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 July 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 R432-152. Mental Retardation Facility.

As in effect on July 1, 2014

Table of Contents

R432-152-1. Legal Authority.

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

R432-152-2. Purpose.

It is the purpose of the rule to meet the intent of the Legislature as expressed in 26-21-13.5.

R432-152-3. Definitions.

(1) The definitions in R432-1-3 apply to this rule. In addition, the following special definitions apply:

(a) "Significantly Subaverage General Intellectual Functioning" is operationally defined as a score of two or more standard deviations below the mean on a standardized general intelligence test.

(b) "Developmental Period" means the period between conception and the 18th birthday.

(c) "Direct Care Staff" means personnel who provide care, training, treatment or supervision of residents.

(d) "QMRP" means a Qualified Mental Retardation Professional as defined in 42 CFR 483.403(a), 1997.

R432-152-4. Licensure.

These rules apply to all Intermediate Care Facilities for the Mentally Retarded licensed prior to July 1, 1990, pursuant to 26-21-13.5.

R432-152-5. Construction and Physical Environment.

Intermediate Care Facilities for the Mentally Retarded shall be constructed and maintained in accordance with R432-5 Nursing Facility Construction.

R432-152-6. Governing Body and Management.

(1) The licensee shall identify an individual or group to constitute the governing body of the facility.

(2) The governing body shall:

(a) exercise general policy, budget, and operating direction over the facility; and

(b) set the qualifications, in addition to the requirements of Title 58, Chapter 15, for the administrator of the facility.

(3) The licensee shall comply with all applicable provisions of federal, state and local laws, regulations and codes pertaining to health, safety, and sanitation.

(4) The licensee shall appoint, in writing, an administrator professionally licensed by the Utah Department of Commerce as a nursing home administrator. The administrator shall supervise no more than one licensed nursing care facility or mental retardation facility.

(a) The administrator shall be on the premises of the facility a sufficient number of hours in the business day, and at other times as necessary, to permit attention to the management and administration of the facility.

(b) The administrator shall designate, in writing, the name and title of a person to act as administrator in any temporary absence of the administrator. This designated person shall have sufficient power, authority, and freedom to act in the best interests of client safety and well-being. It is not the intent of this paragraph to permit an unlicensed de facto administrator to supplant or replace the designated, licensed administrator.

(5) The administrator's responsibilities shall be included in a written job description on file in the facility and available for Department review. The job description must include at least the following responsibilities:

(a) complete, submit, and file all records and reports required by the Department;

(b) function as liaison between the licensee, qualified mental retardation professional, and other supervisory staff of the facility;

(c) respond appropriately to recommendations made by the facility committees;

(d) assure that employees are oriented to their job functions and receive appropriate and regularly scheduled in-service training;

(e) implement policies and procedures for the operation of the facility;

(f) hire and maintain the required number of licensed and non-licensed staff, as specified in these rules, to meet the needs of clients;

(g) maintain facility staffing records for at least the preceding 12 months;

(h) secure and update contracts for required professional and other services not provided directly by the facility;

(i) verify all required licenses and permits of staff and consultants at the time of hire or effective date of contract;

(j) review all incident and accident reports and take appropriate action.

(6) The administrator, QMRP, and facility department supervisors shall develop job descriptions for each position including job title, job summary, responsibilities, qualifications, required skills and licenses, and physical requirements.

(a) The administrator or designee shall conduct and document periodic employee performance evaluations.

(b) All personnel shall have access to facility policy and procedure manuals and other information necessary to effectively perform duties and carry out responsibilities.

(7) The administrator shall establish policies and procedures for health screening that meet R432- 150-10-4.

R432-152-7. Client Rights.

(1) The administrator is responsible to ensure the rights of all clients. The administrator or designee shall:

(a) inform each client, parent, if the client is a minor, or legal guardian, of the client's rights and the rules of the facility;

(b) inform each client or legal guardian of the client's medical condition, developmental and behavioral status, attendant risks of treatment, and of the right to refuse treatment;

(c) allow and encourage individual clients to exercise their rights as clients of the facility, and as citizens of the United States, including the right to file complaints, voice grievances, and recommend changes in policies and procedures to facility staff and outside representatives of personal choice, free from restraint, interference, coercion, discrimination, or reprisal;

(d) allow individual clients to manage their financial affairs and teach them to do so to the extent of their capabilities;

(e) ensure that clients are not subjected to physical, verbal, sexual or psychological abuse or punishment;

(f) ensure that clients are free from unnecessary drugs and physical restraints and are provided active treatment to reduce dependency on drugs and physical restraints;

(g) provide each client with the opportunity for personal privacy and ensure privacy during treatment and care of personal needs;

(h) ensure the clients are not compelled to participate in publicity events, fund raising activities, movies or anything that would exploit the client;

(i) ensure that clients are not compelled to perform services for the facility and ensure that clients who do work for the facility are compensated for their efforts at prevailing wages commensurate with their abilities;

(j) ensure clients the opportunity to communicate, associate and meet privately with individuals of their choice, including legal counsel and clergy, and to send and receive unopened mail;

(k) ensure that clients have access to telephones with privacy for incoming and outgoing local and long distance calls except as contraindicated by factors identified within their individual program plans;

(l) ensure clients the opportunity to participate in social and community group activities and the opportunity to exercise religious beliefs and to participate in religious worship services without being coerced or forced into engaging in any religious activity;

(m) ensure that clients have the right to retain and use appropriate personal possessions and clothing, and ensure that each client is dressed in his or her own clothing each day; and

(n) permit a married couple both of whom reside in the facility to reside together as a couple.

(2) The administrator shall establish and maintain a system that assures a full and complete accounting of clients' personal funds entrusted to the facility on behalf of clients and precludes any commingling of client funds with facility funds or with the funds of any person other than another client.

(a) The client's financial record shall be available on request to the client or client's legal guardian.

(b) The licensee must ensure that all monies entrusted to the facility on behalf of clients are kept in the facility or are deposited within five days of receipt in an insured interest-bearing account in a local bank, credit union or savings and loan association authorized to do business in Utah.

(c) When the amount of a client's money entrusted to the facility exceeds $150, all money in excess of $150 must be deposited in an interest-bearing account as specified in R432-152-7(2)(b) above.

(d) Upon discharge of a client, all money and valuables of that client which have been entrusted to the licensee shall be surrendered to the client in exchange for a signed receipt. Money and valuables kept within the facility must be surrendered upon demand and those kept in an interest-bearing account must be obtained and surrendered to the client in a timely manner.

(e) Within 30 days following the death of a client, except in a medical examiner case, all money and valuables of that client which have been entrusted to the licensee must be surrendered to the person responsible for the client or to the executor or the administrator of the estate in exchange for a signed receipt. If a client dies without a representative or known heirs, the licensee must immediately notify in writing the local probate court and the Department.

(3) The administrator must promote communication, and encourage participation of clients, parents and guardians in the active treatment process. Facility staff shall:

(a) promote participation of parents (if the client is a minor) and legal guardians in the process of providing active treatment to a client unless their participation is unobtainable or inappropriate;

(b) answer communications from clients' families and friends promptly and appropriately;

(c) promote visits by individuals with a relationship to the client, such as family, close friends, legal guardians and advocates, at any reasonable hour, without prior notice, consistent with the right of the client's and other clients' privacy, unless the interdisciplinary team determines that the visit would not be appropriate for that client;

(d) promote visits by parents or guardians to any area of the facility that provides direct client care services to the client, consistent with right of that client's and other clients' privacy;

(e) promote frequent and informal leaves from the facility for visits, trips, or vacations; and

(f) notify promptly the client's parents or guardian of any significant incidents, or changes in the client's condition including, but not limited to, serious illness, accident, death, abuse, or unauthorized absence.

(4) The administrator is responsible to develop and implement written policies and procedures that prohibit abuse, neglect, or exploitation of clients.

(a) Any person, including a social worker, physician, psychologist, nurse, teacher, or employee of a private or public facility serving adults, who has reason to believe that any disabled or elder adult has been the subject of abuse, emotional or psychological abuse, neglect, or exploitation shall immediately notify the nearest peace officer, law enforcement agency, or local office of Adult Protective Services pursuant to Section 62A-3-302.

(i) The administrator must document that all alleged violations are thoroughly investigated and shall prevent further potential abuse while the investigation is in progress.

(ii) The administrator is responsible to report the results of all investigations within five working days of the incident. If the alleged violation is verified, the administrator shall take appropriate corrective action.

(iii) The administrator or designee shall plan and document annual inservice training of all staff on the reporting requirements of suspected abuse, neglect, and exploitation.

(b) A licensee shall not retaliate, discipline, or terminate an employee who reports suspected abuse, neglect, or exploitation for that reason alone.

R432-152-8. Facility Staffing.

(1) A Qualified Mental Retardation Professional must integrate, coordinate and monitor each client's active treatment program.

(2) Each client shall receive the professional services required to implement the active treatment program defined by each client's individual program plan.

(a) Professional program staff shall work directly with clients and with other staff who work with clients.

(b) The licensee shall have available enough qualified professional staff to carry out and monitor the various professional interventions in accordance with the stated goals and objectives of every individual program plan.

(c) Professional program staff shall participate in on-going staff development and training of other staff members.

(d) Professional program staff must be licensed and provide professional services in accordance with each respective professional practice act as outlined in Title 58. A copy of the current license, registration or certificate must be posted or maintained in employee personnel files.

(e) Those professional program staff designated as a human services professional who do not fall under the jurisdiction of state licensure, certification, or registration requirements, specified in Title 58, shall have at least a bachelor's degree in a human services field, including, but not limited to: sociology, special education, rehabilitation counseling, and psychology.

(f) If the client's individual program plan is being successfully implemented by facility staff, professional program staff meeting the qualifications of R432-152-8(2)(d) are not required:

(i) except for qualified mental retardation professionals;

(ii) except for the requirements of R432-152-8(2)(b) of this section concerning the facility's provision of enough qualified professional program staff; and

(iii) as otherwise specified by State licensure and certification requirements.

(3) There shall be responsible direct care staff on duty and awake on a 24-hour basis, when clients are present, to take prompt, appropriate action in case of injury, illness, fire or other emergency, in each defined residential living unit housing as follows:

(a) clients for whom a physician has ordered a medical care plan;

(b) clients who are aggressive, assaultive or security risks;

(c) more than 16 clients; or

(d) each unit of sixteen or fewer clients within a multi-unit building.

(4) There shall be a responsible direct care staff person on duty on a 24-hour basis, when clients are present, to respond to injuries and symptoms of illness and to handle emergencies in each defined residential living unit housing as follows:

(a) clients for whom a physician has not ordered a medical care plan;

(b) clients who are not aggressive, assaultive or security risks; or

(c) residential living units housing sixteen or fewer clients.

(5) Sufficient support staff must be available so that direct care staff are not required to perform support services to the extent that these duties interfere with the exercise of their primary direct client care duties.

(6) Clients or volunteers may not perform direct care services for the facility.

(7) The licensee shall employ sufficient direct care staff to manage and supervise clients in accordance with their individual program plans.

(a) Direct care staff shall meet the following minimum ratios of direct care staff to clients:

(i) for each defined residential living unit serving children under the age of 12, severely and profoundly retarded clients, clients with severe physical disabilities, or clients who are aggressive, assaultive, or security risks, or who manifest severely hyperactive or psychotic-like behavior, the staff to client ratio is 1 to 3.2 (2.5 hours per client per 24 hour period);

(ii) for each defined residential living unit serving moderately retarded clients, the staff to client ratio is 1 to 4 (2.0 hours per client per 24 hour period);

(iii) for each defined residential living unit serving clients who function within the range of mild retardation, the staff to client ratio is 1 to 6.4 (1.25 hours per client per 24 hour period).

(b) When there are no clients present in the living unit, a responsible staff member shall be available by telephone.

(8) Each employee shall have initial and ongoing training to include the necessary skills and competencies required to meet the clients' developmental, behavioral, and health needs.

R432-152-9. Volunteers.

(1) Volunteers may be included in the daily activities with clients, but may not be included in the staffing plan or staffing ratios.

(2) Volunteers shall be supervised by staff and oriented to client's rights and the facility's policies and procedures.

R432-152-10. Services Provided Under Agreements with Outside Sources.

(1) If a service required under this rule is not provided directly, the licensee shall have a written agreement with an outside program, resource, or service to furnish the necessary service, including emergency and other health care.

(2) The agreement shall:

(a) contain the responsibilities, functions, objectives, and other terms agreed to by both parties;

(b) provide that the licensee is responsible for assuring that the outside services meet the standards for quality of services contained in this rule.

(3) If living quarters are not provided in a facility owned by the licensee, the licensee remains directly responsible for the standards relating to physical environment that are specified in R432-5.

R432-152-11. Individual Program Plan.

(1) Each client shall have an individual program plan developed by an interdisciplinary team that represents the professions, disciplines or service areas that are relevant to:

(a) identifying the client's needs, as described by the comprehensive functional assessments required in R432-152-12(4); and

(b) designing programs that meet the client's needs.

(2) Interdisciplinary team meetings shall include the following participants:

(a) representatives of other agencies who may serve the client; and

(b) the client and the client's legal guardian unless participation is unobtainable or inappropriate.

(3) Within 30 days after admission, the interdisciplinary team shall prepare for each client an individual program plan that states the specific objectives necessary to meet the client's needs, as identified by the comprehensive assessment required by R432-152-12, and the planned sequence for dealing with those objectives.

(a) The program objectives shall:

(i) be stated separately, in terms of a single behavioral outcome;

(ii) be assigned projected completion dates;

(iii) be expressed in behavioral terms that provide measurable indices of performance;

(iv) be organized to reflect a developmental progression appropriate to the individual; and

(v) be assigned priorities.

(b) Each written training program designed to implement the objectives in the individual program plan shall specify:

(i) the methods to be used;

(ii) the schedule for use of the method;

(iii) the person responsible for the program;

(iv) the type of data and frequency of data collection necessary to be able to assess progress toward the desired objectives;

(v) the inappropriate client behavior, if applicable; and

(vi) provision for the appropriate expression of behavior and the replacement of inappropriate behavior, if applicable, with behavior that is adaptive or appropriate.

(c) The individual program plan shall also:

(i) describe relevant interventions to support the individual toward independence;

(ii) identify the location where program strategy information, which shall be accessible to any person responsible for implementation, can be found;

(iii) include, for those clients who lack them, training in personal skills essential for privacy and independence, including toilet training, personal hygiene, dental hygiene, self-feeding, bathing, dressing, grooming, and communication of basic needs, until it has been demonstrated that the client is developmentally incapable of acquiring them;

(iv) identify mechanical supports, if needed, to achieve proper body position, balance, or alignment, including the reason for each support, the situations in which each is to be applied, and a schedule for the use of each support;

(v) provide that clients who have multiple disabling conditions spend a major portion of each waking day out of bed and outside the bedroom area, moving about by various methods and devices whenever possible; and

(vi) include opportunities for client choice and self-management.

(4) A copy of each client's individual program plan shall be made available to all relevant staff, staff of other agencies who work with the client or legal guardian.

(5) As soon as the interdisciplinary team has formulated a client's individual program plan, each client shall receive a continuous active treatment program consisting of needed interventions and services in sufficient number and frequency to support the achievement of the objectives identified in the individual program plan.

(a) The facility shall develop an active treatment schedule that outlines the current active treatment program and that is readily available for review by relevant staff.

(b) Except for those facets of the individual program plan that may be implemented only by licensed personnel, each client's individual program plan shall be implemented by all staff who work with the client.

(6) The facility must document, in measurable terms, data and significant events relative to the accomplishment of the criteria specified in individual client program plans.

(7) The individual program plan shall be reviewed at least by the qualified mental retardation professional and revised as necessary; including situations in which the client:

(a) has successfully completed an objective or objectives identified in the individual program plan;

(b) is regressing or losing skills already gained;

(c) is failing to progress toward identified objectives after reasonable efforts have been made; or

(d) is being considered for training towards new objectives.

R432-152-12. Comprehensive Functional Assessment.

(1) Within 30 days after admission, the interdisciplinary team must complete accurate assessments or reassessments as needed to supplement the preliminary evaluation referred to in R432-152-14(3).

(2) The comprehensive functional assessment shall take into consideration the client's age and the implications for active treatment and shall:

(a) identify the presenting problems and disabilities and, where possible, their causes;

(b) identify a client's specific developmental strengths;

(c) identify a client's specific developmental and behavioral management needs;

(d) identify a client's need for services without regard to the actual availability of the services needed;

(e) include physical development and health, nutritional status, sensorimotor development, affective development, speech and language development, auditory functioning, cognitive development, social development, adaptive behaviors and independent living skills necessary for a client to be able to function in the community, and as applicable, vocational skills.

(3) The comprehensive functional assessment of each client shall be reviewed annually by the interdisciplinary team and updated as needed repeating the process required in R432-152-14.

R432-152-13. Human Rights Committee.

(1) The facility shall designate and use a specially constituted committee or committees consisting of members of the facility staff, parents, legal guardians, clients as appropriate, qualified persons who have experience or training in contemporary practices to change inappropriate client behavior, and persons with no ownership or controlling interest in the facility to:

(a) review, approve, and monitor individual programs designed to manage inappropriate behavior and other programs that, in the opinion of the committee, involve risks to client protection and rights;

(b) insure that these programs are conducted only with the written informed consent of the client, parent, if the client is a minor, or legal guardian; and

(c) review, monitor and make suggestions to the facility about its practices and programs as they relate to drug usage, physical restraints, time-out rooms, application of painful or noxious stimuli, control of inappropriate behavior, protection of client rights and funds, and any other area that the committee believes need to be addressed.

R432-152-14. Admissions, Transfers, and Discharge.

(1) The facility may only admit clients who need active treatment services.

(2) The facility shall base its admission decision on a preliminary evaluation of the client. The preliminary evaluation may be conducted or updated by the facility or an outside source and must determine that the facility can provide for the client's needs and that the client is likely to benefit from placement in the facility.

(3) A preliminary evaluation shall contain background information as well as current valid assessments of the following:

(a) functional developmental,

(b) behavioral status,

(c) social status, and

(d) health and nutritional status.

(4) Client transfers and discharges must comply with the requirements of R432-150-22.

R432-152-15. Client Behavior and Facility Practices.

(1) The facility shall develop and implement written policies and procedures for the management of conduct between staff and clients.

(2) The policies and procedures shall:

(a) promote the growth, development and independence of the client;

(b) address the extent to which client choice will be accommodated in daily decision-making, emphasizing self-determination and self-management to the extent possible;

(c) specify client conduct to be allowed or not allowed; and

(d) be available to all staff, clients, parents of minor children, and legal guardians.

(3) To the extent possible, clients shall participate in the formulation of these policies and procedures.

(4) Clients shall not discipline other clients, except as part of an organized system of self- government, as set forth in facility policy.

(5) The facility shall develop and implement written policies and procedures that govern the management of inappropriate client behavior.

(a) The policies and procedures shall be consistent with the provisions of R432-152-15(2).

(b) The policies and procedures shall:

(i) specify all facility-approved interventions to manage inappropriate client behavior;

(ii) designate these interventions on a hierarchy to be implemented, ranging from most positive or least intrusive, to least positive or most intrusive; and

(iii) ensure, prior to the use of more restrictive techniques, that less restrictive measures have been implemented with the results documented in the client's record.

(c) The policies and procedures shall address the following:

(i) the use of time-out rooms;

(ii) the use of physical restraints;

(iii) the use of chemical restraints to manage inappropriate behavior;

(iv) the application of painful or noxious stimuli;

(v) the staff members who may authorize the use of specified interventions; and

(vi) a mechanism for monitoring and controlling the use of such interventions.

(d) Interventions to manage inappropriate client behavior shall be employed with safeguards and supervision to ensure that the safety, welfare and civil and human rights of clients are adequately protected.

(e) A facility may not utilize p.r.n. or as needed programs to control inappropriate behavior.

(6) A client may be placed in a time-out room from which egress is prevented only if the following conditions are met:

(a) The placement is part of an approved systematic time-out program as required by R432-152- 15(5).

(b) The client is under the direct constant visual supervision of designated staff.

(c) The door to the room is held shut by staff or by a mechanism requiring constant physical pressure from a staff member to keep the mechanism engaged.

(d) Placement of a client in a time-out room shall not exceed one hour per incident of maladapted behavior.

(e) Clients placed in time-out rooms shall be protected from hazardous conditions including sharp corners and objects, uncovered light fixtures, and unprotected electrical outlets.

(f) The facility must maintain a log for each time-out room.

(7) A facility may employ physical restraints only:

(a) as an integral part of an individual program plan that is intended to lead to less restrictive means of managing and eliminating the behavior for which the restraint is applied;

(b) as an emergency measure, but only if absolutely necessary to protect the client or others from injury; or

(c) as a health-related protection prescribed by a physician, but only if absolutely necessary during the conduct of a specific medical or surgical procedure, or only if absolutely necessary for client protection during the time that a medical condition exists.

(8) A facility may apply emergency restraints for initial or extended use for no longer than 12 consecutive hours for the combined initial and extended use time period provided that authorization is obtained as soon as the client is restrained or stable.

(9) A facility may not issue orders for restraint on a standing or as needed basis.

(10) Facility staff must check clients placed in restraints at least every 30 minutes and maintain documentation of these checks.

(a) Restraints must be applied to cause the least possible discomfort and may not cause physical injury to the client.

(b) Facility staff must provide and document opportunity for motion and exercise for a period of not less than 10 minutes during each two hour period in which a restraint is employed.

(c) Barred enclosures shall not be more than three feet in height and shall not have tops.

(11) The facility shall not administer drugs at a dose that interferes with a client's daily living activities.

(a) Drugs used for control of inappropriate behavior must be approved by the interdisciplinary team and be used only as an integral part of the client's individual program plan that is directed specifically towards the reduction of and eventual elimination of the behaviors for which the drugs are employed.

(b) Drugs used for control of inappropriate behavior shall be:

(i) monitored closely, in conjunction with the physician and the drug review requirement; and

(ii) gradually withdrawn at least annually in a carefully monitored program conducted in conjunction with the interdisciplinary team, unless clinical evidence justifies that this is contraindicated.

R432-152-16. Physician Services.

(1) The facility shall ensure the availability of physician services 24 hours a day.

(a) The physician shall develop, in coordination with facility licensed nursing personnel, a medical care plan of treatment for a client if the physician determines that the client requires 24-hour licensed nursing care.

(b) The care plan shall be integrated into the client's program plan.

(c) Each client requiring a medical care plan of treatment shall be admitted by and remain under the care of a health practitioner licensed to prescribe medical care for the client.

(d) The facility shall obtain written orders for medical treatment (documented telephone orders are acceptable) at the time of admission.

(e) The facility shall provide or obtain preventive and general medical care as well as annual physical examinations of each client that at a minimum includes:

(i) an evaluation of vision and hearing;

(ii) immunizations, using as a guide the recommendations of the Public Health Service Advisory Committee on Immunization Practices or of the Committee on the Control of Infectious Diseases of the American Academy of Pediatrics;

(iii) routine screening laboratory examinations, as determined necessary by the physician, and special studies when needed; and

(iv) tuberculosis control in accordance with R388-804, Tuberculosis Control Rule.

(2) A physician shall participate in the establishment of each newly admitted client's initial individual program plan as required by R432-152-11.

(a) If appropriate, physicians shall participate in the review and update of an individual program plan as part of the interdisciplinary team process either in person or through written report to the interdisciplinary team.

(b) A physician shall participate in the discharge planning of clients under a medical care plan of treatment. In cases of discharge against medical advice, the facility must immediately notify the attending physician.

R432-152-17. Nursing Services.

(1) The facility shall provide nursing services in accordance with client needs. Nursing services shall include:

(a) participation as appropriate in the development, review, and update of an individual program plan as part of the interdisciplinary team process;

(b) the development, with a physician, of a medical care plan of treatment for a client if the physician has determined that an individual client requires such a plan; and

(c) for those clients certified as not needing a medical care plan, a documented quarterly health status review by direct physical examination conducted by a licensed nurse including identifying and implementing nursing care needs as prescribed by the client's physician.

(2) Nursing services shall coordinate with other members of the interdisciplinary team to implement appropriate protective and preventive health measures that include:

(a) training clients and staff as needed in appropriate health and hygiene methods;

(b) control of communicable diseases and infections, including the instruction of other personnel in methods of infection control; and

(c) training direct care staff in detecting signs and symptoms of illness or dysfunction, first aid for accidents or illness, and basic skills required to meet the health needs of the clients.

(3) Nursing practice and delegation of nursing tasks must comply with R156-31b-701, Delegation of Nursing Tasks.

(a) If the facility utilizes only licensed practical nurses to provide health services, there must be a formal arrangement for a registered nurse to provide verbal or on-site consultation to the licensed practical nurse.

(b) Non-licensed staff who work with clients under a medical care plan must be supervised by licensed nursing personnel.

(4) The administrator shall employ and designate, in writing, a nursing services supervisor.

(a) The nursing services supervisor may be either a registered nurse or a licensed practical nurse.

(b) The nursing services supervisor shall designate, in writing, a licensed nurse to be in charge during any temporary absence of the nursing services supervisor.

(5) The nursing services supervisor is responsible to ensure that the following duties are carried out:

(a) establish a system to assure nursing staff implement physician orders and deliver health care services as needed;

(b) plan and direct the delivery of nursing care, treatments, procedures, and other services to assure that each client's needs are met;

(c) review each client's health care needs and orders for care and treatment;

(d) review client individual program plans to assure necessary medical aspects are incorporated;

(e) review the medication system for completeness of information, accuracy in the transcription of physician's orders, and adherence to stop-order policies;

(f) instruct the nursing staff on the legal requirements of charting and ensure that a nurse's notes describe the care rendered and include the client's response;

(g) teach and coordinate rehabilitative nursing to promote and maintain optimal physical and mental functioning of the client;

(h) inform the administrator, attending physician, and family of significant changes in the client's health status;

(i) when appropriate, plan with the physician, family, and health-related agencies for the care of the client upon discharge;

(j) develop, with the administrator, a nursing services procedure manual including all procedures practiced in the facility;

(k) coordinate client services through appropriate quality assurance and interdisciplinary team meetings;

(l) respond to the pharmacist's quarterly medication report;

(m) develop written job descriptions for all levels of nursing personnel and orient all new nursing personnel to the facility and their duties and responsibilities;

(n) complete written performance evaluations for each member of the nursing staff at least annually; and

(o) plan or conduct documented training programs for nursing staff and clients.

R432-152-18. Dental Services.

(1) The facility shall provide or arrange for comprehensive dental diagnostic services and comprehensive dental treatment for each client.

(a) "Comprehensive dental diagnostic services" means:

(i) a complete extra-oral and intra-oral examination, using all diagnostic aids necessary to properly evaluate the client's oral condition, not later than one month after admission to the facility, unless the client's record contains an examination that was completed within twelve months before admission;

(ii) periodic examination and diagnosis performed annually, including radiographs when indicated and detection of manifestations of systemic disease; and

(iii) a review of the results of examination and entry of the results in the client's dental record.

(b) "Comprehensive Dental Treatment":

(i) the available emergency dental treatment on a 24-hour-a-day basis by a licensed dentist; and

(ii) dental care needed for relief of pain and infection, restoration of teeth, and maintenance of dental health.

(2) If appropriate, a dental professional shall participate in the development, review and update of the individual program plan as part of the interdisciplinary process, either in person or through written report to the interdisciplinary team.

(3) The facility shall provide education and training for clients and responsible staff in the maintenance of clients' oral health.

(4) If the facility maintains an in-house dental service, the facility shall keep a permanent dental record for each client with a dental summary maintained in the client's living unit.

(5) If the facility does not maintain an in-house dental service, the facility shall obtain a dental summary of the results of dental visits and maintain the summary in the client's record.

R432-152-19. Pharmacy Services.

(1) The facility shall provide routine and emergency drugs and biologicals.

(a) Drugs and biologicals may be obtained from community or contract pharmacists, or the facility may maintain a licensed pharmacy.

(b) Pharmacy services shall be under the direction and responsibility of a qualified, licensed pharmacist. The pharmacist may be employed full time by the facility or may be retained by contract.

(c) The pharmacist shall develop pharmacy service policies and procedures in conjunction with the administrator. Pharmacy policies shall address:

(i) drug orders;

(ii) labeling;

(iii) storage;

(iv) emergency drug supply;

(v) administration of medications;

(vi) pharmacy supplies; and

(vii) automatic-stop orders.

(2) The pharmacist, with input from the interdisciplinary team, shall review the drug regimen of each client at least quarterly.

(a) The pharmacist shall report any irregularities or errors in a client drug regimen to the prescribing physician and interdisciplinary team.

(b) The pharmacist shall develop and review a record of each client's drug regimen.

(3) An individual medication administration record shall be maintained for each client.

(4) As appropriate, the pharmacist shall participate in the development, implementation, and review of each client's individual program plan, either in person or through written report to the interdisciplinary team.

(5) The facility shall have an organized system for drug administration that identifies each drug up to the point of administration. The system shall assure that all medications and treatments:

(a) are administered in compliance with the physician's orders;

(b) are administered without error; and

(c) are administered by licensed medical or licensed nursing personnel.

(6) Clients shall be taught how to administer their own medications if the interdisciplinary team determines that self-administration of medications is an appropriate objective.

(a) The client's physician shall be informed of the interdisciplinary team's recommendation that self-administration of medications is an objective for the client.

(b) No client may self-administer medications until he or she demonstrates the competency to do so.

(7) Each telephone orders for medications shall be recorded immediately including the date and time of the order and the receiver's signature and title. The order must be countersigned and dated within 15 days by the person who prescribed the order.

(8) The facility shall maintain records of the receipt and disposition of all controlled drugs.

(a) Records of Schedule III and IV Drugs shall be maintained in such a manner that the receipt and disposition shall be readily traced.

(b) The facility shall, on a sample basis, periodically reconcile the receipt and disposition of all controlled drugs in schedules II through IV, drugs subject to the Comprehensive Drug Abuse Prevention and Control Act of 1970, 21 U.S.C. 801 et sec., as implemented by 42 CFR Part 308.

(9) The facility shall store drugs under proper conditions of sanitation, temperature, light, humidity, and security.

(a) All controlled substances shall be secured in a manner consistent with applicable state pharmacy laws.

(b) Provision shall be made for the separate secure storage of all non-medication items such as poisonous and caustic materials.

(c) Medication containers shall be clearly labeled.

(d) Only persons authorized by facility policy shall have access to medications.

(e) Medication intended for internal use shall be stored separately from medication intended for external use.

(f) Medications stored at room temperature shall be maintained within 59 - 80 degrees F (15 to 30 degrees C); and refrigerated medications shall be maintained within 36 - 46 degrees F (2 to 8 degrees C).

(g) Medications and similar items that require refrigeration shall be stored securely and segregated from food items.

(h) Medications shall be kept in the original pharmacy container and shall not be transferred to other containers. Drugs taken out of the facility for home visits, workshops, school, etc. shall be packaged and labeled in accordance with State law by a person authorized to package medications.

(i) Clients who have been trained to self administer drugs in accordance with R432-152-19(6) may have access to keys to their individual drug supply.

(10) Labeling of drugs and biologicals shall:

(a) be based on currently accepted professional principles and practices; and

(b) include the appropriate accessory and cautionary instructions, as well as the expiration date, if applicable.

(11) The facility shall remove from use outdated drugs and drug containers with worn, illegible, or missing labels.

(12) Drugs and biologicals packaged in containers designated for a particular client shall be immediately removed from the client's current medication supply if discontinued by the physician.

(13) Drugs may be sent with the client upon discharge if so ordered by the discharging physician provided that the drugs are released in compliance with Utah pharmacy law and rules and a record of the drugs sent with the client is documented in the client's health record.

(14) Discontinued individual client drugs supplied by prescription or those which remain in the facility after discharge or death of the client shall be destroyed within one month by the facility in the following manner:

(a) All drugs shall be destroyed by the facility in the presence of the staff pharmacist or consulting pharmacist and an appointed licensed nurse employed by the facility.

(b) If one or both of these persons are not available within the month, a licensed nurse and an individual appointed by the administrator may serve as witnesses.

(c) These appointments shall be rotated periodically among responsible staff members.

(d) The name of the client, the name and strength of the drug, the prescription number, the amount destroyed, the method of destruction, the date of destruction, and the signatures of the witnesses required above shall be recorded in the client's record or in a separate log and retained for at least three years.

(15) Unless otherwise prohibited under applicable federal or state laws, individual client drugs supplied in sealed containers may be returned, if unopened, to the issuing pharmacy for disposition provided that:

(a) no controlled drugs are returned;

(b) all such drugs are identified as to lot or control number; and

(c) the signatures of the receiving pharmacist and a licensed nurse employed by the facility are recorded and retained for at least three years in a separate log which lists the name of the client, the name, strength, prescription number, if applicable, the amount of the drug returned, and the date of return.

(16) An emergency drug supply appropriate to the needs of the clients served shall be maintained in the facility.

(a) The pharmacist in coordination with the administrator shall develop an emergency drug supply policy to include the following requirements:

(i) Specific drugs and dosages to be included in the emergency drug supply shall be listed.

(ii) Containers shall be sealed to prevent unauthorized use.

(iii) Contents of the emergency drug supply shall be listed on the outside of the container and the use of contents shall be documented by nursing staff.

(iv) The emergency drug supply shall be accessible to nursing staff.

(v) The pharmacist shall inventory the emergency drug supply monthly. Used or outdated items shall be replaced within 72 hours.

(17) The pharmacy shall furnish drugs and biologicals as follows:

(a) Drugs ordered for administration as soon as possible shall be available and administered within two hours of a physician's order.

(b) Anti-infectives shall be available and administered within four hours of a physician's order.

(c) All new drug orders shall be initiated within 24 hours of the order or as indicated by the physician.

(d) Prescription drugs shall be refilled in a timely manner.

(e) Orders for controlled substances shall be sent to the pharmacy within 48 hours of the order. The order sent to the pharmacy may be a written prescription by the prescriber, a direct copy of the original order, or an electronic reproduction.

R432-152-20. Laboratory Services.

(1) The facility must provide laboratory services in accordance with the size and needs of the client population.

(2) Laboratory services shall comply with the requirements of the Clinical Laboratory Improvement Amendments of 1988 (CLIA). CLIA inspection reports shall be available for Department review.

R432-152-21. Environment.

(1) Infection control procedures and reporting shall comply with R432-150-11(4).

(2) The facility shall have a safety committee which includes the administrator, QMRP, head housekeeper, chief of facility maintenance, and others as designated by facility policy.

(a) The safety committee must:

(i) review all incident and accident reports and recommend changes to the administrator to prevent or reduce reoccurrence;

(ii) review facility safety policies and procedures at least annually, and make appropriate recommendations; and

(iii) establish a procedure to inspect the facility periodically for hazards.

(b) Inspection reports shall be filed with the safety committee.

R432-152-22. Emergency Plan and Procedures.

(1) The facility shall develop and implement detailed written plans and procedures to meet all potential emergencies and disasters such as fire, severe weather, and missing clients.

(a) The facility shall periodically review and update written emergency procedures.

(b) The emergency plan must be made available to the staff.

(c) Facility staff must receive periodic training on emergency plan procedures.

(d) The emergency plan shall address the following:

(i) evacuation of occupants to a safe place within the facility or to another location;

(ii) delivery of essential care and services to facility occupants by alternate means;

(iii) delivery of essential care and services when additional persons are housed in the facility during an emergency;

(iv) delivery of essential care and services to facility occupants when the staff is reduced by an emergency; and

(v) maintenance of safe ambient air temperatures within the facility. Ambient air temperature of at least 58 degrees F. Must be maintained during emergencies.

(e) Emergency heating must be approved by the local fire department.

(2) The facility's emergency plan shall identify:

(a) the person with decision-making authority for fiscal, medical, and personnel management;

(b) on-hand personnel, equipment, and supplies and how to acquire additional help, supplies, and equipment after an emergency or disaster;

(c) assignment of personnel to specific tasks during an emergency;

(d) methods of communicating with local emergency agencies, authorities, and other appropriate individuals;

(e) the individuals who shall be notified in an emergency, in order of priority;

(f) method of transporting and evacuating clients and staff to other locations; and

(g) conversion of facility for emergency use.

(3) Emergency telephone numbers shall be posted near telephones accessible to staff.

(4) Simulated disaster drills shall be held semi-annually for all staff, in addition to fire drills. Documentation shall be maintained for Department review.

(5) The licensee and administrator shall develop a written fire emergency and evacuation plan in consultation with qualified fire safety personnel.

(a) The evacuation plan shall delineate evacuation routes and location of fire alarm boxes and fire extinguishers.

(b) The written fire-emergency plan shall include fire-containment procedures and how to use the facility alarm systems and signals.

(c) Fire drills and fire drill documentation shall be in accordance with Buildings Under the Jurisdiction of the State Fire Prevention Board, R710-4.

(d) The facility shall evacuate clients during at least one drill each year on each shift including:

(i) making special provisions for the evacuation of clients with physical disabilities;

(ii) filing a report and evaluation on each evacuation drill; and

(iii) investigating all problems with evacuation drills, including accidents, and take corrective action.

R432-152-23. Smoking Policies.

Smoking policies shall comply with UCA Title 26, Chapter 38, the "Utah Indoor Clean Air Act", and Sections 12-7.4 and 13-7.4 of the 1997 Life Safety Code.

R432-152-24. Pets in Long-Term Care Facilities.

(1) Each facility shall develop a written policy regarding pets in accordance with these rules and local ordinances.

(2) The facility shall adhere to the requirements of R432-150-21.

R432-152-25. Housekeeping Services.

(1) There shall be housekeeping services to maintain a clean, sanitary, and healthful environment in the facility.

(2) If the facility contracts for housekeeping services with an outside agency, there shall be a signed and dated agreement that details all services provided.

(3) The housekeeping service shall meet all the requirements of R432-150-26.

R432-152-26. Laundry Services.

The facility shall adhere to the requirements of R432-150-27.

R432-152-27. Maintenance Services.

The facility shall adhere to the requirements of R432-150-28.

R432-152-28. Dietary Services.

The facility shall adhere to the requirements of R432-150-24.

R432-152-29. Client Records.

(1) The facility shall develop and maintain a record keeping system that includes a separate record for each client with documentation of the client's health care, active treatment, social information, and protection of the client's rights.

(a) The facility shall keep confidential all information contained in the client's records, regardless of the form or storage method of the records.

(b) The facility shall develop and implement policies and procedures governing the release of any client information, including consents necessary from the client or client's legal guardian.

(c) All entries into client records must be legible, dated and signed by the individual making the entry.

(d) The facility shall provide a legend to explain any symbol or abbreviation used in a client's record.

(e) The facility shall insure each identified residential living unit has available on-site pertinent information of each client's record.

(f) Client's records shall be complete and systematically organized according to facility policy to facilitate retrieval and compilation of information.

(2) The client record department shall be under the direction of a registered record administrator, RRA, or an accredited record technician, ART. If an RRA or ART is not employed at least part time, the facility shall consult at least semi-annually with an RRA or ART according to the needs of the facility.

(3) Client records shall be safeguarded from loss, defacement, tampering, fires, and floods.

(4) Client records shall be protected against access by unauthorized individuals.

(5) Client records shall be retained for at least seven years after the last date of client care.

(a) Records of minors shall be retained as follows:

(i) at least two years after the minor reaches age 18 or the age of majority; and

(ii) a minimum of seven years.

(b) All client records shall be retained within the facility upon change of ownership.

(c) If a facility ceases operation, provision shall be made for appropriate safe storage and prompt retrieval of all client records, client indices, and discharges for the period specified.

(d) The facility may arrange storage of client records with another facility or may return client records to the attending physician who is still in the community.

R432-152-30. Respite Care.

(1) Mental Retardation Facilities may provide respite services that comply with the following requirements:

(a) The purpose of respite is to provide intermittent, time limited care to give primary caretakers relief from the demands of caring for a person.

(b) Respite services may be provided at an hourly rate or daily rate, but shall not exceed 14-days for any single respite stay. Stays which exceed 14 days are a mental retardation facility admission, and shall be subject to the requirements of this rule applicable to non-respite residents.

(c) The facility shall coordinate the delivery of respite services with the recipient of services, case manager, if one exists, and the family member or primary caretaker.

(d) The facility shall document the person's response to the respite placement and coordinate with all provider agencies to ensure an uninterrupted service delivery program.

(e) The facility must complete a service agreement to serve as the plan of care. The service agreement must identify the prescribed medications, physician treatment orders, need for assistance for activities of daily living and diet orders.

(f) The facility shall have written policies and procedures available to staff regarding the respite care clients which include:

(i) medication administration;

(ii) notification of a responsible party in the case of an emergency;

(iii) service agreement and admission criteria;

(iv) behavior management interventions;

(v) philosophy of respite services;

(vi) post-service summary;

(vii) training and in-service requirement for employees; and

(viii) handling personal funds.

(g) Persons receiving respite services shall be provided a copy of the Resident Rights documents upon initial day of service and updated annually.

(h) The facility shall maintain a record for each person receiving respite services which includes:

(i) Retention and storage of records shall comply with R432-152-29(3) and (4).

(ii) Confidentiality and release of information shall comply with R432-150-25(3).

(iii) The record shall contain the following:

(A) a service agreement;

(B) demographic information and resident identification data;

(C) nursing notes;

(D) physician treatment orders;

(E) records made by staff regarding daily care of the person in service;

(F) accident and injury reports; and

(G) a post-service summary.

(i) If a person has an advanced directive, a copy shall be filed in the record and staff informed.

R432-152-31. 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 Section 26-21-16.

KEY

health care facilities

Date of Enactment or Last Substantive Amendment

July 6, 1999

Notice of Continuation

March 28, 2012

Authorizing, Implemented, or Interpreted Law

26-21-5; 26-21-13.5


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.