3.e.2. the precise action to be taken by
employees if the behavior occurs; and
staff is employees are
responsible for supplying, if any.
13.4. Plan of Care
13.4.a. The plan of care planning and review team shall
be an interdisciplinary team consisting of the
involved in providing services to the child (including at a minimum
a licensed or certified master's level professional), the parents,
the guardian (if other than parent), and the child him or herself,
if the child is of sufficient developmental age to appreciate the
content of the review. Unless clinically or legally contraindicated
in writing, both parents shall be considered members of the care
planning team regardless of the identification of a guardian. The
child or guardian may request the presence of any other individuals
they feel may add to the process. However the organization is not
responsible for bearing any costs related to the presence of other
resources. Teachers or other external providers of service while
the child is receiving services from the organization should be
invited to team meetings and considered part of the team. The
organization is responsible for ensuring that all members of the
team receive adequate notification of team meetings, both by
telephone, if possible, and in writing. The organization shall document its efforts to obtain participation by team members and
any lack of attendance. The organization shall also document
efforts to obtain informed consent for treatment from the parent or
legal guardian if the guardian does not attend the team meeting.
13.4.b. The plan of care shall:
13.4.b.1. Use the summary and recommendations of
the assessment process;
13.4.b.2. Contain plans for maintaining or
strengthening the relationship between the person served and his or
her family if clinically and legally appropriate;
13.4.b.3. Identify the ultimate goal of services
(e.g., return to home, foster care, independent living, post
secondary education, etc.);
13.4.b.4. Identify the services the organization
intends to provide to meet the needs of the child and child's
family as revealed by the comprehensive assessment, including a
list of general goals tied to the problems identified in the
assessment; and desired measurable objectives for each goal stated
in terms that are understandable to the child and guardian;
13..4.b.5. Contain a description of the
interventions to be provided in order to achieve the stated
13.4.b.5.A. Medications prescribed by the
organization or a contracted organization or physician associated with the organization; and
13.4.b.5.B. A description of therapeutic
interventions intended to achieve the outcomes to include behavior
support plans and/or therapy plans as necessary and appropriate;
Contain identification of Identify the
persons responsible for providing each intervention;
13.4.b.7. Identify the frequency of the
Identification of Identify any outside
providers, such as therapists, which the organization has arranged
to treat the child and the goals of the interventions;
13.4.b.9. Include educational, vocational, and
health services, including dietary, provided to the client.
Medications may be altered by the physician or qualified medical
practitioner during the interval between development and review of
the care plan without modification of the care plan itself,
however, notes made and signed by the physician or qualified
medical practitioner shall be present in the record to document
what changes were made and why within one week of alteration of a
medication regimen; and
13.4.b.10. A proposed discharge plan.
13.5. Review of Plan of Care
13.5.a. The organization shall have a policy regarding
regular review of the plan of care. The policy shall dictate schedules of review of the plan depending on the average or
projected length of stay for the child. At no time shall the
schedule allow a period of review to extend more than ninety days
except as permitted in sections for each provider type.
13.5.b. Reviews shall always be performed prior to
discharge and at critical treatment junctures.
13.5.c. The review shall be the result of a conference
of all members of the child's care team including the guardian.
Participation by team members and guardians may be telephonic or,
when appropriate, submitted in writing and included in the progress
summary (e.g., by educational
staff employees). The organization
is responsible for documenting efforts to notify each team member
in a timely fashion of the review.
13.5.d. Changes to the plan of care shall be the result
of recommendations by the review team and shall be dated and
approved in writing by the members of the team including the child
(as developmentally appropriate) and his or her guardian.
13.5.e. Reviews shall be conducted by the
interdisciplinary team and shall be in writing. They shall consist
13.5.e.1. A review of each outcome objective and
its current status;
13.5.e.2. Identification of problems which are
13.5.e.3. Suggestions for dealing with those
13.5.e.4. Modifications and/or additions to be made
to the care plan;
13.5.e.5. A review of any therapeutic service
provided by an outside provider, to include a written report from
that provider if he or she is not present for the review meeting;
13.5.e.6. A summary of all interventions provided
13.5.e.7. A review of any incidents in which the
recipient of service may have been involved since the prior review;
13.5.e.8. A review of the discharge plan and the
permanency plan; and
13.5.e.9. A review of the effectiveness of each
psychotropic medication the child is taking at the time of the
13.6. Permanency Plans
The organization shall assist the MDT in the development of a
permanency plan for each recipient of service, when required by
§78-3-14. Service Delivery.
14.1. Program Description
The organization shall develop a written description of each
service and program that is available to the public and potential consumers. The description shall include:
14.1.a. The goals of the program;
14.1.b. The expected outcomes of the program;
14.1.c. The services provided by the program;
14.1.d. The usual staffing of the program including
ratios and overall credentialing;
14.1.e. Characteristics of children appropriately served
by the program; and
14.1.f. Restrictions in access to the program, if any.
14.2. Involvement of Families and Guardians
14.2.a. The organization shall document efforts to
involve families of biological origin and foster and adoptive
families in developing, modifying and reviewing plans of care
unless contraindicated by the court or unless clinically
contraindicated in writing in the child record, regardless of
14.2.b. When residential or other out-of-home services
cannot be provided close to a child's home, the organization shall
document efforts to maintain family ties and involve the family in
plan of care and delivery.
14.2.c. The organization is responsible for notifying
parents and guardians of:
14.2.c.1. Interdisciplinary team meetings;
14.2.c.2. Changes in the plan of care; and
14.2.c.3. Critical incidents and significant
changes in the child's condition.
14.2.d. The notification shall be completed within one
working day after the event and documented.
14.2.e. If the organization cannot obtain guardian or
parental participation and permission for treatment after
documented efforts to do so, it shall not be held in violation of
regulatory standards regarding permission and participation.
However, the organization shall continue to document on-going
efforts to include parents and guardians in the treatment process.
14.3. Behavioral and Therapeutic Interventions
An organization that uses therapeutic interventions shall:
14.3.a. Use positive approaches whenever possible to
teach pro-social adaptive behavior and to modify behaviors that may
be socially or personally maladaptive;
14.3.b. Identify antecedent conditions that may trigger
inappropriate behavior and determine the most appropriate
14.3.c. Apply interventions in a caring and humane
14.3.d. Carefully describe and document interventions in
the client record and in the plan of care.
14.4.a. The organization shall follow a policy that outlines its practices regarding punishment or discipline of
persons served and this policy shall prohibit the following:
14.4.a.1. Corporal punishment (physical hitting or
physical punishment inflicted in any manner upon the body);
14.4.a.2. Physical exercises such as running laps
or pushups when used solely as a means of punishment;
14.4.a.3. Requiring or forcing the child to take an
uncomfortable position for an extended period of time or forcing
the child to repeat physical movements when used solely as a means
14.4.a.4. The use of aversive conditioning such as
electric shock devices, sound, heat, cold, light, water, noise, hot
pepper, pepper sauce, pepper spray or ammonia;
14.4.a.5. Interventions that involve withholding
nutrition, sleep, or hydration;
14.4.a.6. Punitive work assignments;
14.4.a.7. Sanctioning by peers, except as part of
an organized therapeutic self-government program that is conducted
in accordance with written policy and is supervised directly by
14.4.a.8. Punishment of the group for an individual
child's behavior except as it involves a brief delay to initiation
of the next activity or to ensure safety of the
staff employees and
children or as part of a therapeutic program using logical and natural consequences as a means of discipline;
14.4.a.9. Punishment which subjects the child to
verbal abuse, ridicule or humiliation;
14.4.a.10. Excessive denial of on-grounds program
services or denial of any essential program service solely for
14.4.a.11. Denial of visiting or communication
privileges with family solely as a means of punishment;
14.4.a.12. Enforced silence for long periods of
14.4.a.13. Exclusion of the child from entry to the
14.4.a.14. Assignment of unduly physically
strenuous or harsh work;
14.4.a.15. Use of physical restraint involving
14.4.a.16. Use of physical restraint outside
commonly accepted systematic methods of passive physical control
applied in an appropriately de-escalating fashion; or
14.4.a.17. Use of any technique of manual or
physical restraint as an ongoing intervention for inappropriate or
undesired behavior except in situations involving significant risk
of harm to self or others if the restraint is not used.
14.4.b. The organization shall discontinue use of any intervention if it:
14.4.b.1. Produces adverse side effects such as
illness, physical damage or injury; and/or
14.4.b.2. Is ineffectual or detrimental to meeting
service goals and objectives.
14.5. Medication Control and Administration
14.5.a. Medication shall be prescribed and monitored by
a licensed physician, dentist,
or physician's assistant or nurse
practitioner advanced practice registered nurse. The organization
is responsible for physicians and other medical staff employees
contracted for service just as it is responsible for physicians
considered to be employees. The physicians and other staff shall
have personnel files containing the materials or information
specified in Section 10.5 of this rule. 14.5.b. Organizations that administer medication using
approved medication assistive personnel shall comply with the
Department's rule, "Medication Administration by Unlicensed
Personnel", 64CSR60, effective July 1, 1999.
14.5.c. A child entering a facility with properly
bottled and labeled medications may continue on those medications
with appropriate consents, until such time as the organization can
obtain current physician's orders, either from the organization's
physician or the child's physician, to continue the medications.
At no time shall that period of administration exceed
two week days 72 hours. Physician's orders may be verbal or faxed from the
office of the treating physician. If verbal, they shall be
confirmed in writing within one week. If the orders are given by
a physician unfamiliar with the child, the organization shall
obtain face to face physician contact for the child within one week
of admission, if that child is prescribed medications of any type.
14.5.d. When medication is prescribed and/or
administered, the organization shall:
14.5.d.1. Obtain the written consent of the parent
or legal guardian and the child over age 12 unless the child is
incapable of supplying informed consent or there are compelling and
documented clinical or legal reasons to overlook the child's lack
of consent. If reasons for continued medication administration are
clinical, the organization shall obtain court ordered permission to
treat the child against his or her will within the shortest period
14.5.d.1.A. When the medication is a
psychotropic, the following information shall be provided to the
parent and/or guardian;
14.5.d.1.A.1. Specification of conditions
the medication is to address, such as mood swings, irritability,
14.5.d.1.A.2. Efforts to address
condition without medication;
14.5.d.1.A.3. The expected length of time
14.5.d.1.A.4. Necessary medical testing
needed to determine proper usage of the medication; and,
14.5.d.1.A.5. How often symptoms will be
evaluated to determine effectiveness of the medication.
14.5.d.2. Fully explain the benefits and possible
side effects of the proposed medication (except in cases of routine
refill, changes within a class of medications or dosage changes);
14.5.d.3. Obtain approval from the parent or legal
guardian in advance to dispense medication unless there is
documented inability to reach the guardian within a reasonable
period of time relative to the urgency of the need for the
medication, which shall be documented.
14.5.e. The organization shall have a written procedure
directing the administration and storage of prescribed and over-
the-counter medications to include:
14.5.e.1. An individual record for those children
who receive medications to include:
14.5.e.1.A. Medications administered;
14.5.e.1.B. The date medications were
14.5.e.1.C. The time of administration (medications are to be administered within one hour of the
prescribed time unless otherwise allowed by physician's order); and
14.5.e.1.D. The individual administering the
14.5.e.2. A record of all appointments for
medication management including unscheduled or canceled visits;
14.5.e.3. A record of missed medications and the
14.5.e.4. Protocols for the administration of over-
the-counter medications which includes individualized approval by
a physician or qualified medical practitioner; and
14.5.e.5. Prescription medications shall be
properly labeled and packaged and include:
14.5.e.5.A. The name of the person served;
14.5.e.5.B. The dosage and the name of the
14.5.e.5.C. The name of the prescribing
14.5.e.5.D. An expiration date.
14.5.f. The organization shall have written procedures
14.5.f.1. The safe disposal of discontinued, out-
of-date or unused medications, syringes, medical waste or
14.5.f.2. Provision for locked, supervised storage
of medications with access limited to authorized
14.5.f.3. Medication errors as described under sub-
section 3.51 of this rule.
14.5.g. Only licensed nursing
staff employees may accept
verbal orders for changes in medication regimens. These shall be
signed by the prescribing physician within one week.
14.5.h. Organizations shall have, at a minimum, a
or practical nurse whose responsibilities
shall include as necessary:
14.5.h.1. Generating and reviewing monthly
Medication Administration Records;
14.5.h.2. Matching physician's orders to the
medication administration records;
staff employees supervising
self-administration of medications at least quarterly;
14.5.h.4. Assisting interdisciplinary teams to
develop educational goals for children taking regularly prescribed
medications and participating in a supervised self-administration
staff employees in dietary or
medication administration issues as necessary;
14.5.h.6. Responding to emergency calls from
employees on medical issues, and;
Assessing a Conducting ongoing
assessments of each child's health and health habits on an initial
and on-going basis. needs to include existing medical conditions,
dietary issues and medications.
14.5.i. The nursing
staff employees of the organization
shall assess each child, transitioning adult or transitioning youth
for the ability to self-medicate with supervision if the
organization allows such administration, before the youth is
admitted into the program. No child under the age of 12 shall be
considered capable of self-administration of medications, even
under supervised conditions. The assessment shall be based on the
child's developmental ability to participate in a plan of care.
Children not capable of participating in a plan shall have
medications administered by licensed nursing staff employees or
approved medication assistive staffs employees as set forth in the
Department's rule, "Medication Administration by Unlicensed
Personnel, 64CSR60, effective July 1, 1999. This requirement does
not apply to organizations that operate shelters with a no refusal
14.5.j. Medications may be self-administered under
staff employees under the following conditions:
14.5.j.1. As part of the child's plan of care, he
or she is taught to identify his or her medications, recognize
possible side effects, describe the purpose for the medication and indicate the time of day and frequency of which he or she is to
take the medications;
14.5.j.2. The child is assessed as being
cognitively capable of learning these skills.
and is over the age
14.5.j.3. Medication is kept in a secure location
with limited access to
staff employees only except at dosage times;
Staff is Employees are fully trained as
to the purpose, most common side effects and dangers of each
medication prescribed for children in the facility, and can
identify each medication on sight;
Staff is Employees are trained in
emergency procedures for overdose or abreactions;
14.5.k. The organization shall assess the effect of
medication on the child at regular intervals and base its
14.5.k.1. Documentation by clinical
of the person's behavior in the case record;
14.5.k.2. The observations of the child,
employees, and significant others; and
14.5.k.3. Any commonly recommended medical tests
necessary to determine the impact and safety of the medication on
the persons served (e.g., blood levels, etc.).
14.5.l. Organizations with a length of stay longer than one year shall document attempts to titrate psychotropic medications to
the lowest possible level while still achieving symptom control
prior to discharge.
14.6. Medication as Chemical Restraint
An organization shall not use chemical restraints unless
permitted otherwise by its specific rules. If an organization uses
medications for the purpose of anger and agitation management on an
on-going basis, the medications shall be accompanied by specific
educational or therapeutic interventions designed to teach the
child to modulate and control his or her emotions.
14.7. Case Records
14.7.a. The organization shall maintain a case record
person child served that shall be retained for a minimum
of 5 years following the child's 18th birthday.
14.7.b. Case records are confidential and access to case
records is limited to:
14.7.b.1. The child and/or as appropriate, his or
her parent, guardian or attorney, unless legally contraindicated;
Staffs Employees authorized to see
specific information on a "need-to-know" basis; and
14.7.b.3. Others outside the organization whose
access to the information contained in case records is permitted by
14.7.c. When not being used by authorized
staff employees, case files should be returned to a secure area.
14.7.d. The case record shall comply with all legal
requirements and contain, at a minimum:
14.7.d.1. Biographical or other identifying
14.7.d.2. Copies of custody and guardianship papers
and court orders if appropriate and possible within the time frame
of the program;
14.7.d.3. Reasons for referral and admission date;
14.7.d.4. Assessment information;
14.7.d.5. A plan of care including goals and
objectives of service;
14.7.d.6. Behavior support plans and/or therapy
plans, if any;
14.7.d.7. Reviews of the plan of care as
14.7.d.8. Reports from outside or contracted
providers of service to the child;
14.7.d.9. Copies of all signed, written consent
14.7.d.10. Routine documentation of ongoing
14.7.d.11. Documentation of incidents and/or
investigations or reference to a separate incident file for each incident or investigation;
14.7.d.12. Documentation of any therapeutic
physical restraints used by the organization with the child in
14.7.d.13. Documentation of medication
administration for prior months;
14.7.d.14. Educational records as available
considering average program length;
14.7.d.15. Recommendations for ongoing and/or
future service needs and assignment of aftercare or follow-up
responsibility if needed and appropriate; and
14.7.d.16. A closing summary entered within 30 days
of termination or discharge.
14.7.e. The organization shall document a reasonable
effort to obtain required materials.
14.7.f. When necessary and appropriate, the case record
shall also include:
14.7.f.1. Legal evidence of custody;
14.7.f.2. Court ordered restrictions on the rights
of persons served;
14.7.f.3. Psychological, medical, toxicological,
diagnostic or psychosocial evaluations;
14.7.f.4. Copies of all written orders for
medications or special treatment procedures such as diet and physical therapy;
14.7.f.5. Regular reports from contracted service
providers serving the child or family;
14.7.f.6. Reports relevant to the plan of care from
other providers serving the child with appropriate releases of
14.7.f.7. Other information essential for
delivering service to the child.
14.7.g. Only authorized
staffs employees may make
entries into case records and all entries shall be:
14.7.g.1. Specific, factual and pertinent to the
nature of the service and the needs of the persons served; and
14.7.g.2. Completed, signed, or electronically
identified and dated by the person who provided the service.
14.7.h. Case records shall be clearly legible, kept up-
to-date from intake through termination and contact entries shall
be made within 24 hours, or one working day, unless the group is
away from the main facility, in which case entries shall be made
within 24 hours of return to the main facility or program site.
14.8. Outside Providers of Service
Outside providers of service to children in out of home
therapeutic environments shall provide summaries of intervention
and progress no less than monthly for the organization's client
record unless frequency of contact is less than once per month, in which case, summaries shall be provided quarterly. The
organization and the outside provider shall ensure that therapeutic
interventions are consistent across settings either by joint
development of plans of care or by regular and documented sharing
of information. Outside providers of service include physicians,
therapists, physical therapists, occupational therapists, and other
providers of service relevant to the accomplishment of the goals of
the care plan.
14.9. Termination or Discharge
14.9.a. Discharge goals shall be developed with the
creation of the plan of care.
14.9.b. Termination or discharge shall occur when:
14.9.b.1. The child achieves the goals of his or
her plan of care and/or is no longer in need of out-of-home care;
14.9.b.2. The child has reached maximum benefit or
cannot benefit further from services provided by the organization;
14.9.b.3. The guardian terminates treatment;
14.9.b.4. The child no longer meets eligibility
14.9.b.5. The child refuses to meet program
standards or requirements;
14.9.b.6. The child has needs that exceed
organizational resources; or
14.9.b.7. The child completes court-ordered treatment.
14.9.c. The organization and interdisciplinary team,
guardian, placement organization (such as the court),
multidisciplinary team, and the person or family shall jointly plan
for termination or discharge.
14.9.d. The organization shall link a child that is
involuntarily discharged with appropriate services in another
organization or in the community whenever possible.
14.9.e. 14.9.d. The organization shall enter a closing
summary into the case record upon termination of service or within
thirty days of termination or discharge that:
14.9.e.1. 14.9.d.1. Includes recommendations for
any needed future services; and
14.9.e.2. 14.9.d.2. Provides a summary of services
received while in care and an assessment of service effectiveness.
14.9.f. 14.9.e. The organization that has collaborated
with other organizations or has shared case management
responsibility for the child shall notify those organizations, upon
termination of services, with the written consent of the person
served or his or her guardian. The person served or his or her
parent or guardian shall have the right to refuse the notification,
which the organization shall document.
14.10. Educational Services
14.10.a. The organization shall develop an educational program for each school-age child in care.
14.10.b. All children in residential child care shall be
enrolled in an educational or vocational program (depending on age
and the child's expressed desire) and provided with an educational
or vocational plan, as appropriate, that is integrated into his or
her plan of care and complies with the requirements set forth by
the State Department of Education. The organization is responsible
for ensuring that the child's educational credits are accepted by
the child's home school or county.
14.10.c. When appropriate and unless clinically,
programmatically or educationally contraindicated, children and
transitioning adults shall be enrolled in the public school system.
staffs employees shall maintain regular contact with
school staffs employees at a frequency appropriate for the severity
and type of each child's problems and service needs. The
organization shall have a policy describing the method and
frequency of contact.
14.10.d. The organization shall collaborate with the
public or private school so that information can be exchanged
freely and problem behaviors addressed consistently across all
environments. Upon admission, the organization is responsible for
obtaining parent or guardian permission for information to be
exchanged with the public or private school system which the child
is expected to attend.
14.11. On-Ground Schools
14.11.a. On-ground schools shall meet the guidelines
required by the State Department of Education. At a minimum, on
grounds schools shall attain Exemption A status, be a school
operated by Institutional Services of the Department of Education,
or be conducted in conjunction with or under the auspices of the
local educational authority in the county in which the organization
is operating. When possible the school shall be accredited by a
state or regional accrediting body. Educational
shall be certified to teach in the state of West Virginia. Outdoor
therapeutic educational programs are exempt from this requirement
and shall comply with the requirements set forth in Section 20 of
staffs employees shall:
14.11.b.1. Develop and implement an educational
plan for each student to be incorporated into the overall plan of
care. The plan shall be appropriate for the student's assessed
current level of academic functioning;
14.11.b.2. Integrate educational goals and
activities into the overall service program; and
14.11.b.3. Involve children in community social,
athletic and recreational facilities as appropriate to individual
needs and readiness.
14.11.c. There shall be an adequate educational
staff employees to child ratio for the needs and educational goals of the
14.11.d. Special education students shall be identified
and managed as required by state and federal law (IDEA Public Law
14.11.e. The on-ground school shall request school
records upon admission of the child and provide up to date records
to a new school upon request for information by a new school if the
child is transferred.
14.11.f. When appropriate, the organization shall assess
whether students are ready for placement in an off-campus school
setting and make the placements in accord with the goals and
timetables of the child's individual educational plans and with the
knowledge and cooperation of the local educational authority.
14.11.g. On-ground educational
staffs employees shall
facilitate school transfers and provide consultation as needed and
requested to professionals in off-campus educational settings.
14.11.h. Therapeutic support plans developed in the
residential setting shall be continued in the on-ground educational
setting and vice versa. The educational program and the
residential program shall communicate on a regular basis to ensure
that this occurs and shall exchange data and information regularly.
The organization shall have a policy and an inter
or interoffice agreement specifying how the agencies organizations or offices will interact and the frequency of that interaction.
14.12. Groups and Groupings
14.12.a. The organization shall ensure that therapeutic
activities and groups shall be of an appropriate size to promote
the success of the activity. Generally, the therapeutic group
should consist of no more than 12 children.
14.12.b. Groups shall be separated according to
developmental functioning, sex, social skills, group dynamics, and
other variables if appropriate and necessary. Children shall have
the right to be housed with children of the same approximate ages,
developmental levels and social needs. This separation shall be a
matter of organizational policy.
14.12.b.1. The organization shall not admit a child
under six years of age without prior written approval from the
14.12.b.2. No child over the age of five years
shall occupy a bedroom with a member of the opposite sex.
14.13. Work Programs
The organization may involve the child in voluntary
maintenance of the facility
(cleaning bedrooms and bathrooms,
working in the kitchens, etc.) so long as those work programs do
not replace the organization's need for housekeeping and
maintenance staff employees. Household "chores" may be required as
a condition of participation in the program or as a method of moving to a more privileged level of programming. Descriptions of
the work programs should be included in the organization's
descriptions. All work programs shall be evaluated for their
therapeutic or habilitative value. The organization shall pay the
child for an activity at a level required by state or federal law
and the work activity must be voluntary if there is no therapeutic
or habilitative value in the activity if there is no therapeutic or
rehabilitative value in the activity. Money earned in a work
program belongs to the child, although the organization may
maintain control of the money until the child's discharge, using an
accurate and on-going method of tracking disbursements and
deposits, made available to the child or guardian upon request.
Work programs other than household "chores" shall be evaluated and
approved by the interdisciplinary team.
14.14. Daily Schedules
The interdisciplinary team shall provide each child with a
written daily schedule of activities designed to help him or her
develop positive personal and interpersonal skills and behaviors by
providing activities that are individualized,
and as needed to meet
14.14.a. Appropriate to the age, behavioral level,
emotional needs, strengths and interests of the child;
14.14.b. Specialized to meet the child's identified
strengths and needs as described in the assessment and plan of care;
14.14.c. Normalizing and integrated into the community
to the maximum extent possible given the child's clinical needs and
14.14.d. Available at all times to the
and child; and
14.14.e. Comprehensive of all waking hours while
allowing a reasonable amount of recreational, study and quiet time.
Staff Employee Supervision
14.15.a. At all times, the organization shall have
staff employees to allow the number of children being
served to be adequately supervised, taking into consideration the
complexity of the needs of the children. The organization shall
consider appointments requiring staff employees supervision, staff
employee leave, possible illness of children and any other relevant
factor when scheduling staff employee and child activities.
14.15.b. Except as otherwise provided by this rule,
children shall be supervised at all times unless the child is
engaged in an activity away from supervision authorized by the
clinical team (e.g., home visit, public school, employment,
recreation, etc.). Short breaks in direct supervision shall be
therapeutically indicated and/or necessary for the child to gain
__________14.15.c. Youth actively working toward independence shall be permitted short breaks in supervision to pursue recreation,
employment or educational opportunities that complement his or her
plan of care.
14.15.c. 14.15.d. The organization shall have a policy
regarding ratios of staff employees to children specific for each
of the various program settings and activities.
14.15.d. 14.15.e. The organization shall have a policy
regarding staff employee supervision which ensures the safety,
supervision and security of children who are acutely disturbed
14.15.e. 14.15.f. The organization shall have a policy
regarding supervision of children in off grounds activities which
shall maximize the supervision and safety of children participating
in the activities.
14.15.f. 14.15.g. The organization shall ensure that when
children leave a facility for overnight visits, there is a
procedure for signing or being checked in and out of the program.
The checklist or sign-in sheet shall be dated and shall include
time in and out, the person responsible for the child, as
appropriate, and the location at which the child may be contacted
14.16. Special Services and Populations
14.16.a. If an organization provides specialized
services to a unique population (e.g., children with issues of substance abuse, children with developmental disabilities, sexually
reactive children) the organization shall ensure that:
14.16.a.1. The service and clinical model reflects
knowledge and use of the best practices available in the field;
14.16.a.2. Clinical and professional
are appropriately trained and when possible certified or licensed
in the area of service provided;
14.16.a.3. Direct care
staff employees are
specially trained to understand issues in clinical treatment of the
population and able to use suitable intervention techniques when
necessary and appropriate;
14.16.a.4. The environment and milieu of the
treatment location is clinically, structurally and developmentally
appropriate for the population served; and
14.16.a.5. The facility is suitably secure and
staff employee ratios suitably high to ensure the supervision and
safety of children served.
14.16.b. If an organization accepts into service a child
with unusual clinical and/or programmatic needs, the organization
is responsible for adapting its routine practices to meet the needs
of the child in care to the greatest extent possible. If it
becomes evident that the child cannot benefit from the program,
even with the adaptations the organization is able to make, the
organization is responsible for arranging a more suitable placement at the earliest opportunity in conjunction with the guardian and/or
14.16.c. A residential program that specializes in
serving children and transitioning adults with developmental
mental retardation intellectual disabilities shall
ensure that staff employees are trained to properly provide
habilitation services and supervision in the following areas as
appropriate for the population served:
14.16.c.2. Communication with nonverbal
14.16.c.3. Use of community recreation options;
14.16.c.4. Management of self-abusive and
14.16.c.5. Adaptive living skills;
14.16.c.6. Person first language and attitudes;
14.16.c.7. Therapeutic behavioral supports; and
14.16.c.8. Implementation of the principles of
14.16.d. When serving individuals with developmental
disabilities for more than 30 days, the program shall provide
supportive services to help them fully interact with the community
and achieve maximum independence. If the organization provides or
contracts for the provision of therapeutic services such as individual therapy, it shall ensure that therapeutic interventions
are adapted for the developmental functioning of the child.
14.16.e. An organization that provides services to
children with developmental disabilities shall adhere to and
implement the Principles of Normalization and adapt the
organization's therapeutic facilities to meet the developmental
needs of the child.
14.16.f. The organization shall provide children with
substance abuse problems with specialized services to meet their
needs as identified in the comprehensive assessment. The
organization shall arrange for detoxification and inpatient
services to meet any emergency needs of children.
14.16.g. The organization shall ensure that children are
provided with therapeutic and didactic interventions which directly
address his or her substance abuse and any deficits in adaptive
functioning relating to or concurrent with the abuse of substances.
14.16.h. If the organization specializes in substance
staffs employee training shall comprehensively
address the latest information, theories and techniques in:
14.16.h.1. Identification, diagnosis and treatment
of alcohol and drug abuse;
14.16.h.2. The concept of chemical dependency as a
14.16.h.3. Prevention activities that address both primary and relapse prevention.
14.16.i. When the initial assessment indicates the
presence of a sexually sensitive history (either as offender or
victim) the organization shall:
14.16.i.1. Obtain either directly or by contract or
referral a thorough assessment of the sexual history and
functioning of the child, attending in particular to episodes of
victimization or offense;
14.16.i.2. Obtain either directly or by contract or
referral specialized treatment interventions as appropriate; and
14.16.i.3.. Ensure that the child is appropriately
housed and supervised in order to ensure the safety of all of the
14.16.j. If the organization specializes in the
treatment of sexual offenders:
14.16.j.1. The milieu shall be organized and
maintained in such a way as to maximize the safety and supervision
of the children at all times; and
Staff Employees shall be specially
trained in the supervision and treatment of sexually reactive
staff employees shall be
trained and certified as appropriate in the treatment of sexually
reactive children, or shall be in the process of obtaining certification and properly supervised by certified staff employees.
14.16.k. If the organization discovers that a child is
pregnant and it is not a Maternity and Parenting Program, it shall
provide or make referral for the following health services, at a
minimum, until other arrangements are made;
14.16.k.1. Fetal alcohol syndrome screening;
14.16.k.2. Prenatal care;
14.16.k.3. Well-baby care; and
14.16.k.4. Parenting skills instruction.
14.17. Health Services
14.17.a. The organization shall have a procedure in
place to ensure emergency medical care for all its children on a 24
14.17.b. Each child shall have upon admission or receive
5 days 72 hours of of admission a current medical screening
by a qualified medical practitioner (EPSDT). The screening shall
_______________14.17.b.1. A general history of the
child's and family's health;
_______________14.17.b.2. The patient's current medications;
_____14.17.b.4. Pertinent medical problems requiring
14.17.b.5. Current risk and safety factors;
_______________14.17.b.6. Nutritional status;
_______________14.17.b.7. Immunization status, and
14.17.8. Sleep patterns.
14.17.c. In facilities with stays of longer than thirty
days duration, appropriate dental assessments shall be conducted at
least annually to include provision of any routine dental care as
recommended by the evaluating dentist.
14.17.d. Health services shall also include, in
facilities with stays of longer than thirty days duration, age
appropriate instruction regarding:
14.17.d.1. Pregnancy prevention,
14.17.d.2. AIDS/HIV and STD prevention,
14.17.d.4. Laboratory and/or other diagnostic work
as prescribed by a physician; and,
14.17.d.5. Other general information about the
prevention and treatment of disease.
14.17.e. Educational services shall also be provided
regarding psychotropic medications and mental health as age
appropriate and necessary. When possible, the family of origin or
expected family of projected placement shall be educated as well.
14.18.a. The organization shall ensure that each child
in care has adequate, clean, well fitting, attractive and seasonable clothing as required for health, comfort and physical
well-being and as appropriate to age, sex and individual needs.
The child shall be encouraged to participate in the selection of
14.18.b. A child's clothing shall be identifiably his or
her own and not shared in common.
14.18.c. Clothing shall be kept clean and in good
repair. The child shall be involved in the care and maintenance of
his or her clothing. As appropriate, laundering, ironing and
sewing facilities shall be accessible to the child.
14.18.d. When uniforms are required, the child and
parents or guardians shall be advised of this requirement prior to
14.18.e. The organization shall ensure that discharge
plans make provisions for clothing needs at the time of discharge.
All personal clothing shall go with a child when he or she is
14.19. Personal Belongings
The organization shall allow a child to bring personal
belongings to the program and to acquire belongings. However, the
organization shall, as necessary, limit or supervise the use of
these items. Provisions shall be made for the protection of a
14.20. Personal Hygiene
14.20.a. Procedures to ensure that children receive
assistance and training in personal care, hygiene and grooming
appropriate to their age, sex, race and culture shall be
14.20.b. The organization shall ensure that children are
provided with all necessary toiletry items.
14.20.c. A child shall be permitted a reasonable degree
of freedom in selecting a style of wearing his or her hair and
14.21. Religion and Culture
14.21.a. Children shall have the opportunity to
participate in religious activities and services in accordance with
their own faith. The organization, when necessary, shall arrange
14.21.b. Children may not be coerced or required to
attend religious activities.
14.21.c. The organization shall involve children in
cultural or ethnic activities, appropriate to their own cultural or
§78-3-15. Restrictive Behavioral Interventions.
15.1. Legal Compliance
15.1.a. Restrictive behavior management techniques
include: restraint (physical, mechanical or chemical) and
seclusion. The organization shall have a policy with specific procedures to govern the use of these techniques. The policy shall
delineate the circumstances under which these techniques may be
used and shall describe which techniques may be used in precise
language. Unless indicated otherwise in this rule, restraints are
to be used only in an emergency when there is imminent risk of the
child physically harming himself or herself or others, including
staff employees. Non-physical interventions are the first choice
as an intervention, unless safety issues demand an immediate
physical response. Restrictive behavior management techniques are
not to be used as a part of an approved plan of care.
15.1.b. Group restraints incorporating peers as
restrainers or observers are prohibited in any treatment
15.1.c. Seclusion, chemical and mechanical restraints
shall be used only in facilities with explicit permission to do so
as described in this rule (i.e. psychiatric residential treatment
facilities and intermediate care facilities).
15.2. General Guidelines
15.2.a. Restrictive behavior management techniques shall
be used only in emergency situations to protect individuals from
harming themselves or others and not as part of an on-going plan of
15.2.b. Use of the techniques shall conform to federal
guidelines when guidelines exist unless the guidelines are less stringent than those described in this rule.
15.2.c. The organization shall maintain comprehensive
data on the use of any restrictive behavior management practices,
collected individually for each organization or program it manages,
and shall summarize and review that data quarterly. An annual
report shall be made to the governing body by the safety committee
15.2.d. At admission each child shall be assessed for
his or her potential need for use of restrictive behavior
management interventions. The assessment shall include:
15.2.d.1. The potential for risk of harm to
himself, herself or others;
15.2.d.2. Antecedents (if known) to out of control
15.2.d.3. Effectiveness (if known) of previous use
of these interventions;
15.2.d.4. Psychological or social factors such as
psychosis, claustrophobia or; a history of sexual or physical abuse
that would influence the use of the practices; and
15.2.d.5. Medical factors that might put the person
at risk in a restraint.
15.2.e. If the child is judged likely to require the use
of restrictive behavior management techniques,
shall be alerted to any considerations identified in the assessment and trained appropriately.
15.2.f. The organization shall ensure and document that
the parent or legal guardian:
15.2.f.1. Received notification in writing at the
time of admission that these interventions are used by the
15.2.f.2. Received a copy of the behavior
management protocol; and
15.2.f.3. Was notified immediately if a restraint
was used unless the guardian has requested otherwise.
15.2.g. The organization shall prohibit the following:
15.2.g.1. Use of restrictive behavior management
techniques in non-crisis or emergency situations, as a form of
coercion or discipline, or for the convenience of
15.2.g.2. Excessive or inappropriate use of
restrictive behavior management techniques; and
15.2.g.3. The application of restrictive behavior
management interventions by other persons served or any person
other than trained, qualified
15.2.h. A trained observer should be present whenever
15.2.i. The condition of the restrained or secluded
person shall be monitored. Consciousness, respiration, agitation,
mental status, skin color and skin integrity should be monitored continuously.
Staff members Employees identified as medical
professionals should have the authority to continue or stop a
specific intervention based on health issues.
15.2.k. The organization shall discontinue restrictive
behavior management interventions immediately if they produce
adverse side effects such as illness, severe emotional or physical
stress or physical damage and obtain immediate medical treatment
for the child.
staffs employees with direct contact with
children shall receive documented training in the organization's
restrictive behavior management practices.
15.3.b. All direct care, supervisory and clinical
employees shall receive initial and ongoing competency-based
training on the organization's restrictive behavior management
policies, procedures and practices appropriate for the type of
15.3.c. The training shall include:
15.3.c.1. Recognizing situations, including medical
conditions that may lead to a crisis;
15.3.c.2. Recognizing unique situations which
preclude the use of restraints (medical issues, sexual reactivity,
15.3.c.3. Understanding how
staff employee behavior
can influence the behavior of persons served; and
15.3.c.4. Using appropriate methods for de-
escalating volatile situations, including verbal techniques,
mediation, distraction and diversion and other non-restrictive ways
of dealing with aggressive or out of control behavior.
15.4. Physical Restraint
15.4.a. Written procedures shall govern the use of
physical restraint. They shall specify that:
15.4.a.1. Physical restraint may be used only in
emergency or crisis situations to protect individuals from harming
themselves or others;
Staffs Employees shall use the least
restrictive, safest and most effective methods generally accepted
in the field;
15.4.a.3. Physical restraint may be used in each
instance only when less restrictive measures have proven to be
ineffective or in an immediately dangerous situation which
precludes the use of other interventions;
15.4.a.4. The decision to use physical restraint
shall take into account an analysis which determines that the risk
of the individual's behavior to himself, herself or others
outweighs the potential risk of the use of physical restraint.
This analysis shall be documented as soon as possible after the use of the restraint;
15.4.a.5. Physical restraint shall be discontinued
as soon as possible;
15.4.a.6. All direct service
staff employees shall
have access to a copy of written policies and procedures regarding
the appropriate and limited use of physical restraint;
15.4.a.7. A continuing monitoring system shall be
kept documenting the names of
staff employees restraining children,
the names or identifiers for children restrained, the date and the
time of restraint, other individuals involved, the circumstances
and reasons for physical restraint, the amount of time the child is
restrained, and documentation of supervisory review;
15.4.a.8. Use of physical restraint shall be
documented in the person's case record;
15.4.a.9. Use of a physical restraint shall result
in completion of a report;
15.4.a.10. Significant injuries occurring during a
physical restraint shall be reported to the Institutional
Investigative Unit under mandatory reporting requirements
Code 49- 6A- 9); and
15.4.a.11. The organization shall have
documentation of notification of the parent or guardian unless he
or she indicates in writing that he or she does not wish the
notification or unless the parent or guardian has specified parameters for notification (i.e., in case of injury during
15.4.b. The clinical justification, use,
employees involved, circumstances, efforts to employ less
restrictive measures and length of application shall be clearly
documented for each instance of physical restraint.
15.4.c. The organization shall review each incident of
physical restraint no later than one working day after its use.
15.4.d. Physical restraint may not be used:
15.4.d.1. To force a child into compliance;
15.4.d.2. In response to cursing or screaming;
15.4.d.3. For refusal to participate in an
15.4.d.4. For failure to join a group activity.
15.4.e. The use of physical restraints shall be
discontinued as soon as possible, and shall be limited to the
following maximum time per episode:
15.4.e.1. Fifteen minutes for children aged nine
and younger; and
15.4.e.2. Thirty minutes for persons aged ten and
Staff Employees shall make periodic attempts to
free the child during the period in which the restraint is
15.4.g. If the restraint extends longer than recommended
guidelines, the organization shall document the reason for the
extended restraint and describe action taken to prevent further use
of extended physical restraint.
15.4.h. Following each instance of physical restraint,
a meeting shall be held within 24 hours that includes the
staffs employees (the staff employees restraining
children and supervisory staff employees) and the person restrained
(if developmentally and clinically appropriate) to:
15.4.h.1. Evaluate the well-being of the person
served and identify the need for counseling or other services
related to the incident;
15.4.h.2. Identify antecedent behaviors and modify
the care plan as appropriate; and
15.4.h.3. Analyze how the incident was handled.
Staff Employees and designated supervisory staff
employees shall discuss necessary changes to procedures and/or
staff employee training in order to preclude further restraints to
the maximum extent possible. Recommendations shall be documented.
§78-3-16. Critical Incidents and Crisis Management.
16.1. Abuse and neglect
16.1.a. The organization shall have a policy regarding
identification and reporting of instances of alleged abuse and/or
neglect of children in its care that shall be in compliance with W.Va. Code §49-6A.
16.1.b. Definitions of abuse and neglect and procedures
regarding reporting of abuse and neglect shall be consistent with
those established by state law.
staff employees, volunteers and management
of any organization are considered to be mandatory reporters by
State Law and are required to report any and all allegations of
abuse and neglect to the appropriate state authorities as required
in W.Va. Code §49-6A. All allegations of abuse and neglect shall be
immediately reported by telephone to the Institutional
Investigative Unit of the Department via a telephone call to the
Child Abuse Hotline. Within forty-eight 48 hours of the incident,
the organization shall prepare a written incident report, which
shall be available to the Institutional Investigative Unit upon
request. The Institutional Investigative Unit will inform the
organization if an investigation of the incident shall be
conducted. If the Institutional Investigative Unit indicates that
there shall be no Institutional Investigative Unit investigation
the allegation shall be downgraded to a critical incident and the
organization shall proceed with a full investigation.
16.1.c.1. The organization shall limit internal
assessment of an incident to ensuring the safety of the children in
placement without compromising the Department's subsequent
16.1.d. All incidents which have harmed or may have
represented potential harm to a child or children shall result in
the completion of an incident form. Incidents suspected of being
subject to mandatory reporting requirements as defined by W.Va.
Code §49- 6A-1 shall be reported to the Institutional Investigative
Unit according to organization policy and procedures. This shall
include medication errors with negative outcome for the child and
any injuries occurring in the course of a restraint.
16.1.e. The organization shall cooperate fully in an
investigation of any incident and shall provide all information
requested by the Department.
16.1.f. Any investigations completed by the organization
shall be maintained in a central file and made available to the
state regulatory agency.
16.1.g. In all cases, the organization shall take the
actions necessary to protect the child from further harm until an
investigation is completed. An incident involving the alleged
sexual abuse or physical abuse causing a serious physical injury to
a child by an employee of the organization requires that the
employee be removed from direct service work with children until
the investigation is completed. Otherwise, the organization shall
have a procedure in place for management of
staff employees alleged
to have abused or neglected a child that may include any or all of
16.1.g.1. Removal from duty pending investigation;
16.1.g.2. Increased supervision to ensure child
16.1.g.3. Transfer to a substantially different
area of the organization with different children (higher
developmental functioning, different sex, etc.);
16.1.g.4. Transfer to a different more closely
16.1.g.5. Transfer to different job
responsibilities that does not include contact with children; and
16.1.g.6. Other appropriate actions as indicated by
16.2. Critical Incidents
16.2.a. The organization is responsible for monitoring
and investigating any incident which may have had the potential for
harming a child emotionally or physically with the exception of
those incidents investigated by the Institutional Investigative
Unit. Critical incidents include but are not limited to the
16.2.a.1. Attempted suicide with some potential for
lethality being lethal;
16.2.a.2. Behavior likely to lead to serious injury
or significant property damage;
16.2.a.3. Fire resulting in injury;
16.2.a.4. Behavior resulting in interruption of
services including the necessity for movement to a more intensive
level of care;
16.2.a.5. Major involvement with law enforcement
16.2.a.6. Possession of illicit substances
16.2.a.7. Possession of weapons;
16.2.a.8. Injury resulting in hospitalization or
16.2.a.9. Significant reaction to a medication or
16.2.a.10. Medication errors with negative outcome
which the Institutional Investigative Unit determines it will not
16.2.a.11. Dietary errors resulting in negative
outcome for the child;
16.2.a.12. Extended and unauthorized absence of a
child that exceeds his or her plan of care provision for community
16.2.a.13. Removal of a child from service without
his or her consent and that of the interdisciplinary team including
16.2.a.14. 16.2.a.13. Significant injuries of unknown origin; and
16.2.a.15. 16.2.a.14. Any other incident judged by
staff employees, management or other individual to be significant
and to potentially have a negative impact on the child.
16.2.b. For the purposes of sorting mandatory reporting
incidents from other incidents, the issue of lack of appropriate
staff employee oversight shall always be considered. If the
incident can be is attributed to lack of staff employee oversight,
it is shall be upgraded to a mandatory reporting incident.
16.2.c. All critical incidents shall be documented, then
investigated by a designated member of the
safety committee, or similar committee consisting of at least two
members not in the direct chain of command for the organization,
and The investigation shall result in a report which shall will be
reviewed by the administrator or his or her designee within five
working days of the occurrence of the incident or within five days
of notification by the Institutional Investigative Unit that it
will not investigate. The report shall describe the incident,
possible antecedents, consequences, witnesses, time of day, length
of the incident, the individuals involved and any other information
necessary for quality improvement and/or risk management. Whenever
possible, all witnesses should be interviewed and the results of
the intake documented.
16.2.d. All facilities will also encounter incidents which are not necessarily critical in nature but which will require
investigation. Again, lack of
staff employee oversight shall
always be evaluated as an issue. If that lack led to a negative
outcome for the child, it shall be upgraded to mandatory reporting.
Injuries of unknown origin shall also always be evaluated and
considered for potential of abuse in protected populations.
Non-critical incidents include unusual events
occurring to a child that needs to be recorded and briefly
investigated or reviewed and tracked for risk management or quality
improvement purposes. These incidents would not include behaviors
for which there is a behavior support plan and data tracking
mechanism in place. Examples would be assault by another child
with minor or no injury resulting; seizures; minor injuries of
unknown origin; brief episodes away from supervision; self-
injurious behavior with no significant negative outcome; suicidal
threats or minor gestures without significant injury; medication
error without negative outcome; unsuccessful fire setting; or any
other similarly non-critical event. If a pattern of non-critical
incidents is identified, the organization shall more carefully and
thoroughly investigate incidents typical of the pattern (e.g.,
medication errors, injuries of unknown origin, etc). refer to the
quality assurance team for a thorough investigation of incidents
typical of the pattern.
16.2.f. The organization shall keep a central administrative file of all incident reports and any ensuing
16.2.g. Incident reports shall be completed prior to the
end of the shift of the reporter or individual involved. The
program supervisor shall review and sign off on the report within
one working day. The organization shall immediately make reports
telephone or fax to the Institutional Investigative Unit
immediately, when appropriate. Written reports shall follow within
48 hours. as appropriate. Internal investigations shall be
completed within five days of the incident or within five days of
notification by the Institutional Investigative Unit that it will
not investigate, depending on the nature of the incident.
16.2.h. The organization shall regularly and at least
every 90 days submit all incident reports either
quarterly (depending on the size of the organization and number of
reports) to the organization's safety committee or officer for
review. That review shall result in an annual report to the
governing body and shall be used to improve quality and safety of
care to the children in service.
16.3. Emergency Medical Services
16.3.a. The organization shall have a specific policy
and procedures for directing
staff employees in case of medical
staff employees shall have access to the procedures and to a list of emergency numbers as required by the
staff employees shall be trained in
emergency medical procedures as specified in the policy.
16.3.d. Residential direct care
staff employees shall
have at a minimum the availability of telephone contact with
supervisory staff employees on a 24-hour basis. Telephone numbers
for supervisory staff employees and schedules of on-call
responsibility shall be readily available to all staff employees at
All children's deaths shall be reported to law enforcement,
the Institutional Investigative Unit, the Office of Health Facility
Licensure and Certification, the coroner of the county in which the
organization is located, and to other state or federal agencies as
required by law within twenty-four hours.
§78-3-17. Group Residential Treatment.
Staff Employee Ratios and Training
Staff Employees, for the purposes of this
section, are those individuals who are:
17.1.a.1. Fully oriented and trained according to
organizational policy; and
17.1.a.2. Have job responsibilities which pertain
only to the provision of child care, treatment and supervision.
17.1.b. The group residential program shall have a
policy regarding care and supervision of children that ensures
17.1.b.1. Children receive adequate supervision for
their age, developmental functioning and emotional and behavioral
17.1.b.2. The care plan as developed by the
interdisciplinary team is implemented
as written for each child.
17.1.c. Children shall be cared for and supervised at
the following levels, with clinically justified modifications when
house parents are employed:
17.1.c.1. A minimum of
staff employees to child
ratio of 1:6 shall be maintained during waking hours when children
are on the grounds with a minimum of one staff employee present per
residential living unit at all times when children are present in
the living unit;
17.1.c.2. Additional or back-up care
employees shall be available for emergency situations or to meet
special needs presented by the persons in care; (e.g., physician's
appointments, behavioral outbursts, acute suicidality, etc.); and
staff employee to child ratio of 1:12
shall be maintained during sleeping hours with a minimum, of at
least one staff employee per residential living unit to be awake at
all times when children are present in the living unit.
17.1.d. The organization shall have a policy regarding
the supervision of children in off-grounds activities which shall
ensure that the children are adequately supervised at all times.
17.1.e. As appropriate to the ages and needs of persons
in care, the organization shall ensure that one or more trained
staff members is employees are on duty or available
via an on-call system on a 24-hour basis to provide continuous
supervision to each residential living unit within a residential
17.1.f. The organization which uses a house parent model
shall have a policy that ensures the safety and supervision of
children at night.
17.2. Environmental Issues
17.2.a. To the maximum extent possible, the organization
providing group residential services shall be non-institutional in
appearance and practices. Each child or transitioning adult shall
be permitted to have personal space, personal possessions and a
place to store those possessions unless clinically contraindicated.
Each child is expected to assume some responsibility for an aspect
facility maintenance care of living environment (cleaning,
cooking, etc.) on an ongoing basis.
17.2.b. The organization shall ensure that residential
living units within the milieu consist of no more than 12 children.
The size of the groups shall be dictated by their function and some may be smaller than 12 members. Group therapeutic and residential
living activities should be conducted in an appropriately sized
group format, taking into consideration best practice standards for
sex gender, developmental status, and diagnosis of the members.
17.2.c. Children shall have clearly identifiable
schedules and activities,
individualized for their strengths and
needs. Each child shall have a unique schedule which identifies
therapy times, chore or work assignments, school hours, and other
Staff Employees shall be available in sufficient
quantity and with appropriate credentials to address the needs of
the child as identified by the assessment and interdisciplinary
17.2.e. The residential program that permits pets shall
follow written procedures that address their availability, care,
feeding, and maintenance that includes at a minimum, a veterinary
evaluation and vaccinations as recommended by the veterinarian in
17.2.f. Service elements unique to the population:
17.2.f.1. If the residential program permits
children to operate vehicles while in placement, it shall do so
under the following conditions:
17.2.f.1.A. The child has a valid West
Virginia driver's permit or license;
17.2.f.1.B. The child's vehicle, if any, is
appropriately licensed and insured; and
17.2.f.1.C. The child receives permission in
writing from his or her parent or guardian.
17.2.f.2. The organization shall have a written
plan of basic daily routines which shall be available to all
employees and updated regularly.
17.2.f.2.A. Children shall participate in
planning daily routines.
17.2.f.2.B. Children shall have set routines
for waking and going to bed.
17.2.f.3. The organization shall encourage and
arrange for children to participate in community and school
functions and recreational activities on an individual basis.
§78-3-18. Residential Crisis Support/Emergency Shelter Care.
18.1. Service Description
18.1.a. Children's emergency shelter care services are
provided to children in need of room, board,
and supervision and
support during a familial or personal crisis.
18.1.b. Children's emergency shelter care services are
provided to all children unless services are limited to a specific
target population through a written program description or through
contract with the Secretary.
18.1.c. Children's emergency shelter care is responsible for making reasonable efforts to assist individuals to find
appropriate placement if admission is impossible because of census,
program description, or client variables.
18.1.d. When children are provided shelter without
permission of a parent or guardian, the organization shall:
18.1.d.1. Establish the child's legal status;
18.1.d.2. Conduct a brief interview to ascertain
the circumstances of the need for admission;
18.1.d.3. Notify the parent or guardian of the
admission unless the Shelter documents that the child;
18.1.d.3.A. Is an emancipated minor;
18.1.d.3.B. Has reached age of majority; or
18.1.d.3.C. Could be endangered as a result of
18.1.d.4. Notify the local representative of the
18.1.d.5. Obtain authorization to provide care for
the child if appropriate and necessary.
18.1.d.6. The child shall be informed of the
planned notification, which shall occur immediately after
18.1.e. Stays in the Shelter are voluntary unless the
child has been ordered into the facility by a legal entity with
authority to do so. If a child voluntarily enrolled as a participant chooses to leave the facility,
staff employees shall
document efforts to persuade him or her to remain and/or to arrange
safe alternative placement. If in the staff's employee's
assessment, the child is not capable of adequate self-protection,
the staff employee will take action as delineated by the
18.1.f. Children in Shelter care shall be supervised at
all times unless the child is engaged in an activity away from
supervision authorized by the clinical team (e.g., home visit,
public school, employment, etc.). The shelter shall ensure that
when children leave the building, there is a procedure for signing
or being checked in and out. The checklist or sign-in sheet shall
be dated and shall include the time in/out, the person responsible
for the child, as appropriate, and the location at which the child
may be contacted if necessary.
18.1.g. The shelter shall have policies and procedures
for expelling an individual from a shelter. Policies and
procedures shall be described in an understandable fashion to the
individual at admission and he or she shall also receive a copy of
policies regarding standards of conduct in the shelter at that
time. Policies and procedures shall:
18.1.g.1. Define the reasons or conditions for
which an individual may be expelled;
18.1.g.2. Delineate a clearly defined process for expulsion, including timely due process provisions;
18.1.g.3. Describe the conditions or process for
re-admission to the shelter; and
18.1.g.4. Require that all reasonable efforts be
made to provide an appropriate alternative placement.
18.1.h. All shelters provide services that are designed
to meet the immediate safety and survival needs of the child. As
such, they shall provide, either directly or by referral, the
18.1.h.1. Sleeping accommodations;
18.1.h.4. Personal hygiene supplies and facilities;
18.1.h.5. Crisis intervention;
18.1.h.6. Case management and assistance;
18.1.h.7. A mailing address;
18.1.h.8. Information and referral for services;
18.1.h.9. Linkage to medical services;
18.1.h.10. Eyes-on supervision;
18.1.h.11. Supportive group counseling;
18.1.h.12. Supportive individual counseling;
18.1.h.13. Access to recreational activities; and
18.1.h.14. Educational assistance, if necessary.
18.1.i. The Shelter shall:
18.1.i.1. Provide prompt admission;
18.1.i.2. Emphasize short term stay by working
aggressively to arrange more appropriate alternative placement;
18.1.i.3. Provide an organized written program of
daily activities for each child that includes social, recreational
and educational activities;
18.1.i.4. Promote continued contact and
communication between a parent or guardian and his or her child
unless legally or clinically contraindicated; and
18.1.i.5. Assist in developing supportive aftercare
or other services to ameliorate the problems that led to the need
for the shelter.
18.1.j. Shelters are exempt from subsection 14.10
(educational services) of this rule. Shelters shall:
18.1.j.1. Informally evaluate educational needs
upon admission of school-age children;
18.1.j.2. Arrange admission to the public school
18.1.j.3. Provide educational activities for each
school age child in the Shelter environment as required by the
state Department of Education.
Staff Employee Ratios and Training
The Shelter shall have the following
18.2.a. Direct care
staff employees who provide continuous supervision for children twenty-four hours per day at
ratio of not less than 1:5 with one staff employee present at all
times in each residential living unit;
18.2.b. A shelter manager to provide coordination and
staff employees and operations, possessing a minimum
of a bachelor's degree and two year's experience in working either
in management or with children and families;
18.2.c. A consulting licensed psychologist, available as
staff employees or the children;
18.2.d. A case manager or service coordinator, to
provide case management services and supportive counseling. The
minimum educational requirements are a bachelor's degree and one
year experience working with children and families. The case
manager shall be appropriately supervised on a regularly documented
basis by a qualified behavioral health clinician or social worker;
18.2.e. A consulting registered nurse available onsite
at least weekly who is responsible for:
18.2.e.1. Performing nursing assessments on each
child within five working days of admission;
18.2.e.2. Completing medication administration
records for each child, updated as necessary;
18.2.e.3. Monitoring medication administration
including supervising Approved Medication Assistance
employees if necessary;
18.2.e.4. Assessing children for their ability to
self-medicate under supervised conditions and developing
appropriate educational materials or facilities for educating
children about their medications or other health conditions;
staff employees to meet the
demands of children with unusual health conditions such as
diabetes, epilepsy, etc.; and
18.2.e.6. Monitoring medication availability,
storage, record-keeping, and disposal and medication errors.
18.3. Treatment Teams
Shelter treatment teams shall consist of the child if
developmentally appropriate, a direct care
staff person employee,
the case manager and the shelter manager at a minimum. The
consulting psychologist shall review and approve all activities of
the treatment team if he or she was not an active participant.
When appropriate for children with medical issues, the consulting
nurse shall also be a member of the team or shall approve the
team's activities in writing. The organization shall notify
parents or guardians and the child's social worker and request they
participate in team activities unless time lines for team
activities prohibit such involvement or parental or guardian
participation is not clinically or legally appropriate. The social
worker shall receive a copy of the team's actions within 24 hours
if not a direct participant.
18.4. Care Plans
18.4.a. Shelters are exempt from the plan of care
subsections 13.3 and 13.4 of this rule as long as the child is
present in the facility less than thirty days. If the child is
present in the facility for thirty or more days, an extended plan
of care shall be developed as required by subsection 13.4 of this
rule and all other aspects of the rule apply with regard to service
delivery, plans of care, and reviews of plans of care.
18.4.b. Upon admission, the Shelter shall complete the
collection of any background material and history available either
from the child, a social worker, or a parent or guardian. From
that information, the Shelter shall develop an intake plan which
shall describe the following:
18.4.b.1. Further testing, evaluation or collection
of information necessary to complete the comprehensive assessment
of the child and tentative time lines for completion of that
18.4.b.2. Safety plans or behavioral protocols, if
necessary, to deal with any predictable inappropriate behaviors
(e.g., need for eyes on at all times,
one to one staffing employee
to child ratio of one to one, likelihood of sexual reactivity,
18.4.b.3. Plans for referrals for the necessary
medical screenings; and
18.4.b.4. Permission to administer properly bottled
prescription and non-prescription medications brought in by the
18.4.c. The intake plan shall be completed within
twenty-four hours and approved by the admitting parent or guardian
within seventy-two hours.
18.4.d. Within seven days, the shelter shall develop a
list of problems identified in the assessment. The list may
include not only behavioral health problems but also legal,
familial, financial, medical and academic problems, among others.
The shelter shall determine through an interdisciplinary team
meeting those problems which the shelter intends to address prior
to discharge and those problems which may need to be addressed in
an aftercare plan. At all times, consideration shall be given to
improving the child's relationship with his or her family unless
clinically or legally contraindicated.
18.4.e. The shelter shall provide objectives for each
problem that it has determined that it shall address prior to
18.4.f. Objectives shall be stated in simple language,
understandable to the child whenever possible.
18.4.g. The intervention to be used in addressing the
objective shall be described and the person or persons responsible
named, if appropriate.
18.4.h. If an objective includes an individual or group
therapy intervention, the intervening organization or provider,
whether the shelter's employee or a contractual or other provider
to whom the organization refers, shall be responsible for
developing a specific therapy plan that describes the processes the
therapist intends to use, in specific language, and the skills to
be learned or behaviors to be increased or reduced by the child.
If necessary, a plan or protocol shall be provided to direct care
staff employees to attempt to generalize behaviors discussed in
therapy to the shelter environment. Outside providers shall be
responsible for providing written feedback to the shelter prior to
discharge, in writing, regarding progress made in therapy or lack
thereof and rationale for the lack of progress.
18.4.i. Physicians or qualified medical practitioners
providing services to children in the shelter, whether by
contractual or referral relationship, shall be responsible for
communicating with the shelter nurse regarding medication changes,
and for providing written records regarding changes in medications
and the rationale for the changes.
18.5. Behavior Plans
18.5.a. If a child requires a specific behavior support
plan or a protocol for
staff employees to use in dealing with an
inappropriate behavior, the plan or protocol shall be in writing
and shall be in terms which make it clear to direct care staff employees:
18.5.a.1. The behaviors to be monitored and
18.5.a.2. The precise action to be taken by
employees if the behavior occurs; and
18.5.a.3. The documentation
staff is employees are
responsible for supplying, if any.
18.6. Reviews of Plans of Care
The treatment team shall meet
weekly to review progress in
implementing the plan of care and to modify it, as necessary, on a
monthly basis when a youth stays beyond 30 days. The plan of care
shall be a flexible document to which may be added additional
problems or objectives, as they become identified in the assessment
process. Other problems may be resolved and objectives discontinued
as they become irrelevant or are achieved. A copy of any revisions
to the plan shall be sent to the child's social worker for approval
if the social worker is not available for the weekly team meeting.
Parents or guardians shall also receive amendments unless
clinically or legally contraindicated.
18.7. Planning for Discharge
The treatment team of the shelter shall begin planning for
discharge at admission. When possible, seven days prior to
discharge the child, his or her parent or guardian (as appropriate
and possible), the child's social worker (if any) and the treatment team shall meet to develop a discharge plan. Issues to consider in
developing the plan are:
18.7.a. Remaining problems to be addressed from the
initial problem list and any problems added later during the
18.7.b. Appropriate placement for the child considering
issues of safety, permanency and clinical need;
18.7.c. Recommendations for aftercare including
recommended behavioral health and medical services; and
18.7.d. Any other relevant and compelling information or
§78-3-19. Program-specific Rules for Maternity and Parenting
19.1. Maternity Care
Care to a pregnant or parenting adolescent or transitioning
adult includes, but is not limited to:
19.1.a. Appropriate health care and health education;
19.1.b. Education needs specific to the pregnant or
parenting young woman;
19.1.c. Nutritional guidance and support;
19.1.d. Counseling services specific to making decisions
and planning for her child;
19.1.e. Parenting educational services; and
19.1.f. Maintenance of an environment conducive to the safety of children (infant through toddler) and pregnant women.
19.2. Appropriate health care and health education
19.2.a. The organization shall provide or arrange for
health services to the expectant and parenting teens that includes:
19.2.a.1. A written health summary, including
family medical history, immunizations,
procedures and childhood illnesses;
19.2.a.2. A general medical examination which will
occur at the time of admission, and an obstetrical/gynecological
examination for the pregnant young woman within the first two weeks
of admission or sooner if the young woman is considered to be high
19.2.a.3. Thorough medical supervision of the
pregnancy, including all needed prenatal care; testing and post
natal care shall be done by an
specialist appropriately licensed health care professional with a
specialization in women's health; and
19.2.a.4. Direct provision or referral for services
to meet the needs of high risk pregnancy or high risk infant care-
19.2.b. Registered nursing
staff employees with
obstetrical/gynecological experience are to be available on the
grounds at least twelve hours per day, with twenty-four hour
19.2.c. The pregnant or parenting young woman shall
receive ongoing health education with age-appropriate instruction
regarding pregnancy prevention, HIV/AIDS prevention, and general
information about the prevention and treatment of disease.
19.2.d. The organization shall be located within fifteen
minutes of a hospital or birthing center
with maternity care that
provides maternity care and labor and delivery services.
19.2.e. Standing medical orders for pregnant young women
shall be carefully evaluated and shall take into consideration
cautions necessary for pregnant young women.
19.2.f. All pregnant or parenting young women shall have
access to educational services as appropriate:
19.2.f.1. All pregnant or parenting young women,
once assessed, shall participate in some type of educational
service such as GED classes, public school, and/or alternative
19.2.f.2. Child care services shall be in close
proximity to the education facilities; and
19.2.f.3. Supportive services for child care shall
be available to assure that the young woman can have necessary
19.3. Nutritional Guidance and Support
19.3.a. All parenting and pregnant young women will be
assessed at a minimum within the first thirty days of admission by a registered dietitian, unless dietary problems are indicated at
19.3.b. Ongoing dietary support shall be encouraged
through a nutritional education program and if indicated by
individual instruction provided by the registered dietitian or
19.3.c. All pregnant and parenting young women shall
receive counseling services specific to parenting and alternative
choices, on an ongoing basis.
19.3.d. The organization shall have policy and
procedures related to the involvement of the putative father of the
19.3.e. Supportive counseling services will be extended
to the family of the young woman, the biological father (unless
contra-indicated by court order) and the family of the biological
19.3.f. The organization shall offer an ongoing parent
education program with a curriculum that comprehensively addresses
at a minimum, the following topics:
19.3.f.1. Personal growth and maturity;
19.3.f.2. Interpersonal relationships;
19.3.f.3. Early childhood development;
19.3.f.4. Infant stimulation,
development and bonding/attachment;
19.3.f.5. Safety and accident prevention, including
First Aid and CPR;
19.3.f.6. Physical care, nutrition, and health of
infants and young children;
19.3.f.7. Signs and symptoms of child abuse and
19.3.f.8. Time, budget, and household management;
19.3.f.9. Community resources that provide
19.3.f.10. Child care use and how to choose
19.3.g. Parenting education may be offered in both a
formal and informal setting using classroom instruction, small
groups, and individual and experiential teaching methods, based on
the needs of the mother.
19.3.h. The organization shall maintain an environment
conducive to the safety of a child (infant through toddler) and a
19.3.i. The facility shall contain at least one area for
routine medical examination, counseling and treatment for clients.
This area shall be private and in adherence with all universal
precautions, Occupational Safety and Health Administration (OSHA)
standards and best medical practice.
19.3.j. All living areas
shall be child proofed and all infant and child furniture shall be maintained in good repair and
meet the Child Product Safety Commission (CPSC) guidelines.
19.3.k. The exposure of the pregnant teen and infant to
cleaning supplies and pesticides should be limited. The
organization shall be cognizant of the possible side effects of
exposure and limit it accordingly.
19.4. Baby Care
19.4.a. An organization shall provide a plan of care for
babies that includes, but is not limited to the following:
19.4.a.1. Appropriate health care;
19.4.a.2. Appropriate daily care; and
19.4.a.3. Appropriate daily stimulation.
19.4.b. An organization shall also provide:
19.4.b.1. A warm and child friendly environment;
Staff Employees specifically trained to
meet the needs of infants through toddlers.
19.4.c. The organization shall document that all babies
receive a thorough assessment prior to leaving the hospital or at
the time of admission to the organization.
19.4.d. The organization shall assure that all children
receive health care according to the Early Periodic Screening,
Diagnosis and Treatment Program (EPSDT) standards of care.
19.4.e. The organization shall have policy and procedures to assure that the health and well-being of the child is
protected once he or she leaves the hospital.
19.4.f. The organization shall have policy and
procedures to assess and treat babies and children who show signs
of illness, which include but are not limited to diarrhea,
vomiting, fever, etc.
19.4.g. If at any time the baby's mother is unable or
refuses to care for her baby, the organization shall have policy
and procedures to assure that appropriate interventions are used to
secure the health of the child.
19.4.h. Appropriate daily care:
19.4.h.1. The organization shall ensure that all
babies have the necessities to meet their basic daily needs.
including but not limited to, diapers, clothing, bottles, bedding
needs, bathing supplies, car seats, etc. 19.4.h.2. The organization shall ensure the basic
needs of the baby are consistently met.
, including but not
limited to bathing, bottle-making using sterile bottles, feeding,
laundry, baby sitting, diaper changing, and, when appropriate,
19.4.h.3. All babies under twelve months of age
shall have a feeding and diet plan prescribed by the physician.
19.4.i. The organization shall handle breast milk and
formula in the following manner:
19.4.i.1. Prepared bottles
are to shall be capped
and clearly labeled with the child's name, contents and the date
19.4.i.2. Prepared bottles
are to shall be
refrigerated in a separate section of the refrigerator and
accessible only to staff employees;
19.4.i.3. Breast milk shall be stored in
plastic or glass bottles with tight lids containers specific to the
19.4.i.4. Breast milk or formula when it remains at
a temperature higher than forty-one (41) degrees Fahrenheit for
more than one hour shall be discarded;
19.4.i.5. Refrigerated breast milk shall be used
within forty-eight hours of receipt, frozen breast milk within two
weeks of receipt and deep frozen breast milk within three months of
19.4.i.6. Formula bottles shall be used
twenty-four hours of preparation or discarded; and within time
frames established by the manufacturer and listed on the package;
19.4.i.7. A microwave oven is not permitted for the
heating of breast milk or formula bottles.
19.4.j. Solid food, including cereals are not to be
placed in a bottle unless prescribed by a physician.
19.4.k. Jar baby food is to be served from a bowl and
not from the jar.
19.4.l. Until a baby is able to hold a bottle securely,
a baby and the bottle shall be held while the baby is being fed.
At no time is the bottle to be propped.
19.4.m. All babies shall receive daily stimulation to
encourage the emotional, physical and intellectual development of
the child. This includes:
19.4.m.1. Holding, rocking, and playing whenever
possible, including while bathing, dressing and carrying the child;
19.4.m.2. Encouraging positive communications and
language development by making eye-to-eye contact with the child,
singing, talking, reacting to the child's sounds, naming
objectives, reading stories and playing musical games;
19.4.m.3. Paying attention to crying and meeting
the immediate needs of the child;
19.4.m.4. Ensuring that no child is routinely left
in a crib or playpen, except for sleep or rest; and
19.4.m.5. Providing a child who is awake with play
equipment and opportunities to play freely on a clean floor.
19.4.n. The organization shall ensure that all products
containing potentially hazardous chemicals, including identified
poisons, medications, certain cleaning supplies, and art supplies
not clearly labeled as "nontoxic", are inaccessible to all children in a locked cabinet away from food, and when possible, stored in
their original containers and never in containers originally
designed for food.
19.4.o. The organization shall ensure that all
electrical outlets within the reach of a child when not in use are
protected by a cover.
19.4.p. The organization shall ensure that when an
electrical appliance is used, an adult is present at all times to
supervise the use of the appliance.
19.4.q. The organization shall provide a shield to
protect a child from hot pipes or radiators and shall not use
unvented fuel fire heaters.
19.4.r. The organization shall ensure that barriers and
gates are appropriately used.
19.4.r.1. All temporary walls or items being used
as physical barriers shall be firmly anchored so that they pose no
threat to the safety of the child.
19.4.r.2. Stairways to which the child has access
shall have appropriate railing and safety gates or other barriers
at the top and at the bottom.
19.4.s. The organization shall ensure that strings,
cords and hanging items are of no threat to the children.
19.4.s.1. The drawstring on clothing such as on
hoods or collars shall be removed or secured to prevent potential risk to the child.
19.4.s.2. Pacifiers attached to a string or ribbon
that is 6 inches or more in length shall not be placed around a
child's neck or affixed to the child's clothing; and
19.4.s.3. No child is to have access to a string or
cord that is 6 inches or more in length and attached to a fixed
object, such as a window shade, nor access to any other potentially
dangerous hanging item, such as a tablecloth.
19.4.t. The organization shall ensure that there is an
outdoor play area appropriate and safe for young children.
19.4.u. The organization shall ensure the safety of the
child during transportation. The driver or qualified
employee shall ensure that each child three years of age and under
is secured in an approved child safety seat.
19.4.v. The organization shall ensure that the overall
environment of the children's area of the facility is clean,
pleasant in appearance, well-lighted and conducive to the
development of children.
Staff Employee Training
19.5.a. The organization shall ensure that all
employees are specifically trained to meet the needs of the very
staff employees shall be trained within the
first thirty days of employment on basic infant care. Prior to completion of the training, the new employees shall be scheduled to
work only with fully trained staff employees.
19.5.c. At a minimum, all
staff employees shall be
19.5.c.1. Child development;
19.5.c.2. Infant CPR and first aid;
19.5.c.3. Basic child care;
19.5.c.4. Sick baby care; and
19.5.c.5. Parenting skills.
§78-3-20. Outdoor Therapeutic Educational Programs.
Staff Employee Ratios
Staff Employee ratios to children shall be
appropriate for the activity in which the group is engaged.
Staff Employee ratios for high risk activities
(rock-climbing, rope-walking, white water, etc.) shall be a minimum
of four staff employees to ten children. (4:10).
staff employee ratio for away from main camp
on low risk activities shall be a minimum of three staff employees
to ten children (3:10).
20.1.d. In main camp, the
staff employee ratio shall be
a minimum of two staff employees to ten children (2:10).
Staff Employee ratios for groups away from camp
may be adjusted downward for smaller groups; however, safety and
the adequacy of supervision shall be a paramount concern.
20.1.f. At night:
20.1.f.1. Under normal weather conditions,
each gender shall sleep separately with one counselor assigned to
each sex. In cases of extreme weather, sexes may be in the same
building or structure but the staff employees on duty shall
functionally separate them;
20.1.f.2. There shall be a minimum of one
employee per sleeping group. That staff employee may be sleeping
when the group is in the main camp or in the field. When the group
is in the main camp, at least one staff person employee shall be
awake and monitoring children at all times. The organization shall
have a policy regarding staffing employee ratios to ensure the
safety and security of children at night when away from the main
20.2. Credentials of
20.2.a. Direct care
staff employee shall have a minimum
of a high school diploma or GED and skills, certifications and/or
abilities unique to the environment, such as residential child care
experience, search and rescue certification, wilderness survival
skills, camping skills, etc.. Direct care staff employees shall be
responsible for group supervision and monitoring on a day to day
basis, including teaching basic living skills, role modeling
effective individual and group problem-solving skills and anger
management, and completing daily documentation as required.
20.2.b. Counselors shall have a minimum of an
undergraduate degree in a human services field and shall work under
the direct supervision of an appropriately licensed or certified
behavioral health professional. Counselors shall be responsible for
supportive counseling of children, teaching and modeling
appropriate problem-solving and anger management skills, teaching
and modeling appropriate interpersonal skills and positive role
20.2.c. Teachers certified to teach by the state of West
Virginia shall be responsible for the oversight and supervision of
the educational program of the organization. The organization
shall have at least one teacher.
Staff Employee Training
staff employees responsible for the direct
care of children shall be trained in the following areas in
addition to those cited in subsection 11 of this rule:
20.3.a.1. Water procurement, preparation and
20.3.a.2. Shelter construction;
20.3.a.3. Food preparation and storage in the
20.3.a.4. Fire site preparation and fire building;
20.3.a.5. Low-impact wilderness expedition and
environmental conservation skills and procedures;
20.3.a.6. Sanitation procedures related to food,
water and waste;
20.3.a.7. Management of health issues unique to the
outdoor therapeutic educational program environment including
acclimation to the environment and environmental elements;
20.3.a.8. Basic training in rescue and water safety
staff employees responsible for water activities. A
minimum of one adult so trained shall be present at all times at
all water activities;
20.3.a.9. Navigation skills including map and
compass use and contour navigation;
20.3.a.10. Local environmental precautions
including sensitivity to terrain, weather, insects, poisonous
plants, wildlife and the proper response to adverse situations
involving any of these factors; and
20.3.a.11. Management of the health and safety of
the group in severe weather conditions including a possible
20.3.b. All new
staff employees shall be accompanied at
all times by experienced staff employees during the first month of
employment in the field and until all required trainings have been
completed, whichever is later.
20.4. Service Elements
20.4.a. The organization shall have an on grounds
educational program that is of sufficient quality to allow students
to transfer educational credits to their county of origin. A
teacher certified to teach in the state of West Virginia shall be
coordinating and providing oversight to the educational program.
Whenever possible, the educational program shall be accredited by
an appropriate educational accreditation body.
20.4.b. The organization shall have complete policies
and procedures to guarantee child safety in any off grounds
activity, including but not limited to:
20.4.b.3. Tent building and other construction;
20.4.b.4. Ropes courses;
20.4.b.5. Van trips;
20.4.b.6. Off property outings;
20.4.b.7. Canoe trips or white water rafting;
20.4.b.8. Swimming or wading;
20.4.b.9. Mountain biking;
20.4.b.11. Soloing; and
20.4.b.12. Rock climbing.
20.4.c. The policy shall discuss the following:
Staff Employee to child ratios for the activity;
Staff Employee training and/or
certification prerequisites for participation.
20.4.c.3. Child training prerequisites for
participation, including safety training;
20.4.c.4. Special equipment or provisions required
for the activity including safety equipment such as life jackets,
safety ropes, helmets, etc., and food, water, etc. as necessary and
20.4.c.5. Evacuation plans if they should become
necessary during an activity;
20.4.c.6. Safety plans unique to the activity
(e.g., backpacking weights, rope safety and monitoring, etc.); and
20.4.c.7. The documentation necessary for the
20.4.d. All policies and procedures shall be in
conformity with nationally accepted standards for the activity, if
they are available. If
staff employee certification or training is
available in the activity, at least one staff employee present
during the activity shall be trained or certified. During water
activities, at least one staff employee shall be fully certified
in water safety and lifesaving.
20.4.e. If the organization contracts with an
independent provider to guide or supervise the activities, the contractor shall be appropriately certified if a certification is
20.4.f. General safety considerations:
20.4.f.1. Personal gear supplied to children shall
be appropriate in size, amount and protectiveness for the child and
the expected weather;
20.4.f.2. No child shall be expected to pack more
than 30% of his or her body weight at any time and special health
considerations shall be taken into account if they are necessary;
20.4.f.3. Adequate food and water shall be
staff employees and children at all times in all
20.4.f.4. Equipment shall be regularly inspected as
a matter of policy by the safety committee or its designee for
signs of wear or damage and the inspections shall be documented and
20.4.f.5. Prior to any water activity, the swimming
ability of all children and
staff employees shall be evaluated and
documented by an appropriately trained staff employee person. The
organization shall document that adequate arrangements for
protection of non-swimmers have been made on each activity;
20.4.f.6. Soloing activities shall only be
conducted with the written consent of a licensed mental health
clinician who has personally evaluated the child within twenty-four hours prior to the onset of the solo activity. At all times,
employees shall be in earshot of a distress call if it is
necessary and shall conduct random face to face checks of the
status and condition of the child on intervals not to exceed six
20.4.f.7. The organization shall have a policy to
ensure safety and security of children who are acutely disturbed
20.5. Abrogation of Client Rights
While items of clothing may not be withheld as a punishment,
children may be prevented from access to certain items of clothing
(such as belts) as a safety measure. The criterion shall be
whether the potential safety created by the restriction outweighs
the harm of the restriction. The organization shall have a written
policy regarding restriction of access to articles of clothing,
approved by the governing body.
20.6. Environmental Issues
20.6.a. The environment of an outdoor therapeutic
educational program is by definition limited in its handicapped
accessibility. The organization shall have an admissions policy
which clearly describes its degree of accessibility to clients with
physical handicaps. The organization shall make a reasonable
effort to enable family members with physical handicaps to access
children, family therapy interventions and program sites.
20.6.b. Outdoor therapeutic education facilities are
generally considered to be inappropriate for serving children with
serious physical handicaps; however, the organization is
responsible for finding a method of incorporating family members
with physical handicaps to a maximum degree into the therapeutic
20.6.c. The organization shall have policies pertaining
to the following with reference to any activities conducted away
from the main campus or building:
20.6.c.1. Unique adaptations to dietary
requirements as appropriate;
20.6.c.2. Sanitation and infection control;
20.6.c.3. Waste management;
20.6.c.4. Food storage and handling;
20.6.c.5. Maintenance of safe body temperature;
20.6.c.6. Clothing and footwear;
20.6.c.7. Field equipment;
20.6.c.8. Communication with the main campus or
management on an on-going and emergency basis;
20.6.c.9. Medication storage and security away from
20.6.c.10. Disaster and severe weather plan
including procedures for evacuation; and
20.6.c.11. Procedures to follow for runaways and elopements.
§78-3-21. Intermediate Care Facilities for the
Intellectually Disabled or Developmentally Disabled.
Intermediate care facilities for children with
retardation intellectual disabilities and developmental
disabilities shall comply with the federal Conditions of
Participation (42 CFR §§440.150 et. seq. and 483.410 through
483.480) except where state licensing standards are more stringent
21.2. An intermediate care facility for the
retarded/intellectually disabled and/or developmentally disabled
may accept a seventeen year old into an adult group home under the
21.2.a. The average age, developmental levels and social
needs of the adult residents in the home is approximately that of
the child unless the prospective child and the other adult
residents of the home have developmental disabilities which are
severe or profound and/or the adult residents are non-ambulatory,
nonverbal or have multiple physical handicaps;
21.2.b. The home has arranged educational programming
for the child which is as normative as possible;
21.2.c. The child has a reasonable ability to
participate in age-appropriate community activities;
21.2.d. The placement is developmentally consistent with
other adult residents of the home; and
21.2.e. None of the adult residents of the home have a
history of sexual predation.
21.3. Restrictive behavior management techniques shall
conform to federal guidelines for intermediate care facilities for
mentally retarded intellectually disabled or developmentally
§78-3-22. Psychiatric Residential Treatment Facility.
A psychiatric residential treatment facility for persons under
twenty-one is a freestanding or physically distinct part of a
psychiatric inpatient organization that provides services and
treatment to children who do not need acute care but require
intensive and coordinated services in a residential setting in a
manner consistent with federal requirements.
(42 CFR §§483.350 and
441.151). A psychiatric residential treatment facility provides a
continually, medically-supervised interdisciplinary program of
behavioral health treatment.
22.2. Accreditation Requirements
A psychiatric residential treatment facility shall be
appropriately accredited as required by federal standards. Where
differing accreditation, certification or licensing standards
exist, the more stringent standard applies.
22.3. Employee Ratios
22.3.a. The average
staffing employee ratio for a
psychiatric residential treatment facility shall be one staff
employee to three patients (1:3) during day and evening hours (one
staff employee whose primary responsibility is providing direct
care for every 3 children during the day and evening). During
nighttime sleeping hours, the ratio shall be one staff employee to
six patients (1:6). During all hours with there shall be capability
to increase staff employee ratio in response to acuity, extending
to the provision of one-on-one (1:1) care when necessary. Staff
Employees assigned to work a defined unit and providing care to the
children on that unit including nursing, teachers, and activity's
therapists may be included in the staff employee to client ratio.
Staff Employees assigned to supervisory duties or whose duties
cause them to be away from the unit (nursing supervisor) may not be
included in the count.
Nnursing coverage shall include a registered
nurse during day and evening shifts with at minimum, a licensed,
practical nurse overnight.
22.3.c. There shall be a supervisor present on all shifts and
staff employees shall have access to other administrative staffs
employees at all times.
Staff Employee Training and Credentials
22.4.a. All direct care
staff employees shall have a minimum
of a high school diploma or GED and professional staff employees
shall have appropriate education and certification consistent with
professional licensing standards.
22.4.b. In addition to the requirements for
training prescribed in section 11 of this rule, direct care staff
employees shall receive refresher training in emergency safety
interventions twice a year, which shall include both didactic and
experiential activities. This training may include, but is not
limited to: 22.5. Treatment Services
22.4.b.1. Conflict resolution;
22.4.b.2. Managing behavior;
22.4.b.3. Psychiatric emergencies; and
22.4.b.4. Avoiding power struggles.
The residential treatment facility shall provide the following
22.5.a. A physician shall be available twenty-four hours a
day, seven days a week to respond to medical and psychiatric
psychiatrist physician licensed in the State of
West Virginia and board certified in psychiatry shall perform
observation and assessment at least weekly; and
22.5.c. Routine assessments shall be performed by the physician to effectively coordinate all treatment, manage
medication trials and/or adjustments, minimize serious side
effects, and provide medical management of all psychiatric and
22.5.d. A weekly note shall be made by the attending or
covering psychiatrist that evaluates the patient's current
condition and progress in treatment and outlines any
recommendations for revisions in the plan of care. 22.6. Assessments
22.6.a. A comprehensive assessment process shall include
22.6.a.1. Psychiatric health;
22.6.a.2. Physical health;
Nursing Ability to self-medicate with
22.6.a.4. Psychosocial history;
22.6.a.5. Recreational activities;
22.6.a.6. Spiritual and cultural preferences and interests;
22.6.a.7. Behavioral and adaptive living skills, both
strengths and deficits; and
22.6.a.8. Educational functioning.
22.6.b. An additional diagnostic assessment shall be provided
as needed, either onsite or by using community providers.
22.6.c. All required clinical assessments shall be completed prior to the development of the
master plan of care. Assessments
conducted within thirty days prior to admission by qualified
professionals may be used if reviewed and approved for treatment
planning by the responsible psychiatrist and Interdisciplinary
22.6.d. A psychiatric evaluation shall be completed within
twenty-four hours of admission and shall include:
22.6.d.1. The reason for admission;
22.6.d.2. The current clinical presentation;
22.6.d.3. Psychosocial stressors related to the recent
22.6.d.4. A current or potential risk to self or others;
22.6.d.5. A history of the present illness;
22.6.d.6. A past psychiatric history;
22.6.d.7. A developmental assessment;
22.6.d.8. The presence or absence of physical disorders or
conditions affecting the presenting problem;
22.6.d.9. An alcohol
and/or drug history; and
22.6.d.10. A mental status examination.
22.6.e. A diagnosis on all five axes shall be given, based on
the current version of the Diagnostic and Statistical Manual of
Mental Disorders (DSM).
22.6.f. A physical health examination shall be provided
within 24 hours of admission.
22.6.g. A Registered Nurse practitioner shall provide a
health assessment within 24 hours of admission. The assessment
22.6.g.1. A general history of the patient's and family's
22.6.g.2. The patient's current medications;
22.6.g.4. Pertinent medical problems requiring nursing
22.6.g.5. Current risk and safety factors;
22.6.g.6. Nutritional status;
22.6.g.7. Immunization status; and
22.6.g.8. Sleep patterns.
22.7. Plan of Care
22.7.a. A preliminary plan of care shall be developed within
seventy-two hours of admission.
22.7.b. The interdisciplinary team shall have thirty days to
complete all assessments while providing any immediately necessary
psychiatric and therapeutic treatment. Prior to the end of the
thirty-day period or when all initial assessments are completed,
whichever comes first, the team shall complete a plan of care.
22.7.c. The plan of care shall be reviewed by the
interdisciplinary team for effectiveness and shall be revised when
major changes in treatment occur, or at least every thirty days.
22.8. Transfer Agreement
The organization shall have a written transfer agreement with one
or more hospitals that ensures that an individual can be
transferred to an appropriate setting in a timely manner when
transfer is necessary for more intensive psychiatric care or for
emergency or specialized medical care.
22.9. Transitioning Adults
22.9.a. The psychiatric residential treatment facility may
serve individuals aged eighteen to twenty-one so long as the
transitioning adult is court ordered, voluntary or committed under
the requirements of Chapter 27 of the West Virginia Code.
22.9.b. The building, staff and activities shall be in
compliance with Section 25 of this rule. 22.10. Restrictive Behavior Management
Restrictive Behavior Management techniques shall conform to all
federal guidelines for psychiatric residential treatment
§78-3-23. Therapeutic Residential School.
Staff Employee Ratios and Training
Staff Employees, for the purposes of this section, is
defined as those individuals who are:
23.1.a.1. Fully oriented and trained according to
organizational policy; and
23.1.a.2. Have job responsibilities which pertain only to the provision of child care, treatment and supervision.
23.1.b. The therapeutic residential school shall have a
policy regarding care and supervision of children that ensures
23.1.b.1. Children receive adequate supervision for their
age, developmental functioning and emotional and behavioral needs;
23.1.b.2. The care plan as developed by the
interdisciplinary team is implemented as written for each child.
23.1.c. Children shall be cared for and supervised at the
following levels, with clinically justified modifications when
house parents are employed:
23.1.c.1. A minimum
staff employee to child ratio of 1:10
during the waking hours when children are on the grounds with a
minimum of one staff person employee present per residential living
unit at all times;
23.1.c.2. The availability of additional or back-up care
staffs employees for emergency situations or to meet special needs
presented by the child; (e.g. physician appointments, behavioral
outbursts, acute suicidality, etc.) ; and
staff employee to child ratio of 1:12 during
the sleeping hours with a minimum of at least one staff employee
per residential living unit to be awake at all times.
23.1.d. The organization shall have a policy regarding supervision of children in off-grounds activities which shall
ensure that children are adequately supervised at all times.
23.1.e. As appropriate to the ages and needs of
children in care, the organization shall ensure that one of more
trained professional staff members employees are on duty or
available via an on-call system on a 24 hour basis to provide
continuous supervision to each residential living unit within a
23.1.f. The organization which uses a house parent model
shall have a policy that ensures the safety and supervision of
children at night.
23.2. Environmental Issues
23.2.a. To the maximum extent possible, the organization
providing therapeutic residential school services shall be non-
institutional in appearance and practices. Each child or
transitioning adult shall be permitted to have personal space,
personal possessions and a place to store those possessions unless
clinically contraindicated. Each child is expected to assume some
responsibility for an aspect of facility maintenance (cleaning,
cooking, etc. ) on an ongoing basis.
23.2.b. Group therapeutic and residential living activities
should be conducted in an appropriately sized group format, taking
into consideration best practice standards for the sex,
developmental status and diagnosis of the children.
23.2.c. Children shall have clearly identifiable schedules
and activities, individualized for their strengths and needs. Each
child shall have a unique schedule which identifies therapy times,
chore or work assignments, school hours, and other activities.
Staff Employees shall be available in sufficient
quantity and with appropriate credentials to address the needs of
the child as identified by the assessment and interdisciplinary
23.2.e. The residential therapeutic school that permits pets
shall follow written procedures that address their availability,
care, feeding, and maintenance that includes at a minimum, a
veterinary evaluation and vaccinations as recommended by the
veterinarian in writing.
23.2.f. Service elements unique to the population:
23.2.f.1. If the organization permits children to operate
vehicles while in placement, it shall do so under the following
23.2.f.1.A. The child has a valid West Virginia driver's
license or permit;
23.2.f.1.B. The child's vehicle, if any, is
appropriately licensed and insured; and
23.2.f.1.C. The child receives permission in writing
from his or her parent or guardian, as appropriate.
23.2.f.2. The organization shall have a written plan of basic daily routines which shall be available to all
employees and updated regularly.
23.2.f.2.a. Children shall participate in planning daily
23.2.f.2.b. Children shall have set routines for waking
and going to bed.
23.2.f.3. The organization shall encourage and arrange for
children to participate in community, school functions and
recreational activities on an individual basis.
§78-3-24. Residential Programs Serving Transitioning Youth and
__24.1 Level one agencies serving transitioning youth and
transitioning adults shall develop an operating manual, made
available to employees and residents, that includes:
__________24.1.a. Policies and provisions developed by the
organization based upon Departmental requirements. ; and
__________24.1.b. A complete and detailed description of the range
of services offered and eligibility requirements for admission; and
__________24.1.c. Age requirements for transitioning youth and
transitioning adults with a minimum of age 16 and a maximum of age
The A transitioning youth's case record shall contain:
__________24.2.a. Written permission from a guardian to be exempted
from any Medication Administration Regulation as outlined in the transitioning youth's plan of care and how it will assist the goal
__________24.2.b. A written assessment that documents the
transitioning youth's or transitioning adult's educational,
vocational, physical health, mental health and social needs;
__________24.2.c. A plan of care outlining the transitioning youth's
or transitioning adult's specific needs and strategies for
obtaining educational, vocational, physical health care, mental
health and social needs in the community; and
_____24.2.d. Youth-specific requirements for
supervision if less than 24 hours per day, seven days per week.'"