Utah Department of Administrative Services Division of Administrative Rules

Utah Administrative Code

The Utah Administrative Code is the body of all effective administrative rules as compiled and organized by the Division of Administrative Rules (Subsection 63G-3-102(5); see also Sections 63G-3-701 and 702).

NOTE: For a list of rules that have been made effective since March 1, 2014, please see the codification segue page.

NOTE TO RULEFILING AGENCIES: Use the RTF version for submitting rule changes.


R432. Health, Family Health and Preparedness, Licensing.

Rule R432-151. Mental Disease Facility.

As in effect on March 1, 2014

Table of Contents

R432-151-1. Legal Authority.

This rule is adopted pursuant to Title 26, Chapter 21.

R432-151-2. Purpose.

The purpose of the rule is to establish program standards for a mental disease facility (MDF) that is engaged primarily in providing diagnosis, treatment or care of persons with mental disease, including medical attention, nursing care and related services.

R432-151-3. General Provisions.

(1) R432-150 also applies to a Mental Disease Facility.

(2) The Department shall consider the following to determine whether a facility is an MDF:

(a) The facility specializes in providing psychiatric care and treatment, with emphasis on active treatment programs which focus on mental disease.

(b) Fifty per cent or more of the residents in the facility have a diagnosis of mental disease (using the ICD-9-CM codes) excluding the following:

(i) 290 through 294.9 and 310 through 310.9 for senility or organic brain syndrome;

(ii) 317 through 319 for mental retardation;

(iii) 314 through 315.9 for individuals suffering impairment of general intellectual functioning or adaptive behavior similar to that of mentally retarded persons; and

(iv) 309 and 316 for Adjustment Reaction or Psychic factors associated with disease classified elsewhere.

(3) A facility that is determined to be an MDF according to this rule must be licensed as a mental disease facility.

(4) When a facility census identifies 40 per cent or more of the resident population with a mental disease diagnosis, the Department may request the facility to submit a completed Utah Level of Care Survey (ULOCS).

R432-151-4. Definitions.

(1) See common definitions in rule R432-1-3.

(2) Special definitions.

(a) "Utah Level of Care Scale" means the results of an empirical, validated assessment of resident level of function using the Utah Level of Care Survey instrument.

(b) "Utah Level of Care Survey" means a survey which includes a set of behavioral observations that provide a cross-sectional profile of resident functional deficits and care needs. The scale defines six service pattern types which reflect simultaneous consideration of physical and psychosocial care needs.

R432-151-5. Treatment Programs.

The facility shall develop and maintain standards through written policies and procedures for staff participation and for resident services.

(1) Goals, objectives, and available programs for treatment of mental disease shall be developed in such a manner that performance and effectiveness can be measured.

(2) These standards shall comply with the rules and shall encourage both quality of care and quality of life.

R432-151-6. Program Standards.

(1) Each resident shall receive individualized treatment, which includes at least the following:

(a) Provision of treatment services, regardless of the source(s) of financial support;

(b) Provision of services in the least restrictive environment possible;

(c) Provision of an individualized resident care plan which has regular periodic review;

(d) Invitation for active participation by residents and their responsible parent, relative, friend, or guardian in the development of resident care plans;

(e) Competent, qualified, and experienced professional staff to implement and supervise the resident care plan.

(2) The facility shall develop policies to assure that services are provided with sufficient resources (such as program funds, staff, equipment, supplies, and space) to meet resident needs.

(3) The facility shall maintain programs, beds, and services that are available 24 hours a day, seven days a week.

(4) Written policies and procedures shall define what action is to be taken when maladaptive behavior exceeds criteria for program participation.

(5) Services not directly provided within the facility must have written agreements or arrangements to obtain such services whenever they are authorized or prescribed. Such services may include special assessments or therapeutic treatment programs.

(6) The facility shall establish written policies and procedures which include:

(a) Admission criteria which describe selection of the population served, including age groups and other relevant characteristics;

(b) The intake process;

(c) Criteria for resident participation in programs;

(d) Specific treatment modalities;

(i) Identify services provided in the modality; and

(ii) Identify goals and objectives of the modality;

(e) Crisis intervention and emergency services;

(f) Use of involuntary medication or physical restraints;

(g) Restrictive procedures;

(h) Methods to collect, process, report, and disseminate resident assessment data;

(i) Case coordination and case management;

(j) Development and periodic review of plans of treatment;

(k) Discharge planning;

(l) Staff in-service needs;

(m) Responsibility for medical and dental care;

(n) Provisions for family participation in the treatment program;

(o) Arrangements for clothing, allowances, and gifts;

(p) Provisions to allow resident departure from the facility as part of activities offered in the program;

(q) When the resident leaves the facility against medical advice.

(7) The facility shall develop job descriptions to delineate the roles and responsibilities of team members and to establish supervisory and organizational relationships.

(8) The professional staff shall determine qualifications required to assume specific responsibilities. Individual personnel files shall contain documentation to verify whether health care staff meet state and local requirements for certificates, licenses, or registrations.

(9) There shall be a written and dated consent form signed by the resident or the resident's legal guardian for the use of, participation in, or performance of the following:

(a) Surgical procedures;

(b) Procedures that place the resident at risk;

(c) Transfer;

(d) Other procedures where consent is required by law.

(10) The resident shall be allowed visitors, regardless of age, unless such visits are clinically contraindicated, and if so, the reasons must be documented by the professionals who made this decision.

(11) Areas shall be provided for residents to visit in private, unless such privacy is contraindicated and documented in the resident's record and plan of treatment.

R432-151-7. Environment.

(1) Each facility shall establish an environment to enhance a positive self-image of residents and preserve individual dignity.

(a) Programs which assume responsibility for security and yet maintain an open-door policy are encouraged.

(b) Treatment programs shall be conducted without disruption of, or disturbance to, other facility programs.

(2) The facility shall be designed, constructed, equipped, and operated to promote efficient and effective conduct of treatment programs and to protect health and safety both for the residents served and for the staff.

(3) The facility shall meet environmental needs of the residents.

(4) The facility shall provide adequate space for the program to carry out its goals.

(a) When resident needs or program goals include outdoor activity, areas and facilities shall be provided.

(i) Natural terrain and community resources may provide options for outdoor activities.

(ii) Other areas appropriate to resident activities may include an auditorium, stage, swimming pool, canteen, etc. (iii) Activities may take place within the community setting in affiliation with churches, schools, organizations, etc.

(b) Content of program plans shall describe circumstances for use of available resources, and when necessary, have written affiliation agreements.

(c) Recreational equipment must be maintained in working order.

(5) Design, location, and furnishings of program areas shall accommodate residents and visitors. The need for privacy or support from staff as well as goals of the facility programs shall be taken into consideration.

(6) Clocks and calendars shall be provided to promote awareness of time and season.

(7) Books, current magazines, and daily newspapers shall be available to the residents.

(8) Areas shall be available for a range of social activities from two-person conversations to group activities. Areas shall also be available where a resident can be alone when this is not in conflict with the individual's treatment program.

(9) Noise-producing equipment and appliances shall not interfere with other activities or the therapeutic program. Written policies and procedures shall address the use and location of this equipment such as radios, televisions, record players, musical instruments, tape players, etc.

(10) Space and general equipment shall be provided for table games and pursuit of individual hobbies.

(a) Equipment and games shall be accessible to residents.

(b) Hobby supplies, as well as arts and crafts materials used in therapeutic activity, shall be available according to residents' cultural or educational backgrounds and needs under the management of Activity Services.

(11) Dining areas shall be pleasant and promote a congenial, relaxed atmosphere.

(a) Dining rooms shall be supervised during meals by staff personnel to provide assistance and to ensure that each resident receives adequate amounts and varieties of foods.

(b) Food shall be served in an attractive and appetizing manner, as planned in menus, and at realistic mealtimes.

(c) Menus shall provide color and variety in meeting nutritional needs.

(d) Provisions shall be made in the menus and dining areas to cover special occasions, holidays, and weekends.

(e) The facility shall make available an area which allows resident access for preparation and serving of food, beverages, or snacks. Facility policy shall establish guidelines for resident use, such as leisure time activity, or, to offer rehabilitation or habilitation in a therapeutic environment.

(f) Bedrooms shall be assigned on the basis of the resident's need for group support, privacy, or independence.

(i) Rooms shall have doors for privacy, and an appropriate bed with mattress, pillow, fresh linens, and blankets furnished by the facility.

(ii) There shall be closet or storage space for personal items and clothing which the resident has and shall be allowed to use or wear.

(iii) The selection of residents assigned to a room shall be appropriate to the ages, development, and needs of the resident and to the goals of the program.

(iv) When rooms are shared, individual privacy must be provided by curtains, by partitions or by furniture arrangement.

(v) Provision shall be made for residents who need extra sleep, who have sleep disturbances, or who need greater privacy.

(g) Residents shall be encouraged to maintain their sleeping and living areas and perform other day- to-day housekeeping activities to support non-impaired functioning, or to learn rehabilitation or habilitation responsibilities. Staff assistance and equipment shall be provided as needed.

(h) Residents shall be allowed to keep and display personal belongings and to add personal decorations to their rooms. The facility shall have written policies to govern use of decorative displays.

(i) Grooming and personal hygiene articles shall be readily accessible and shall be appropriate to the age, behavior, and clinical status of the resident.

(i) If access to potentially dangerous grooming aids or other personal items is contraindicated, a resident's personal articles may be kept under lock and key by the staff.

(ii) The professional staff must explain to the resident the conditions under which the articles may be used.

(iii) The treatment plan must also incorporate such restrictions and use.

(j) Good standards for grooming and personal hygiene including bathing, oral hygiene, care of hair and nails, and toilet habits shall be taught or maintained. Individual resident goals shall be written in the plans of treatment.

(k) Clothing shall be appropriate.

(i) Clothing shall be in good repair, of proper size, suited to the climate, and similar to clothing worn in the community.

(ii) Training and assistance in the selection and proper care of clothing shall be available as needed.

(iii) Training goals must be incorporated into the resident care plan.

(iv) An adequate amount of clothing shall be available to permit laundering, cleaning, and repair.

(l) Toilet and bathing facilities shall afford privacy with doors, toilet seats, partitions, and shower curtains.

(m) There shall be opportunity to participate in social events with persons of the opposite sex under adequate supervision.

(n) The resident shall retain possession of personal items such as tobacco products, cosmetics, watches, appliances, and money, except where possession may be restricted in the resident care plan.

(o) The resident shall have access to a personal funds account maintained by the business office or as specified by facility policy. Personal resource funds which a resident may have should be kept in this account.

R432-151-8. Construction and Physical Environment.

Refer to R432-5, Nursing Facility Construction.

R432-151-9. Administration and Organization.

(1) Program Director.

(a) The program director shall be a qualified health professional with a minimum of one year's experience in an established program for treatment of mental disease.

(b) The program director shall have a degree in administration, psychology, social work, nursing, or medicine and be licensed, certified or registered by the Utah Department of Commerce.

(c) The program director shall be appointed in writing by the governing body, and shall be accountable for the overall function of the program.

(d) The program director shall be accountable, whether by performance or by delegation, for the following functions:

(i) Develop written short-term and long-term goals for the treatment program;

(ii) Develop written policy and procedures, review them at least annually, and revise as necessary. Dates of review shall be documented;

(iii) Utilize quality assurance methods to assess efficiency and effectiveness of the program;

(iv) Supervise the development and implementation of each resident's individualized resident care plan;

(v) Supervise appropriate delivery of program modalities and services;

(vi) Integrate various aspects of the treatment program;

(vii) Maintain thorough clinical records for each resident;

(viii) Establish periodic reviews of each resident care plan;

(ix) Provide orientation for each new employee to acquaint them with the philosophy, organization, practices, and goals of the treatment program;

(x) Provide in-service training for any employee who has not achieved the desired level of competence;

(xi) Promote continuing education opportunities for all employees to update and improve their skills.

(2) Professional Staff.

(a) The facility shall have administrative, qualified health care professional, and support staff available to assess and address resident needs within its scope of services.

(b) Qualified professional staff includes psychiatrists, physicians, clinical psychologists, social workers, licensed nurses, and other health care professionals in sufficient number to provide services offered by the facility.

(c) When qualified professional staff members other than nursing staff are not available on a full- time basis, they shall be available on a part-time basis or by contract agreement to fulfill the requirements and needs of the treatment programs offered.

(d) The professional staff shall determine what qualifications are required to assume specific responsibilities.

(i) All members of the treatment team who have been assigned specific responsibilities shall be qualified for that position by training and experience.

(ii) Services shall be supervised by qualified, licensed personnel.

(e) All staff shall be licensed, certified or registered as required by the Utah Department of Commerce, Division of Occupational and Professional Licensing.

(i) The facility shall maintain documentation and copies of the license, certification, or registration for Department review.

(ii) Failure to ensure that employees are current for licensure, certification or registration may result in sanctions to the facility license.

(f) The facility shall have a Health Surveillance policy which conforms with R432-150-10(4).

(3) Orientation.

(a) These rules shall apply in addition to R432-150-10(5).

(b) All new employees shall be oriented to job requirements, personnel policies, and job training beginning the first day of employment.

(c) Documentation shall be signed by the employee and supervisor to indicate basic orientation has been completed during the first three months of employment.

(d) New employees shall receive orientation to the following:

(i) Administration, organization, policies and procedures, job training, responsibilities, and philosophy of the treatment program;

(ii) Resident rights;

(iii) Safety and security procedures for fire, disaster, and AWOL;

(iv) Symptoms of residents with maladaptive behaviors;

(v) Training how to respond appropriately to residents' sexual behavior;

(vi) Suicide precautions;

(vii) Procedures for first aid and medical emergencies;

(viii) Medical recording or charting; medication sheets if pertinent to the job assignment;

(ix) Reporting abuse, neglect and exploitation; and

(x) Quality assurance objectives.

(e) Registered nurses and licensed practical nurses will receive additional orientation to the following:

(i) Concepts of treatment for residents with mental disease;

(ii) Roles and functions of nurses in treatment programs for residents with mental disease;

(iii) Nursing policy and procedure manuals;

(iv) Psychotropic medications.

(4) Staff growth and development.

(a) These rules shall apply addition to R432-150-10(6).

(b) In-service sessions shall be planned in advance and shall be held at least quarterly.

(c) In-service education shall be available to all employees.

(i) Aides shall receive at least the following training:

(A) Basic health - to learn nursing skills in non-complicated nursing situations;

(B) Basic first aid;

(C) Communications;

(D) Introduction to human services;

(E) Understanding behavior - the resident's and the staff's; appropriate and inappropriate behaviors; responsibility to report undesirable behaviors to supervisors.

(ii) Licensed professional staff shall receive continuing education to keep informed of significant new developments and skills.

(iii) The facility should make use of opportunities outside the facility, such as workshops, institutes, seminars, and formal classes to supplement the facility's program of continuing education.

R432-151-10. Resident Evaluation.

(1) Evaluation - Recognition of mental health needs and intervention/treatment for residents should be considered, documented, and implemented.

(2) At least two of the following criteria, which can be verified through medical record documentation, shall be used to identify whether there is a need for evaluation of mental disease:

(a) When there are marked changes in the person's behavior;

(b) When behavioral and socially functional strengths become weaknesses, and to what extent this has occurred;

(c) When the mood of a resident is prolonged, exaggerated, and not in keeping with the circumstances of the attending situation and environment;

(d) When these abnormal exaggerated states extend over unusually long periods of time, whether lasting for days, weeks, or months; criteria for abnormal behavior involves depth, duration, and situations;

(e) When observations of behavior take into account the resident's postures, gestures, tone of voice, walk, ideas expressed, intellectual symptoms, emotions/emotional responses, and degree of motor activity;

(f) When there are special supervisory precautions recommended for the health and safety of the resident (situations such as suicidal; runaway; careless smoker; history of non-compliance with medication).

(3) Service patterns shall be determined using the Utah Level of Care Survey. The outcome may affect whether the facility should be considered an MDF.

R432-151-11. Admission.

(1) This section shall apply in addition to R432-150-13.

(2) Admission shall be determined by treatment program criteria and the needs of the residents.

(a) Admission criteria shall be clearly stated in writing in facility policies.

(b) Acceptance of a resident for treatment shall be based on the following:

(i) The resident requires treatment appropriate to the environmental restrictions and level of care provided by the facility;

(ii) The treatment required is appropriately provided within the program;

(iii) Alternative placement for less intensive care or less restrictive environment is not available.

(c) Admitting personnel will inform applicants during the intake process about the following:

(i) Services that are available;

(ii) Activities and goals of the treatment program;

(iii) Information shall be obtained during the intake process to facilitate development of a preliminary resident care plan.

R432-151-12. Resident Rights.

(1) These rules shall apply in addition to R432-150-12 and shall provide emphasis to resident rights.

(2) The facility shall support and protect the resident's basic rights as follows:

(a) being allowed to take responsibility for oneself;

(b) to be free to exercise judgement;

(c) to exist as an individual;

(d) to preserve unimpaired functions.

(3) These rights shall include the following:

(a) The resident has the right to receive treatment that does not create irreversible conditions.

(b) Residents shall be allowed to conduct private telephone conversations with family and friends.

(i) When therapeutic indications necessitate restrictions on visitors, telephone calls, or other communications, those restrictions shall be evaluated for therapeutic effectiveness by responsible staff at least every seven days.

(ii) Evaluations and determinations will be documented.

(iii) When limitations on visitors, telephone calls, or other communications are indicated for practical reasons due to expense of travel or long distance telephone calls such limitations shall be determined with participation of the resident and other persons involved.

(c) Each resident shall have the right to request the opinion of a consultant at his or her expense, or to request an in-house review of the individual treatment plan.

(d) Each resident shall be informed of his or her rights in a language and vocabulary the resident should understand.

(e) The resident shall have the right to be fully informed about the following:

(i) Rights and responsibilities of residents, including rules governing resident conduct and types of infractions that can result in restrictions or discharge.

(ii) Staff members who are responsible for resident care, their professional status, their staff relationship, and reasons for changes in staff;

(iii) Type of care, procedures, and treatment the resident will receive;

(iv) Use and disposition of special observation and audiovisual techniques;

(v) Risks, side effects, and benefits of medications and treatment procedures used;

(vi) Alternate treatment procedures that are available;

(vii) The right to refuse specific medications or treatment procedures and medical consequences as a result of such refusal;

(viii) Costs to be borne by the resident or family, and itemized cost, whenever possible, of services or treatment rendered;

(ix) Sources of reimbursement and any limitations placed on duration of services.

(f) The resident shall be informed immediately whenever a right is taken away and why. The circumstances to regain the right shall also be explained.

(g) Residents shall have the right to free exercise of religious beliefs and to participate in religious worship services. No individual will be coerced or forced into engaging in any religious activity.

R432-151-13. Resident Care Plans.

(1) These rules shall apply in addition to R432-150-13 and shall provide emphasis regarding resident care plans.

(2) The written resident care plan shall be based on a complete assessment of each resident, and should include the resident's physical, emotional, behavioral, social, recreational, legal, vocational, and nutritional needs.

(a) The facility staff shall obtain, review, and update assessment data.

(b) When information has been obtained by other facilities or agencies prior to the resident's admission, reports should be obtained which cover the required assessments.

(3) The preliminary resident care plan shall be completed within seven days of admission.

(a) Plans must be reviewed on a monthly basis for the first three months; thereafter at intervals determined by the interdisciplinary team but not to exceed every other month at approximately 60-day intervals.

(b) When a resident is discharged and readmitted, a new resident care plan must be developed.

(4) A physician or nurse practitioner shall assess each resident's physical health within five days prior to or within 48 hours after admission.

(a) A history and physical exam shall be done which includes appropriate laboratory work-up;

(b) a determination of the type and extent of special examinations, tests, or evaluations needed; and

(c) when indicated, a thorough neurological exam.

(5) A written comprehensive health assessment, compiled by professional staff members, shall include the following:

(a) Alcohol and drug history including the following:

(i) drugs used in the past;

(ii) drugs used recently, especially within the preceding 48 hours;

(iii) drugs of preference;

(iv) frequency with which each drug is used;

(v) route of administration of each drug;

(vi) drugs used in combination;

(vii) dosages used;

(viii) year of first use of each drug;

(ix) previous occurrences of overdose, withdrawal, or adverse drug reactions;

(x) history of previous treatment received for alcohol or drug abuse;

(b) Degree of physical disability and indicated remedial or restorative measures including:

(i) nutrition,

(ii) nursing,

(iii) physical medicine, and

(iv) pharmacologic intervention;

(c) Degree of psychological impairment and appropriate measures to be taken to relieve treatable distress or to compensate for non-reversible impairments;

(d) Capacity for social interaction and what appropriate rehabilitation or habilitation measures are to be undertaken, including group living experiences and other activities to maintain or increase the individual's capacity to independently manage daily living.

(e) A written emotional or behavioral assessment of each resident shall be entered in the resident's record. The assessment shall include the following:

(i) A history of previous emotional or behavioral problems and treatment;

(ii) The resident's current level of emotional and behavioral functioning;

(iii) A psychiatrist's evaluation within 30 days prior to or within one week after admission;

(iv) When indicated, a mental status assessment appropriate to the age of the resident;

(v) When indicated, psychological assessments which include intellectual and personality testing;

(vi) Other functional assessments such as language, self-care ability, and visual-motor coordination.

(f) A written social assessment of each resident shall include information about the following:

(i) Home environment;

(ii) Childhood history;

(iii) The resident's family circumstances; the current living situation; social, ethnic, and cultural background; sexual abuse;

(iv) Resident and family strengths and weaknesses;

(v) Military service history if applicable;

(vi) Financial resources;

(vii) Religion;

(g) A written activities assessment of each resident shall include information about current skills, talents, aptitudes, interests, and attitudes.

(h) A nutritional needs assessment shall be conducted and documented.

(i) When appropriate, a written vocational assessment of the resident shall include:

(i) Previous occupations including brief descriptions of the type of work, duration of employment, reasons for leaving, etc.;

(ii) Education history, including academic or vocational training;

(iii) Past experiences and attitudes toward work, present motivations, areas of interest, and possibilities for future education, training, or employment.

(j) When appropriate, a written assessment of the resident's legal status shall include:

(i) A history with information about competency, court commitment, prior criminal convictions, any pending legal actions;

(ii) The urgency of the legal situation;

(iii) How the individual's legal situation may influence treatment.

(k) The facility shall develop procedures which describe early intervention for symptoms that are life-threatening, are indicative of disorganization or deterioration, or may seriously affect the treatment process.

(l) The resident care plan shall comply with R432-150-13(4) and include the following:

(i) Treatment goals expressed as standards of achievement;

(ii) Services or treatment to be provided (based on assessments), at what intervals, and by whom;

(iii) Nutritional requirements;

(iv) Security precautions;

(v) Precautions and interventions for maladaptive behaviors;

(vi) Restrictions or loss of privileges, if any; factors to regain privileges;

(vii) Date the plan was initiated and dates of subsequent reviews;

(viii) Discharge planning.

R432-151-14. Active Treatment.

(1) Active treatment programs shall provide services reasonably expected to improve the resident's condition.

(2) Active Treatment services shall be offered in an environment that encompasses as many physical, interpersonal, cultural, therapeutic, rehabilitative, and habilitative components as necessary to achieve this purpose.

(3) Active treatment shall fulfill these objectives:

(a) To modify or minimize symptoms and conditions contributing to the need for treatment;

(b) To promote humane conditions, such as abilities to relate constructively, to care, and to fulfill human needs (affection, recognition, self-esteem, self-realization) within individual capabilities.

(c) If the planned or prescribed activities are primarily diversional in nature and thus provide only some social or recreational outlet for the resident, they shall not be regarded as active treatment to improve the resident's condition.

(d) Administration of a drug or drugs expected to significantly alleviate a resident's symptoms shall not of itself constitute active treatment.

(e) An active treatment program shall include the following components:

(i) Supervision by a physician.

(ii) An interdisciplinary professional evaluation.

(A) that is completed preferably before admission to the facility and definitely before the facility requests payment;

(B) that consists of complete medical diagnosis, social and psychological evaluations, and evaluation of the individual's need for psychiatric care;

(C) that is made by a psychiatrist (physician), a social worker, and other professionals, at least one of whom is qualified by at least one year of experience in treatment of residents with mental disease.

(iii) Periodic reevaluation (preferably on a quarterly basis, but not to exceed six month intervals) medically, socially, and psychologically by the staff involved in carrying out the resident's individual plan of care. This reevaluation must include review of the individual's progress toward meeting the plan objectives, appropriateness of the plan of care, assessment of continuing need for institutional care, and consideration of alternative methods or placement for care.

(iv) An individualized written plan of care that sets forth measurable goals or objectives stated in terms of desirable behavior and that prescribes an integrated program of activities, experiences, or therapies necessary for the individual to reach those goals or objectives.

(v) A post-institutional plan, as part of the individual plan of care, developed by the interdisciplinary team prior to discharge. This plan must include considerations for follow-up services, protective supervision if necessary, and other services available as needed in the resident's new environment.

(vi) The resident's regular participation in professionally developed and supervised activities, experiences, or therapies in accordance with the resident's individualized plan of care.

R432-151-15. Special Treatment Procedures.

(1) The facility shall identify special treatment procedures that require justification for use, and shall develop standards governing the use of these procedures consistent with resident rights and facility policy.

(2) Standards must include:

(a) Use of seclusion and time out;

(b) Prescription and administration of drugs;

(c) Use of involuntary medication;

(d) Use of procedures that involve physical risk for the resident;

(e) Use of procedures to treat maladaptive behaviors other than use of painful stimuli.

(3) Use of painful stimuli is not allowed.

(4) Indications for use of special treatment procedures shall be documented in the resident's record.

R432-151-16. Security.

(1) The facility shall follow its established written procedure in the event of resident AWOL or elopement so that the resident is returned to the facility in as short a time as possible.

(2) In all cases of AWOL, the program director, family or significant others, and appropriate agencies outside the facility (police, highway patrol, etc.) shall be notified according to written facility policy and procedure.

(3) There shall be documentation and review of all aspects of the AWOL.

(a) Notation of the AWOL must be in the resident record with more detail in an incident report kept by the administrator.

(b) These reports shall be made available for Department review upon request.

(4) Facility policy shall define the staff's escort responsibility, conduct, and liability.

R432-151-17. Industrial Therapy.

(1) Job placement may be an element of resident treatment and may be offered to provide therapeutic benefit on an individual basis.

(2) The goal of the industrial program shall include development of the resident's skills to deal with situations and problems which happen on the job, to accept responsibility, and to perform under direction of supervisors.

(3) No resident shall work as a substitute for staff.

(4) The job placement shall comply with local, state, and federal laws and regulations.

(5) Compensation.

(a) Residents who have a job shall receive pay commensurate with the economic value of the work.

(b) The resident shall receive appropriate compensation for labor performed away from the facility.

(c) Residents may be encouraged to perform personal housekeeping tasks without compensation as part of a rehabilitation or habilitation program.

R432-151-18. Transfer Agreements.

(1) This section shall apply in addition to R432-150-22.

(2) Each referral to and from the facility shall be governed by criteria that the most effective treatment in the least restrictive environment shall be available and accessible to a resident.

(a) The staff shall assess resident needs and provide necessary services within the facility according to its treatment capabilities.

(b) Services of other facilities shall be utilized when the resident requires care beyond the capabilities of the facility.

(3) Transfer agreements between facilities shall be obtained.

(a) Continuity of resident care shall be a joint responsibility between the facilities involved.

(b) Continuity of resident care is assured by providing:

(i) Reason(s) for the referral;

(ii) Information about the resident such as current treatment, medications, behavior, special precautions;

(iii) Current treatment objectives;

(iv) Suggestions for continued coordination between the receiving and referring facility;

(v) Information whom to contact, such as significant others or treatment coordinator.

(4) Residents shall not be transferred to another facility without prior contact with that facility. The referring treatment coordinator shall contact the receiving facility immediately or within 24 hours to insure temporary placement or admission.

(5) All information pertaining to clients shall be kept confidential and disclosed only by authorized staff to others directly involved in the resident's care and treatment except under the following conditions:

(a) When a resident's written informed consent is obtained to share specific information with appropriate parties;

(b) When an emergency exists with reason to believe there is imminent danger to the resident or others;

(c) When there is a court order to produce specific records;

(d) When the law enforcement agency requires release of specific pertinent information.

R432-151-19. Physician Services.

(1) This section shall apply in addition to R432-150-16.

(2) A physician should be responsible to monitor physical or medical needs; a psychiatrist must be responsible to monitor mental health needs and medications prescribed for these needs.

(3) General requirements.

(a) Each resident in need of psychiatric services shall be under the care of a psychiatrist licensed to practice in Utah.

(b) Each resident shall be permitted to choose a personal psychiatrist.

(c) Psychiatrist responsibilities.

(i) A psychiatrist must complete a psychiatric evaluation within 30 days prior to, or within one week after, admission.

(ii) Requirements for psychiatrist visits shall be the same as requirements for physician visits in R432-150-16. EXCEPT:

(A) Whenever possible, visits should be made on alternating months from physician visits.

(B) The psychiatrist shall see the resident whenever necessary but at least every other month at approximately 60-day intervals.

(C) The psychiatrist may have the option to establish and follow an alternate schedule of visits, but visits must not exceed four month intervals.

(D) A progress note shall be written in the resident's record at each visit.

R432-151-20. Nursing Services.

(1) Nursing services shall be available to residents who require such services.

(2) There shall be nursing staff available according to Table 1 to meet medical needs.

(a) There shall be 24-hour licensed nurse coverage.

(b) In a skilled nursing facility, a registered nurse shall be on duty at least sixteen hours per 24-hour period seven days a week to plan, assign, supervise or provide, and evaluate nursing care needs of the residents.

(3) All prescribed medications shall be administered by licensed personnel.

(4) In an intermediate care facility, if the health services supervisor is a licensed practical nurse, the registered nurse consultant shall be contacted within three days of a new admission to review the resident care plan.

(5) Schedules shall be maintained to indicate hours worked in the treatment program by regularly assigned and relief registered nurses, licensed practical nurses, and aides. The facility shall retain staff schedules and payroll records for at least a 12-month period.

(6) Aides performing housekeeping, dietary, or other functions shall maintain time records reflecting actual time spent in nursing care and time spent in other tasks. Time spent in other tasks will not be included in nursing care staffing ratios.

(7) Table 1 represents the minimum acceptable standards for hours of nursing care; additional staffing time may be necessary to accommodate variables such as staff illness or vacation, resident census, or status and behavior of residents.

                                                    TABLE 1

                            HOURS OF NURSING CARE PER SKILLED AND INTERMEDIATE LEVEL RESIDENT

    Type of           Total Nursing           Licensed Nursing
    Resident          Hours per Resident      Hours per resident
                       per 24 hrs.             per 24 hrs.
                      (RN + LPN + Aide)       (RN + LPN only)

    SKILLED           2.5 (150 minutes)       30% (45 minutes)(a)

   INTERMEDIATE       2.0 (120 minutes)       30% (36 minutes)(a)

     (a)  Shall not include director of nursing or health services supervisor in a facility with a resident census over 60.
                                                            

R432-151-21. Resident Records.

(1) These rules shall apply in addition to R432-150-25 and shall provide emphasis regarding resident records.

(2) Contents of the resident record shall describe the resident's physical and mental health status at the time of admission, the services provided, the progress made, and the resident's physical and mental health status at the time of discharge.

(3) The resident record shall contain the following:

(a) Identifying data that is recorded on standardized forms:

(i) the resident's name;

(ii) home address;

(iii) home telephone number;

(iv) date of birth;

(v) sex;

(vi) race or ethnic origin;

(vii) next of kin;

(viii) education;

(ix) marital status;

(x) type and place of last employment;

(xi) date of admission;

(xii) legal status, including relevant legal documents;

(xiii) date the information was gathered; and names and signatures of the staff members gathering the information.

(b) Information for review and evaluation of treatment provided to the resident.

(c) Documentation of resident and family involvement in the treatment program.

(d) Prognosis.

(e) Information on any unusual occurrences, such as treatment complications; accidents or injuries to or inflicted by the resident, procedures that place the resident at risk, AWOL.

(f) Physical and mental diagnoses using a recognized diagnostic coding system.

(g) Progress notes written by the physician, psychiatrist. nurse, and others involved in active treatment.

(i) progress notes should contain an on-going assessment of the resident.

(ii) Progress notes shall be written in the resident's record by each professional discipline at least monthly for the first three months and every other month thereafter at approximately 60 day intervals.

(iii) Progress notes shall be summaries of notes written at more frequent intervals, as determined by the condition of the resident or by facility policy, including the following:

(A) Documentation which supports implementation of the resident care plan and the resident's progress toward meeting these planned goals and objectives;

(B) Documentation of all treatment and services rendered to the resident;

(C) Chronological documentation of the resident's clinical course;

(D) Descriptions of changes in the resident's condition;

(E) Descriptions of resident response to treatment, the outcome of treatment, and the response of significant others to these changes.

(iv) All entries involving subjective interpretation of the resident's progress should be supplemented with a description of the actual behavior observed.

(v) Efforts should be made to secure written progress reports from outside sources for residents receiving services away from the facility.

(h) Reports of laboratory, radiologic, or other diagnostic procedures, and reports of medical or surgical procedures when performed;

(i) Correspondence and signed and dated notations of telephone calls concerning the resident's treatment.

(j) A written plan for discharge including information about the following:

(i) Resident's preferences and choices regarding location and plans for discharge;

(ii) Family relationships and involvement with the resident;

(iii) Physical and psychiatric needs;

(iv) Realistic, basic financial needs;

(v) Housing needs;

(vi) Employment needs;

(vii) Educational/vocational needs;

(viii) Social needs;

(ix) Accessibility to community resources;

(x) Designated and documented responsibility of the resident or family for follow-up or aftercare.

(k) A discharge summary signed by the physician and entered into the resident record within 60 calendar days from the date of discharge;

(i) In the event a resident dies, the discharge statement shall include a summary of events leading to the death.

(ii) Transfer to another facility for more than 72 hours shall cause the resident record to be closed with a discharge summary.

(A) A new record shall be initiated at the time of readmission.

(B) If the interval from discharge to readmission is less than 30 days, previous assessments may be reviewed and a copy brought forward from the prior record. The assessment must be identified either as an original or as a copy, and include updated information.

(l) Reports of all assessments.

(m) Consents for release of information, the actual date the information was released, and the signature of the staff member who released the information:

(i) The facility may release pertinent information to personnel responsible for the individual's care without the resident's consent under the following circumstances:

(A) In a life-threatening situation;

(B) When an individual's condition or situation precludes obtaining written consent for release of information;

(C) When obtaining written consent for release of information would cause an excessive delay in delivering treatment to the individual.

(ii) When information has been released under the conditions listed in R432-151-21(3)(m), the transaction shall be entered into the resident's record, including at least the following:

(A) The date the information was released;

(B) The person to whom the information was released;

(C) The reason the information was released;

(D) The reason written consent for release of information could not be obtained;

(E) The specific information released;

(F) The name of the person who released the information.

(iii) The resident shall be informed of the release of information as soon as possible.

(n) Pertinent prior records available from outside sources.

(4) The confidentiality of the records of substance abuse residents shall be maintained according to 42 CFR, Part 2, "Confidentiality of Alcohol and Drug Abuse Patient Records."

R432-151-22. Quality Assurance.

(1) This section shall apply in addition to R432-150-11.

(2) The quality, appropriateness, and scope of services rendered shall be reviewed and evaluated on at least a quarterly basis by an interdisciplinary quality assurance committee.

(3) A written report of findings from each meeting shall be submitted to the administrator and shall be available for review by the Department.

(4) Committee composition.

(a) Members of the quality assurance committee shall be appointed by name in writing by the administrator for a given term of membership.

(b) The committee shall have a minimum of three members with representation from at least three different licensed health care professions.

(5) Methodology for evaluation includes:

(a) Review and evaluation of active and closed resident records to assure that established policies and procedures are being followed;

(b) Facility policy and procedure will determine the method(s) to be followed for selection and review of the representative sample of active and closed records;

(c) Review and evaluation whether needed services were provided;

(d) Review and evaluation of coordination of services whenever appropriate through documentation of written reports, telephone consultation, or case conferences; and

(e) Review and evaluation of the resident plans of treatment for content, frequency of updates, and whether progress notes correspond to goals stated in the resident care plan.

R432-151-23. Housekeeping.

Housekeeping services shall comply with R432-150-26.

R432-151-24. Penalties.

Any person who violates any provision of this rule may be subject to the penalties enumerated in 26- 21-11 and R432-3-6 and be punished for violation of a class A misdemeanor as provided in 26-21-16.

KEY

health care facilities

Date of Enactment or Last Substantive Amendment

March 3, 1995

Notice of Continuation

March 28, 2012

Authorizing, Implemented, or Interpreted Law

26-21-5; 26-21-16


Additional Information

Contact

For questions regarding the content or application of rules under Title R432, please contact the promulgating agency (Health, Family Health and Preparedness, Licensing). A list of agencies with links to their homepages is available at http://www.utah.gov/government/agencylist.html or from http://www.rules.utah.gov/contact/agencycontacts.htm.