016.05.07 Ark. Code R. § 005 - Licensing Standards for Center-Based Community Programs
INTRODUCTION
The licensing standards for DDS Community Programs have been developed to accomplish: normalization, least restrictive alternatives, affirmation of individuals' constitutional rights, provision of quality services, the interdisciplinary service delivery model, and the positive management of challenging behaviors.
Individual program plans shall be developed with the participation of the individual (18 years and older), as appropriate, the family, and representatives of the services required. The team is responsible for assessing needs, developing a plan to meet them, and contributing to its implementation.
NOTE: It is imperative that all Medicaid providers be enrolled with the Division of Medical Services and meet all enrollment requirements for the specific Medicaid Program for which they are enrolling as an Arkansas Medicaid Provider.
All standards are applicable to all services provided, unless otherwise specified.
Administrative Rules and Regulation Sub-Committee of the Arkansas Legislative Council:________________, 2007
Effective Date:________________, 2007
Implementation Date:________________, 2007
100
GOVERNINGBOARD/LEADERSHIP
Guiding Principles: The Governing Board/Leadership is that body of people who have been chosen by the corporation and vested with legal authority to be responsible for directing the business and affairs of the corporation. The responsibilities assured by each board member by their acceptance of membership are to provide effective and ethical governance leadership on behalf of its owners'/stakeholders' interest to ensure that the organization focuses on its purpose and outcomes for persons served, resulting in the organization's long-term success and stability.
The mission statement of the organization is based on the board's philosophical motivations, the services provided, and values of the members. The mission statement should identify the population to be served and the services to be provided. This description shall be nondiscriminatory by reason of sex, age, disability, creed, marital status, ethnic, or national membership.
NOTE: See Arkansas Code Ann. §§ 20-48-201 - 20-48-211 for examples of Board responsibilities.
NOTE: All information regarding your organization shall be readily available to staff, consumers, referral and funding sources, and the interested public at all times.
100.1 The Board
maintains a plan which shall identify annual and long range goals; the plan
should address community needs and target populations and should be reviewed
and updated annually.
A. Each Board will
develop a long-range plan of action for that organization. Examples include,
but are not limited to starting a new component, accessing individualized
services in the community, etc.
B.
Development of the plan shall include stakeholder input. The organization shall
maintain evidence of this input (i.e., letters of input, minutes of open
meetings, questionnaires, surveys, etc.)
C. The plan shall be reviewed annually and
updated as needed. The Board shall approve the C initiation, expansion, or
modification of the organization's program based on the needs of the community
and the capability of the organization to have an effect upon those needs
within its established goals and objectives. Note: The Board of
Directors, at its discretion, may assign this responsibility to
staff.
100.2
The Board shall demonstrate corporate social responsibility while maintaining
overall accountability for the administration and direction of the
organization, and shall delegate authority and responsibility to executive
leadership as deemed appropriate by the organization.
A. The organization shall identify:
1. Its leadership structure.
2. The roles and responsibilities of each
level of leadership.
B.
The identified leadership shall guide the following:
1. Establishment of the mission and direction
of the organization.
2. Promotion
of value/achievement of outcomes in the programs and services
offered.
3. Balancing the
expectations of both the persons served and other stakeholders, as defined by
the organization's policies.
4.
Financial solvency.
5. Compliance
with insurance and risk management requirements.
6. Ongoing performance improvement.
7. Development and implementation of
corporate responsibilities.
8.
Compliance with all legal and regulatory requirements.
C. The organization shall respond to the
diversity of its stakeholders with respect to:
1. Culture.
2. Age.
3. Gender.
4. Sexual orientation.
5. Spiritual beliefs.
6. Socioeconomic status.
7. Language.
102 The Board of Directors shall adopt a
mission statement to guide its activities and to establish goals for the
organization. The plan shall show evidence of participation by stakeholders
(evidence of open meeting, letters of input, survey, questionnaire,
etc.).
102.1 The Board of Directors
shall review the mission statement annually and shall make changes as necessary
to ensure the overall goals and objectives of the organization are reflected in
its mission.
103 The Board shall
create a mechanism for monitoring the decisions and operations of the
organization's programs which includes provisions for the periodic review and
evaluation of its program in relation to the program goals and shall.
Documentation of the review must be maintained on file for review.
Documentation may include but not be limited to Board minutes, reports,
etc.
104
Guiding Principle:
An organized training program for Board Members prepares them for their
responsibilities and assures that they are kept up-to-date on issues concerning
services offered to individuals with a developmental disability.
The Board shall maintain a general plan for Board training and will ensure that all items listed as required topics are covered in the required three-hour training.
A. Training
shall be provided for all Board members. Where the Board, because of its size,
lacks sufficient resources to conduct a Board training program, it will make
arrangements with another Board organization, agency, appropriate community
resource, or training organization to provide such training.
104.1 New Board Members
must participate in a minimum of three hours of training.
A. The following topics shall be required
during the first year of service
1. Functions
and Responsibilities of the Board
2. Composition and Size of the
Board
3. Legal
Responsibilities
4. Funding Sources
and Responsibilities,
5. Equal
Employment Opportunity/Affirmative Action,
6. Due Process
7. Ark. Code Ann. §§
25-19-101 -
25-19-107
"Freedom of Information Act of 1967"
8. U. S. C. § 12101 et. seq. "Title 42
THE PUBLIC HEALTH AND WELFARE-CHAPTER126-EQUAL OPPORTUNITY FOR INDIVIDUALS WITH
DISABILITIES--§ 12101. Findings and purpose"
9. DDS Service Policy 3004-I Maltreatment
Prevention, Reporting and Investigation;
10. DHS Policy 3002-I, Incident
Reporting.
11. DDS Administrative
Policy 1077
12. Chemical Right to
Know
13. The Health Insurance
Portability and Accountability Act (HIPAA)
Note: Possible Training resources include Aspen Publications, which has materials on Board and Administrator training.(www.aspenpublishers com) Resources or additional information should be obtained from DDS Licensure.
B. All Board new members as they begin
service shall participate in training. For those new Board members unable to
attend formally scheduled sessions, others who participate will disseminate the
information and document the transference of information shall be maintained.
(Note: Training may be documented in Board minutes or by Certificates of
Attendance.)
104.2 All
Board members shall complete a minimum of three hours annual training. Topics
may be selected by the Board of Directors and must be germane to the annual
plan. Training should be documented in Board minutes, by Certificates of
Attendance or sign in sheets from approved training.
104.3 Board members shall visit program
components of the organization during operating hours yearly.
A. All components of the organization must be
observed annually. If on-site observations to each physical location are not
feasible, at least 1 physical site from each program component must be observed
during the calendar year. The sites must be rotated yearly. Committees or
individual Board Members may be appointed to visit specific components and
report back to the other Board members on observations. Documentation of
reports in Board minutes shall be accepted as verification.
105 The organization
shall be a legally incorporated as a non-profit entity under the appropriate
federal, state or local statues as defined by its official Articles of
Incorporation and is registered to do business in the State of Arkansas.
A. The governing body should periodically
review the appropriateness of its governing documents. (Ark. Code Ann.
§§
20-48-201 -
20-48-211
). This shall include the organizations mission statement as filed with the
Secretary of State, and the Articles of Incorporation.
B. Any changes in the Articles of
Incorporation must be filed with the Secretary of State. This includes name
changes, amendments, or any reconstitution of the Governing Board. The
organization shall provide copies of any changes to DDS upon filing.
106 Bylaws shall be
established which govern the internal affairs of the organization and will
address each of the following areas:
A.
Composition of Board
1. This shall include
the number of Board members and the eligibility criteria (i. e. citizenship and
residency).
2. Selection of Board
members
a. Twenty percent (20%) consumer and
advocate representation on the board is required. (Note: defined as a
consumer, immediate family member of a consumer receiving services or has
received services at the organization or person in a qualified position that
advocates on behalf of the population served)
B. Term of membership:
1. Number of years as dictated by the
organization's Articles of Incorporation.
Note: It is recommended that membership on the governing body be rotated periodically
C. Replacement/removal of directors:
1. Refers to written criteria for Board
membership. Shall include any contingency to include but not be limited to
resignation of Board members and removal for non-attendance or other reasons.
D. Election of officers
and directors:
1. Describe the election
process
E. Duties and
responsibilities of Board officers are described in writing
1. Must document each position's purpose,
structure, responsibilities, authority, if any, and the relationship of the
advisory committee of Board members to other entities involved with the
organization.
F.
Appointment of committees, if applicable;
1.
Duties and functions of standing committees are described in writing, if
applicable.
G. Meetings
of the Board and its committees. All meetings shall be planned, organized, and
conducted in accordance with the organization's by-laws, policies, procedures,
applicable statutes, or other appropriate regulations. In no event shall the
full Board meet less than four times per year.
Note: The Board and its committees should meet with a frequency sufficient to discharge their responsibilities effectively.
H. The Board shall adopt written
procedures to guide the conduct of its meetings (i.e. Parliamentary Procedure,
Robert's Rules of Order, etc.);
I.
The Board shall maintain minutes of all actions taken by the Board for review
by DDS. Minutes shall accurately document all members present and any action
taken at the committee meetings to include any committee recommendations to the
Board.
1. Written minutes of previous Board
meetings should be made available by posting the adopted minutes in a location
convenient to the staff and individuals served, and made available to members
of the public upon request, as required under the Freedom of Information Act.
107 The Board
shall establish a procedural statement addressing nepotism as it relates to
Board and staff positions.
107.1
The Board shall establish a procedural statement addressing conflict of
interest
Note: The intent of the standard does not rule out a business relationship, but does call for the governing body to decide in advance what relationships are in the best interest of the organization.
A. Paid employees may not serve as Board
members.
B. Directors of
organizations may serve as non-voting ex officio Board members.
This DOES NOT include individuals receiving services.
108 Board meetings and public meetings shall
be conducted at a time and place which make the meetings accessible to the
public
A. Board meetings and Executive
sessions shall be announced to be in compliance with Ark. Code Ann.
§§
25-19-101 -
25-19-107
"Freedom of Information Act "
B.
All local media are to be notified one week in advance and a notice posted in a
prominent place by the organization. Called meetings shall be announced to the
local media and others who have requested notification at least two hours in
advance of meeting. Documentation of Notification may include newspaper
clippings, copy of item posted on bulletin board, radio contact forms,
etc.
D. If the meetings are held
each month at the same time and location, one notification and posting shall be
sufficient.
109 The
Board shall establish and approve policies and procedures which define
Eligibility criteria, Readmission criteria, and transition/discharge/exit
criteria
110 The Board shall
establish policy regarding financial oversight of the organization that
addresses the following:
A. The
organization's financial planning and management activities reflect strategic
planning designed to meet:
1. Established
outcomes for the persons served.
2.
Organizational performance objectives.
B written budgets are prepared that:
1. Include:
a. Reasonable projections of revenues and
expenditures.
b. Input from various
stakeholders, as required.
c.
Comparison to historical performance.
2. Are disseminated to:
a. Appropriate personnel.
b. Other stakeholders, as
appropriate.
C.
Actual financial results are:
1. Compared to
budget.
2. Reported to:
a. Appropriate personnel.
b. Persons served, as appropriate.
c. Other stakeholders, as required. 3.
Reviewed at least quarterly.
D. The organization identifies and reviews,
at a minimum:
1. Revenues and
expenses.
2. Internal and external:
a. Financial trends.
b. Financial challenges.
c. Financial opportunities.
d. Business trends.
e. Management information.
3. Financial solvency, with the
development of remediation plans, if appropriate.
200 PERSONNEL
PROCEDURES & RECORDS
201 The organization
shall maintain written personnel procedures that are approved by the Board and
are reviewed annually and which conform to state and federal laws, rules and
regulations.
NOTE: DDS SHALL NOT BECOME DIRECTLY INVOLVED IN PERSONNEL ISSUES UNLESS IT DIRECTLY IMPACTS CONSUMER CARE AND/OR SAFETY
201.1 Personnel procedures shall
be clearly stated and available in written form to employees as required by
42
U.S.C. §
2000a- 2000 h-6 "Title VI of
the Civil Rights Act of 1964" and U.S.C. § 1201 et. Seq. Americans with
Disabilities Act. These include but are not limited to:
A. Hiring and promotional procedures which
are nondiscriminatory by reason of sex, age, disability, creed, marital status,
ethnic, or national membership
B. A
procedure for discipline, suspension and/or dismissal of staff which includes
opportunities for appeal
C. An
appeals procedure allowing for objective review of concerns and
complaints
201.2 One
copy of the organization's Personnel procedures must be available in the
personnel or administrator's office. This copy must be readily accessible to
each employee.
201.3 The
organization shall develop and implement steps to voice grievances within the
organization. All grievances are subject to review by the Governing Board and
Court of Law (
29 U.S.C. §§
706(8),
794
-
794(b),
the "Rehabilitation Act of 1973 Section 504; 20 U.S.C. § 14000 et. Seq.
Section 615 "The Individual Disabilities Education Act".
A. All steps in the Grievance Procedure
should be time-bound and documented, including initial filing of
grievance.
201.4 The
organization shall develop and implement policies regarding whether
pre-employment and random drug testing will be required. If the organization
chooses to do drug testing they must establish guidelines for actions to be
taken when the drug test results are obtained, whether positive or negative.
(The organization may contact Arkansas Transit Association for further
information on drug testing)
202
Prior to employment, a completed job application mu st be submitted which
includes the following documents.
A. The
organization shall obtain and verify PRIOR to employment and maintain
documentation of the following:
1. The
credentials required
2. That
required credentials remain current
3. The applicant has completed a statement
related to criminal convictions
4.
A criminal background check has been initiated. Refer to DDS Policy
1087.
5. Declaration of truth of
statement on j ob application.
6. A
release to complete reference checks is signed and reference checks have been
completed
7. Results of
pre-employment drug screen, if required by organization.
NOTE: The items in 202A.5 and 202A. 6 WILL not be rated for employees hired prior to July 1, 1986.
B. The organization shall obtain and verify
within 30 days of employment and maintain documentation of the following:
1. Adult Maltreatment Central Registry Ark.
Code Ann. §§
5-28-201 has been
completed and the response is filed, or a second request submitted
2. Arkansas Child Maltreatment Central
Registry Ark. Code Ann. §§ 12-12-501 - 12-12-515 has been completed
and the response is filed, or a second request submitted. This check will
provide documentation that prospective employee's name do not appear on the
statewide Central Registry.
a. The
organization should adopt policy requiring subsequent criminal checks and
registry checks. The organizations that provide licensed daycare services must
adhere to Child Care Licensing regulations regarding Criminal background checks
and central registry checks.
Note: Staff holding professional licenses may be used in lieu of criminal background and adult and child maltreatment checks
3. TB skin test a.
Renewed yearly for ALL STAFF.
4.
Hepatitis B series or signed declination
5. The results of criminal background check
of the will be on file.
6.
Employment reference verification and signed release a. On file within thirty
(30) days of hire date
C. The organization shall obtain and verify
information in 202 A and B in response to information received (i.e., a
complaint is received that a person's license has lapsed or a person has been
convicted of a crime since they were hired).
203 The agency shall ensure sub-contractor's services
meet all applicable standards and will assess performance on a regular basis.
A. The organization shall ensure that
sub-contractors providing direct care services are in compliance with DDS
policies and must have verification and documentation of all applicable items
listed in 202A.
Note: Staff holding professional licenses may be used in lieu of criminal background and adult and child maltreatment checks.
B. The organization shall
demonstrate:
1. Reviews of all contract
personnel utilized by the organization that:
a. Assess performance of their
contracts
b. Ensure all applicable
policies and procedures of the organization are followed
c. Ensure they conform to DDS standards applicable to
the services provided
d. Are
performed annually
204 The organization shall develop, implement
and monitor policies and procedures for staff recruitment and retention so that
sufficient staff is maintained to ensure the health and safety of the
individuals served, according to their plans of care.
A. The organization must ensure there are an
adequate number of personnel to:
1. Meet the
established outcomes of the persons served.
2. Ensure the safety of persons
served.
3. Deal with unplanned
absences of personnel.
4. Meet the
performance expectations of the organization.
B. The organization shall demonstrate:
1. Recruitment efforts.
2. Retention efforts.
3. Identification of any trends in personnel
turnover.
205
The organization shall develop and implement procedures governing access to
staff members' personnel file.
A. An access
sheet shall be kept in front of the file to be signed and dated by those who
are examining contents, with stated reasons for examination.
B. The policy shall clearly state who, when,
and what is available concerning access to personnel files and be in compliance
with the Federal Privacy Act and Freedom of Information Act. At no time shall
the policy allow access that violates the provisions of the Health Insurance
Portability and Accountability Act (HIPAA).
206 The organization shall develop written
job descriptions which describe the duties, responsibilities, and
qualifications of each staff position.
A. The
organization shall:
1. Identify the skills
and characteristics needed by personnel to:
a. Assist the persons served in the
accomplishment of their established outcomes.
b. Support the organization in the
accomplishment of its mission and goals.
2. Assess the current knowledge and
competencies of personnel at least annually.
3. Provide for the orientation and training
needs of personnel.
4. Provide the
resources to personnel for learning and growth.
5. Identify the supervisor of the position
and the positions to be supervised.
B. Performance management shall include:
1. Job descriptions that are reviewed and/or
updated annually.
2. Promotion
guidelines.
3. Job posting
guidelines.
4. Performance
evaluations for all personnel directly employed by the organization shall be:
a. Based on measurable objectives that tie
back to specific duties as listed in the Job Description.
b. Evident in personnel files.
c. Conducted in collaboration with the direct
supervisor with evidence of input from the personnel being evaluated.
d. Used to:
1. Assess performance related to objectives
established in the last evaluation period.
2. Establish measurable performance
objectives for the next year.
e. Performed annually.
207 The organization
shall establish employment practices for students, interns, volunteers and
trainees utilized by the organization who have regular, routine contact with
consumers.
A. The organization shall define
who has and what constitutes regular, routine contact with consumers.
B. If students, interns, volunteers or
trainees are used by the organization, the following shall be in place:
1. A signed agreement.
a. If professional services are provided,
standards or qualifications applied to comparable positions must be
met.
2. Identification
of:
a. Duties.
b. Scope of responsibility.
c. Supervision.
3. Orientation and training.
4. Assessment of performance.
5. Policies and written procedures for
dismissal.
6. Confidentiality
policies.
7. Background checks,
when required.
300
STAFF TRAINING
Guiding Principle: Staff Training is an organized program which prepares new employees to perform their assigned duties competently and maintains and improves the competencies of all employees. Staff Training for the organization shall provide an on-going mechanism for the evaluation of the impact of the program on services provided to individuals with developmental disabilities. This should include service outcomes to individuals, meeting of the organization objectives and overall mission, compliance with regulatory and professional standards and positive changes in staff performance and attitudes. The needs of individuals with developmental disabilities require the efforts of competent personnel who continually seek to expand knowledge in their fields.
300.1 The organization shall
establish a policy designating one or more employees to be responsible for
coordinating in-service staff training.
A.
The employee responsible for staff training should have broad knowledge of care
and service needs of persons with developmental disabilities, and possess the
necessary skills to organize and implement an in-service training program as
evidenced in resume.
301 The organization shall establish a
written training plan. This plan must show how the training will be provided
and the areas covered. If training occurs during regularly scheduled service
hours, documentation must be present that individual staff ratios were
maintained.
301.1 ALL Personnel
shall receive initial and annual competency-based training to include, but not
limited to:
A. Health and safety practices.
1. First Aid (review yearly, renew as
required by American Heart Association, Red Cross, or Medic First Aid,
applicable for ALL direct service personnel)
a. There is immediate access to:
(1) First aid expertise.
(2) First aid equipment and supplies.
(3) Emergency information on the:
(a) Persons served.
(b) Personnel.
b. CPR (Initial Certification, renew as
required by American Heart Association or Red Cross).
1. ALL direct care staff members, including
bus and van drivers, shall be trained and certified to provide CPR, unless they
are deemed physically incapable of performing this task by a licensed medical
professional, such as a nurse or doctor. Documentation must be maintained in
the personnel file. Staff that are physically incapable of performing CPR must
complete and have documentation of CPR training.
2. The organization shall develop and monitor
policy regarding timeframe for CPR certification after hire date. (Timeframe
not to exceed 90 days)
c. Medication - Implications, Side Effects,
Legality of Administering medication
d. Infection Control Plan
1. The organization shall implement an
infection control plan that includes:
(a) .
Training regarding the prevention and control of infections and communicable
diseases for:
(1) . Persons served, when
applicable.
(2).
Personnel.
(b). The
appropriate use of standard or universal precautions by all
personnel.
(c) . Procedures that
specify that employees with infectious diseases shall be prohibited from
contact with individuals until a physician's release has been provided to the
organization director.
B. Identification of unsafe environmental
factors.
1. Issues Regarding Prevention of
Acquired Immunodeficiency Syndrome(AIDS) , Hepatitis B (HIV) and other
Bloodborne Pathogens
C.
Emergency procedures and Evacuation Procedures
1. Emergency and Disaster
Preparedness
2. Fire and Tornado
Drills, Violence in the Workplace, Bomb Threats, Earthquake
D. General Information
1. Overview of Department of Human
Services
2. Overview of
Developmental Disabilities Services
3. Philosophy, Goals, Programs, Practices,
Policies, and Procedures of Local Organization
4. HIPPA policies and procedures
5. Orientation to history of Developmental
Disabilities
6. Current Issues
Affecting Individuals with Developmental Disabilities
7. Introduction to Principles of
Normalization
8. Procedures for
Incident Reporting
9. Appeals
Procedure for Individuals Served by the Program
10. Introduction to Behavior Management
11. Community Integration
Training.
E. Legal
1. Overview of Federal and State Laws related
to serving individuals with a developmental disability (NOTE: Laws may change
every 2 years)
2. Legal Rights of
Individuals with Developmental Disabilities
3. Application of Federal Civil Rights Laws
to Persons with AIDS or HIV related condition (or those who may be perceived to
have AIDS or HIV related conditions).
4. Ark. Code Ann. §§
6-41-201 -
6-41-222 --The
Children With Disabilities Act of 1973
5. Ark. Code Ann. §§
20-48-201 -
20-48-211;
--Arkansas Mental Retardation Act
6. Ark. Code Ann. §§
25-19-101 -
25-19-107
--Freedom of Information Act
7.
Ark. Code Ann. §§
28-65-101
-
28-65-109;
--Guardians Generally
8. Ark. Code
Ann. §§
5-28-101 -
5-28-109; --Abuse of
Adults
9. Ark. Code Ann.
§§ 12-12-501 - 12-12-515; --Arkansas Child Maltreatment Act
10. Ark. Code Ann. §§
25-2-104,
25-2-105,
25-2-107, Type
1, Type 2 and Type 4 Transfers
11.
Ark. Code Ann. §§
25-10-102
-
25-10-116;
Department of Health and Human Services General Provisions
12. Ark. Code Ann. §§
20-78-215
-- Child sexual abuse - Federal funds
13. U.S.C. § 12101 et. seq. -Americans
with Disabilities Act of 1990 P.
L. 101-336
14.20 U.S.C. §
14000 et. seq. (Part B and Part C -- P. L. 94-142 Individuals with Disability
Education (IDEA) P.L. 99-457 Part C
15.
42U.S.C.
§
2000a- 2000 h-6-- Title VI of the
Civil Rights Act of 1964
16.
29 U.S.C. §§
706(8) Rehabilitation Act of
1973, 794 - 794(b) Section 504
17.
5 U.S.C. §
552a -- Federal Privacy Act
18.
42 U.S.C. §§
6000 -- Developmentally Disabled Assistance
& Bill of Rights Act of 1984
19. Deficit Reduction Act and False Claims
Act
Note: Documentation of prior training of individual staff may be used for the required topics, if this situation is addressed in the organization's training plan.
301.2. Documentation of prior training of
individual staff may be used for the required topics, if this situation is
addressed in the organization's training plan.
301.3. Training Requirements for
professional/administrative staff as defined by the agencies policies
1. Fifteen (15) hours minimum completed
within ninety (90) days of employment (does not include First Aid and CPR
training)
301.4.
Training Requirements for direct care staff
1.
Fifteen (15) hours minimum completed within (30) days of employment (does not
include First Aid and CPR training)
NOTE: In addition to those areas addressed in these standards, other identified needs based on staff input should be addressed.
NOTE: SEE APPENDIX B for Training Resources
301.5 In addition to the
requirements in Section 301.1-301.4, all direct care staff shall receive annual
in-service training and/or continuing education as follows:
A. Minimum of fifteen (15) hours of training
annually, including the required topics.
1.
Topics must be applicable to the job and are to be chosen by the organization
based on identified needs. Topics may be a combination of required and job
specific training.
2. Behavior
management techniques/programming
B. Prior to beginning service delivery,
direct care staff must be trained in the individual's plan of care and specific
health and safety needs (i.e., medication, positive behavior programming,
etc.). Documentation of the training shall be maintained in the staffs
personnel file and shall be evidenced by the signatures of the trainer and the
direct care staff the date the training was provided and the specific
information covered.
302
Annual in-service training and/or continuing education for Managerial Staff as
defined by the agencies policies.
A. Topics
Chosen must be related to the job performed.
B. Minimum of fifteen (15) hours of training
required yearly, from the following list:
1.
Issues Regarding Prevention of Acquired Immunodeficiency Syndrome (AIDS),
Hepatitis B (HIV) and other Blood Borne Pathogens
2. Application of Federal Civil Rights Laws
to persons with AIDS or HIV related Conditions (or those who may be perceived
to have AIDS or HIV Related conditions)
3. Management of Non-Profit
Organizations
4. Procedures for
Preventing and Reporting Alleged Maltreatment of Children and Adults
5. Effective Supervision/Management
Techniques /-
6.
Selection and Interviewing
7. Fair
Employment Principles
8.
Performance Evaluation
9.
Techniques for Working with the Board
10. Overview of Federal and State Laws
Related to Serving Individuals with a Developmental Disability (up-dated every
two (2) years)
11. Federal and
State Laws:
a. Ark. Code Ann. §§
6-41-201 -
6-41-222 --The
Children With Disabilities Act of 1973
b. Ark. Code Ann. §§
20-48-201 -
20-48-211
-Arkansas Mental Retardation Act
c.
Ark. Code Ann. §§
25-19-101 -
25-19-107
--Freedom of Information Act
d.
Ark. Code Ann. §§
28-65-101
-
28-65-109;
--Guardians Generally
e. Ark. Code
Ann. §§
5-28-101 -
5-28-109; --Abuse of
Adults
f. Ark. Code Ann.
§§ 12-12-501 - 12-12-515; --Arkansas Child Maltreatment Act
g. Ark. Code Ann. §§
25-2-104,
25-2-105,
25-2-107, Type
1, Type 2 and Type 4 Transfers
h.
Ark. Code Ann. §§
25-10-102
-
25-10-116;
Department of Health and Human Services General Provisions
i. Ark. Code Ann. §§
20-78-215
-- Child sexual abuse - Federal funds
j. U.S.C. § 12101 et. seq. --Americans
with Disabilities Act of 1990 P.
L. 101-336
k.20 U.S.C. §
14000 et. seq. (Part B and Part C -- P. L. 94-142 Individuals with Disability
Education (IDEA) P.L. 99-457 Part C
l.
42U.S.C.
§
2000a- 2000 h-6-- Title VI of the
Civil Rights Act of 1964
m.
29 U.S.C. §§
706(8) Rehabilitation Act of
1973, 794 - 794(b) Section 504
n.
5 U.S.C. §
552a -- Federal Privacy Act
C. Managerial
Staff, as defined by the agencies policies, who have been with the agency for 2
or more years may select from the above list or choose from continuing
education courses.
Note: SEE APPENDIX B for Training Resources
303 All employees who provide
transportation services shall have a minimum of six (6) hours of training
scheduled within thirty (30) days of employment and completed within
seventy-five (75) days of employment. This training shall be in addition to the
required new employee training listed in Section 301
A. Required topics are:
1. Passenger safety and emergency
procedures
2. Vehicle maintenance
programs
3. Defensive Driving
B. Other recommended
topics are:
1. Understanding Mobility needs
for Passengers
2. Emergency
Procedures for Rural Drivers
C. Possible training sources:
1. Arkansas State Police
2. Arkansas Transit Association
3. Local School District
400
Individual/Parent/Guardian Rights
Guiding Principle: The organization shall implement a system of rights that nurtures and protects the dignity and respect of the persons served. The organization shall protect and promote the rights of the persons served. This commitment shall guide the delivery of services and ongoing interactions with the persons served.
401 The organization shall implement policies
promoting the following rights of the persons served and ensures all
information is transmitted to the person served and/or their parent or guardian
in a manner and fashion that is clear and understandable:
A. Being free from physical or psychological
abuse or neglect, retaliation, humiliation, and from financial
exploitation.
B. Having control
over their own financial resources.
C. Being able to receive, purchase, have and
use their own personal property.
D.
Actively and meaningfully making decisions affecting their life.
E. Access to information pertinent to the
person served in sufficient time to facilitate his or her decision
making.
F. Having
Privacy.
G. Being able to associate
and communicate publicly or privately with any person or group of people of the
individual's choice.
H. Being able
to practice the religion of their choice.
I. Being free from the inappropriate use of a
physical or chemical restraint, medication, or isolation as punishment, for the
convenience of the provider or agent, in conflict with a physician's order or
as a substitute for treatment, except when a physical restraint is in
furtherance of the health and safety of the individual.
J. Not being required to work without compensation,
except when the individual is living and being provided services outside of the
home of a member of the individual's family, and then only for the purposes of
the upkeep of their own living space and of common living area and grounds that
the individual shares with others.
K. Being treated with dignity and
respect.
L. Receiving due process.
M. Having access to their own
records, including information about how their funds are accessed and utilized
and what services were billed for on the individual's behalf
N. Informed consent or refusal or expression
of choice regarding:
1. Service
delivery.
2. Release of
information.
3. Concurrent
services.
4. Composition of the
service delivery team.
5.
Involvement in research projects, if applicable.
O. Access or referral to legal entities for
appropriate representation.
P.
Access to self-help and advocacy support services.
Q. Adherence to research guidelines and
ethics when persons served are involved, if applicable.
R. Investigation and resolution of alleged
infringement of rights.
1. The agency
maintains documentation of all investigations of all alleged violations of
individual's rights and actions taken to intervene in such situations. The
organization ensures that the individual has been notified of their right to
appeal according to DDS Policy 1076.
R. Rights and responsibilities of
citizenship
S. Other legal and
constitutional rights
402 Records of persons served
A. The organization shall maintain complete
records and treat all information related to persons served as
confidential.
B. The organization
shall create policy for the sharing of confidential billing, utilization,
clinical and other administrative and service-related information, and the
operation of any Internet-based services that may exist.
1. Information that is used for reporting or
billing shall be shared according to confidentiality guidelines that recognize
applicable regulatory requirements such as the Health Insurance Portability and
Accountability Act (HIPAA).
C. The organization shall comply with its own
service delivery design for the development of the record. Electronic records
are acceptable. Electronic records must meet the following:
1. Format must meet DHHS/ Office of Systems
and Technology standards and be acceptable by the Department.
2. Files must be uniformly organized and
easily accessible.
D.
The location of the case record, and the information contained therein, shall
be controlled from a central location as defined by the agency, shall be stored
under lock and with protection against fire, water, and other hazards in an
accessible location at each site. The organization shall establish and
implement policies and procedures to ensure direct care staff have adequate
access to the individual's current plan of care and other pertinent information
necessary to ensure the individual's health and safety (i.e., name and
telephone number of physician, emergency contact information, insurance
information, etc.). If services are not provided at the central location, at a
minimum the following information must be maintained at the service delivery
site:
1. Access Sheet
2. Face Sheet to include emergency contact
information and pertinent health information
3. Signed consent for emergency
treatment
4. A copy of the
consumer's current program plan
5.
Copies of current progress reports
6. Documentation of service provision to
include date, time in and time out, summary of activities, and signature of
implementor for the period of the current program plan
E. Records maintained on computer shall be
backed up at a minimum weekly and the duplicate copy shall be stored under lock
and with protection against fire, water, and other hazards.
F. A list of the order of the file
information shall either be present in each individual case file or provided to
DDS Licensure staff upon request. The documents in active individual case
records should be organized in a systematic fashion. An indexing and filing
system shall be maintained for all case records.
G. Each organization shall have written
procedures to cover destruction of records. Procedures must comply with all
state and federal regulations
H.
Access sheets shall be located in the front of the file to maintain
confidentiality according to
5 U.S.C. §
552a. If there is a signed release for a list
of authorized persons to review the file, only those not listed will need to
sign the access sheet with date, title, reason for reviewing, and signature. If
there is not a signed release for authorized persons to review, all persons
must sign the access sheet whenever the file is reviewed or any material is
placed in the file.
402.1
DDS staff shall have access upon demand to all individual case records as
designated in Ark. Code Ann. §§
20-48-201 -
20-48-211,
DDS Policy 1090, Licensing Policy for Center-Based Community
Services.
402.2 The organization
shall ensure confidentiality of all case records is maintained. Access to case
records shall be limited to Individual/Parent/Guardian, professional staff
providing direct services to the person served, plus such other individuals as
may be authorized administratively or by the consumer. All authorizations
either those listed above or others shall be in writing.
A.. Access to individual files shall be
limited to only those staff members who have a need to know information
contained in the records of persons served.
B. Individual service records shall be
maintained according to provisions of the Privacy Act:
C. Access to computer records shall be
limited to those authorized to view records
D. The organization shall ensure the right of
all persons served to access their own records.
E. The organization shall ensure that all
persons served know how to access their records and the organization ensures
that appropriate equipment is available.
F. An organization shall not prohibit the
persons served from having access to their own records, unless a specific state
law indicates otherwise. It is recognized that the organization must comply
with HIPAA regulations as it relates to specific information that cannot be
disclosed to persons served without authorization (i.e., psychotherapy
notes).
402.2 Adult
individuals who are legally competent shall have the right to decide whether
their family will be involved in planning and implementing the individual
service plan. A signed release or document shall be present in individual case
record giving permission for family to be involved.
402.3 The Individual /Parent /Guardian shall
be informed of their rights. The organization shall maintain documentation in
the individual's file that the following information has been provided in
writing: The information listed in 402.3 A-I must be provided upon admission
and annually thereafter.
A. All possible
service options, including those not presently provided by the
program.
B. A copy of the rules of
conduct and mission statement of the organization.
C. Current list of Board members of the
community program.
D. Summary of
funding sources.
E. Copy of the
appeal procedure for decisions made by the organization.
F. Solicitation Guidelines **See Solicitation
under Definitions
G. All external
advocacy services.
H. Right to
appeal any service decision to DDS, under DDS Policy 1076
I. Name and phone number of the DDS Service Specialist
for that area
403
Grievances and Appeals
Guiding Principle: The organization identifies clear protocols related to formal complaints, including grievances and appeals. An organization may have separate policies and procedures for grievances and appeals, or may include these in a common policy and procedure covering complaints, grievances, and appeals. A review of formal complaints, grievances, and appeals gives the organization valuable information to facilitate change that results in better customer service and results for the persons served.
A. The organization shall
identify clear protocols related to formal complaints, including grievances and
appeals.
B. The organization shall:
1. Implement a policy by which persons served
may formally complain to the organization.
2. Implement a procedure concerning formal
complaints that:
a. Is written.
b. Specifies:
1. That the action will not result in
retaliation or barriers to services.
2. How efforts will be made to resolve the
complaint.
3. Levels of review,
which includes availability of external review.
4. Time frames that are adequate for prompt
consideration and that result in timely decisions for the person
served.
5. Procedures for written
notification regarding the actions to be taken to address the
complaint.
6. The rights and
responsibilities of each party.
7.
The availability of advocates or other assistance.
C. These
procedures shall be explained to personnel and persons served in a format that
is easily understandable and meets their needs. This explanation may include,
but not limited to a video or audiotape, a handbook, interpreters,
etc.
403.1 The
organization shall annually review all formal complaints filed.
A. A written review of formal complaints:
1. Determine:
a. Trends.
b. Areas needing performance
improvement.
c. Action plan or
changes to be made to improve performance and to reduce complaints
403.2 The
organization shall document a review of any action plan or changes made to
determine if the plan/changes were effective in reducing complaints and shall
make adjustments to the plan as deemed necessary to ensure quality services.
404 Health Related Issues
Guiding Principle: A successful health and safety program goes beyond compliance with regulatory requirements and strives to manage risk and to protect the health and safety of persons served, employees, and visitors. A successful health and safety program addresses both minimizing potential hazards and compliance activities.
A. The organization shall implement
policies/procedures to ensure the rights of individuals who have or who are
perceived as having Acquired Immunodeficiency Syndrome (AIDS) or Human Immune
Virus (HIV) related condition (or those who may be perceived as having AIDS or
AIDS related conditions including Hepatitis B are not discriminated against in
accordance with
29 U.S.C. §§
706(8),
794
-
794(b);
U.S.C. § 12101 et. seq. A copy of the policies/procedures shall be
provided to each Individual/Parent/Guardian(s).
B. The organization shall implement
policies/procedures concerning any person admitted for services or anyone
proposed for admission to ensure confidentiality shall be maintained for all
information related to HIV testing, positive HIV infection, any HIV associated
condition, AIDS or Hepatitis B.
C.
Each organization will protect the confidentiality of records or computer data
that is maintained which relates to HIV, AIDS or Hepatitis
B.
405 Incident /
Accident Reporting
A. The organization shall
report the following incidents to the DDS Licensing Unit in
accordance with DHHS Policy 1090. This report shall contain: date,
accident/injury, time, location, persons involved, action taken, follow-up,
signature of person writing the report. The following are reportable incidents:
1. Use of seclusion or restraint.
2. Maltreatment or abuse as defined in
statutes (See Ark. Code Ann. §§ 12-12-501 - 12-12-515 (503); Ark.
Code Ann. §§
5-28-101 - 5- 28-109
(102))
3. Incidents involving
injury:
a. Accident/injury reports shall be
completed for each accident/injury that requires the attention of an EMT,
Paramedic or Physician.
1. Accident is
defined as an event occurring by chance or arising from unknown
causes.
2. Injury is defined as an
act that damages or hurts and results in outside medical attention.
3. A copy of the report must be sent to
parent/guardian of all children (0-18), and to guardian of adults regardless of
severity of injury.
4. Other
health-related conditions resulting in Emergency treatment or
hospitalization.
5. Communicable
disease
6. Violence or
aggression
7. Sentinel events
(i.e., an unexpected occurrence involving death or serious physical or
psychological injury or the risk thereof)
8. Elopement and/or wandering defined as
anytime the location of a person cannot be determined within 2 hours
9. Vehicular accidents
10. Biohazardous accidents
11. Use or possession of licit or illicit
substances
12. Arrests or
convictions
13. Suicide or
attempted suicide
14. Property
destruction
15. Any condition or
event that prevents the delivery of DHHS services for more than 2
hours
16. Behavioral incidents
(incidents involving an individual's actions that are aggressive, disruptive
and/or present a danger to the individual or to others)
17. Other areas, as required
NOTE: For individuals 3-21 years of age, destruction of incident reports must be in compliance with Department of Education .
B. The organization shall notify the
parent/guardian of all children (0-18) or adults who have a guardian any time
an incident/ injury report is submitted.
C. The organization shall develop and
implement policies and procedures regarding follow-up of all incidents to
include a time-line for action, remediation and preventative measures that do
not exceed DDS established timeframes, in accordance with DHHS Policy
1090.
407 Behavioral
Management
A. The organization shall develop
policy and procedure that demonstrates a commitment to a system that nurtures
personal growth and dignity, and supports the use of positive approaches and
supports.
B. The organization's
policy and procedure shall ensure that when behavior management approaches are
used, positive behavior interventions are implemented prior to the use of
restrictive procedures.
C. Written
behavior management policy developed by the organization shall ensure the
rights of individuals.
1. The policy will be
incorporated by the interdisciplinary team in programming, as
appropriate.
2. The plan must be
reviewed quarterly or as dictated by the needs of the individual
served.
3. This shall include all
types of behavior management used i.e., time out, token economy, etc... This
cannot include procedures that are punishing, physically painful, emotionally
frightening, or deprivation, or that puts the individual served at medical risk
which are used to modify behaviors
D. If restrictions are placed on the rights
of a person served:
1. The organization shall
follow its policies and procedures.
2. The organization shall obtain informed
consent from the individual/parent/guardian prior to implementation.
3. The organization shall have methods to
reinstate rights as soon as possible.
4. Staff members are trained on proper
implementation of all restrictions utilized by the organization.
E. The organization shall assure
that maltreatment or corporal punishment of individuals will not be allowed.
1. Policies and Procedure must state that
corporal punishment is prohibited.
a.
"Corporal punishment" refers to the application of painful stimuli to the body
in an attempt to terminate behavior or as a penalty for behavior.
b.20 U.S.C. § 14000 et. seq.;
Maltreatment laws, Ark. Code Ann. §§ 12-12-501 - 12-12-515; Ark. Code
Ann. §§
5-28-101 -
5-28-109.
F. Individuals shall
have the right to obtain and retain private property.
1. Personal possessions are regarded as the
private property of the individuals and shall not be taken away unless danger
to safety of the individual or to others is present.
G. Emergency Basis Procedure
An emergency safety situation is defined as unanticipated behavior that places the person served or others at serious threat of violence or risk of injury if no intervention occurs.
1.
The organization shall establish policies/procedures for the use of restraint
and/or emergency intervention procedures that must be used/undertaken in the
event of a emergency circumstances for a consumer who has no behavior
management plan in place. The policies/procedures must identify the
circumstances under which emergency procedures will be used as a protective
measure in a life- or safety- threatening situation only when de-escalation has
failed or is not possible.
2.
Emergency basis procedures may not be repeated more than three (3) times within
six months without the interdisciplinary team meeting to revise the individual
program plan. Each incident consists of a behavior was exhibited, a procedure
was used, the individual was no longer thought to be dangerous, the procedure
was discontinued.
Note: The number three (3) means three (3) distinct incidents The three (3) distinct occurrences could take place in one (1) day.
500 SERVICE PROVISION STANDARDS
501 The organization shall establish written
policies and procedures for intake, evaluation, and diagnosis necessary to
determine the eligibility of a person to receive services shall be
documented.
501.1 The organization
shall designate specific staff positions assigned with the responsibility for
intake, evaluation, assessment, family contact, planning, updating, and
alternate placement.
502 Face
sheets shall be completed at intake and shall be updated as needed and at least
annually as documented by date of signature of the person designated in
organization's policy.
502.1 Every
person receiving services shall have a service record face sheet that contains
the information in 502.1 A-Q and will be filed in a prominent location in the
front of the file.
A. Full name of
individual
B. Address, county of
residence, telephone number and email address, if applicable
C. Marital status, if applicable
D. Race and gender
E. Birth date
F. Social Security number
G. Medicaid Number
H. Legal status
I. Parents or guardian's name and address and
relationship, if applicable
J.
Name, address, telephone number and relationship of person to contact in
emergency, someone other than item H
K. Health insurance benefits and policy
number
L. Primary
language
M. Admission
date
N. Statement of
primary/secondary disability
O.
Physician's name, address and telephone number
P. Current medications with dosage and
frequency, if applicable
Q. All
known allergies or indicate none, if applicable
502 A case manager/service
coordinator/evaluator shall be designated in writing and shall organize the
provision of services for every individual served. The case manager/service
coordinator/evaluator shall provide the individual or parent/guardian with the
name and contact information in writing.
A.
For every individual served, the case manager /service coordinator/ evaluator
shall:
1. Assume responsibility for intake,
assessment, planning and services to the person
2. Coordinate the individual program
plan
3. Cultivate the individual's
participation in the services
4.
Monitor and update services to assure that:
a.
The person is adequately oriented
b. Services proceed in an orderly, purposeful, and
timely manner
c. The transition
and/or discharge decision and arrangements for follow-up are properly
made.
503 Intake
A. A written intake procedure shall be
available upon request, shall be understandable to the individual receiving the
services, shall be presented to those requesting services, and shall be
followed by the organization in the evaluation of a person to determine
eligibility for services.
B. The
organization shall implement policies and procedures for acceptance into
services. Policies and procedures must:
1.
Establish the criteria for the order of acceptance of any person awaiting
service.
2. Identify the position
or entity responsible for making acceptance decisions.
3. Provide opportunities for persons to learn
about the organization and its services.
4. When a person is found ineligible:
a. The person is informed of the reason
s.
b. The person is given
information about potential alternative services.
5. Ensure that all involved are aware of
their responsibilities regarding services prior to the planning and delivery of
services
6. Ensure signed informed
consent for services are obtained and retained as required by funding sources
and for legal reasons
7. Ensure
persons served are given information about setting their individual service
goals, when applicable, planning the services to be delivered and how progress
on service goals will be communicated with them.
504 Information gathered prior to
admission shall include the following information and shall be filed in the
individual's record:
A. Signed emergency
medical release and all other necessary release forms (i.e., Publicity, field
trip, fund raising, etc.). The emergency medical release form shall remain
current (yearly) for the protection of the organization and the individual.
1. Competent adults must always sign their
releases
2. Publicity releases
shall be obtained on an as-needed basis (for each occurrence)
3. Field trip releases shall be obtained on a
per occurrence basis unless that field trip is part of the regular program
(i.e. bowling each week, swimming each week, etc.)
4. Emergency medical releases must be taken
on field trips or incorporated in the field trip release.
B. Statement of Legal (competency) status;
See Ark. Code Ann. §§
28-65-101
-
28-65-109
(see index)
1. If the
individual is under the age of 18, he/she is a minor. Organizations shall
determine the who is the legal guardian of the child: Natural parent(s), ward
of the state (DCFS/foster home, etc.) and shall ensure the legal guardian signs
all appropriate documents.
2. If
the individual is age 18 or older, he/she is considered competent unless the
court has appointed a legal guardian. Copies of guardianship orders must be
maintained in the individual's record.
Note: An individual for whom a guardian has been appointed retains all legal and civil rights except those which have been expressly limited by court order or which have been specifically granted by order of the court to the guardian.
505 Application for services
A. The organization shall develop and
implement a written application to be made available upon request or presented
to those requesting services. At a minimum, the application shall contain name,
address and telephone number of individual/parent/guardian and a statement of
the individual's needs. Applications shall be available in an alternate format
and assistance to complete shall be offered to individual's that may require
it
506 The organization
shall complete a Financial Screen for all applicants for services as
applicable.
A. The screen shall be completed
prior to admission and is used by the program in the evaluation of a person's
financial status
B. The
organization shall include all information about benefits for Medicaid
eligibility and, for individuals who may not be eligible for Medicaid, shall
include information about Tax Equity Family Reform Act eligibility.
C. If the family refuses to complete
financial screening, the organization shall obtain a written statement to this
effect from the family and maintain it in the individual's file.. Services
shall not be withheld solely for refusal to complete the financial
screen.
507 Medical
prescription for services shall be obtained, if applicable
A. A current prescription for services
(within twelve months), signed by qualified medical personnel, shall be on file
prior to admission
508
The organization shall complete or obtain a full assessment at the time of the
admission process. The assessment shall include the following items:
A. Social history
1. A social history shall be written or
procured within thirty (30) days of admission. The social history must be
comprehensive, in narrative form or a completed questionnaire. The social
history must be updated annually as evidenced by dated signature.
B. Medical history and evaluation
1. A physical examination/assessment signed
by qualified medical personnel shall be on file and current within 5 days but
not longer than thirty (30) days after admission. In cases where a physical
cannot be obtained within 5 days, documentation of a physical within 1 year
will be accepted until a new physical can be obtained
2. Early Periodic Screening Diagnosis
Treatment process for Medicaid eligible individuals (0-21)
a. All individuals 0-21 years of age eligible
for Medicaid should have evidence in the file that they are participating in
the EPSDT process
509 A psychological evaluation report shall
be on file prior to admission for adults (age 18 and older) and for children
(age 5-18) if applicable
A. Adults (age 18-up)
transferring from a DDS Licensed provider may be admitted with a copy of the
most current psychological evaluation
B. A new psychological evaluation may be
conducted if an Interdisciplinary Team determines that it is reasonable and
necessary based on significant life changes of the
individual.
510 Therapy
evaluations must be completed or procured within thirty (30) days after
admission, when applicable or when prescribed by a physician or a therapist
working under a physician's orders. Recommendations from therapy evaluations
shall be incorporated into the individual's plan of care as
appropriate.
511 When applicable,
all psychiatric evaluation shall completed by a qualified person and must be on
file within thirty (30) days after admission. Recommendations from psychiatric
evaluations shall be incorporated into the individual's plan of care as
appropriate.
512 The service needs
assessment must be completed on every individual seeking services
NOTE: See Section 521 for further guidelines
(Children's services Section).
A. The person and/or family served and/or
their legal representatives shall be involved in:
1. Assessments of potential risks to each
person's health in the setting in which they receive services as well as in the
community
2. Assessments of
potential risks to each person's safety in the setting in which they receive
services as well as the community
3. Decisions to accept or reject such
risks
4. Identification of actions
to be taken to minimize risks
5.
Identification of individuals responsible for those actions
513 Personal Futures
Planning
Guiding Principle: Individual's with developmental disabilities and their families have competencies, capabilities and personal goals that shall be recognized, supported, encouraged, and any assistance to such individual's shall be provided in an individualized manner, consistent with the unique strengths, resources, priorities, concerns, abilities, and capabilities of such individuals. Any plan of service developed should significantly reflect the person for whom it is intended. Services/ supports are most effective when they are adapted to address individual outcomes
1. The organization shall prepare a written
person-centered support plan for each individual that shall meet their
individual needs. At a minimum, the plan shall:
A. Be developed only after consultation with
the individual/parent/guardian, and other individuals from the individual's
support network as determined by the individual/parent/guardian;
B. Contain a description of the individual's
preferred lifestyle, including:
1. The type
of setting in which the individual wants to live or work;
2. With whom the individual wants to
socialize;
3. The social, leisure,
religious, or other activities in which the individuals wants to
participate;
4. Reflect the
individual's / family's choice of services which are relevant to the
individual's age, abilities, life goals/outcomes
5. Address areas such as the individual's /
family's health, safety and challenging behaviors which may put the individual
at risk
6. Demonstrates the rights
and dignity of individual/ family
7. Incorporates the culture and value system
of the individual/family
8. Ensures
the individual's/ family's orientation and integration to the community, its
services and resources.
9. The
necessary activities, training, materials, equipment, assistive technology and
services needed to assist the individual in achieving their preferred
lifestyle;
10. Describes how
opportunities for individual choice will be provided;
11. Be approved, in writing by the
individual/parent/guardian.
2. The organization shall regularly review
and revise the plan whenever necessary to reflect changes in the individual's
preferred lifestyle; achievement of goals or skills outlined within the plan or
the goal is no longer deemed appropriate for the individual
514 Every individual
shall have a written Individualized Program Plan
NOTE: See individual program sections for specific time frames (Children's services See Section 521).
A. The organization shall include the person
served as an active participant giving direction in all aspects of the planning
and revision processes
B. Services
shall be provided based on the choices of the individual/parent/guardian (as
appropriate) and on the strengths and needs of the individuals to be served by
the organization
C. Individual
choice shall be determined by personal futures planning as specified in Section
513 and a comprehensive assessment which addresses:
1. Relevant medical history
2. Relevant psychological
information
3. Relevant social
information
4. Information on
previous direct services and supports
5. Strengths
6. Abilities
7. Needs
8. Preferences
9. Desired outcomes
10. Cultural background
11. Other issues, as
identified
514.1 The Individualized Program Plan:
A. Shall be developed with the input of the
person served and/or their legal guardian.
B. Shall Identify:
1. Least restrictive environment
a. Documentation of discussion of least
restrictive environment appropriate for individual strengths and
needs
b. The program must document
the justification for specialized environments if they are to be used. Plans
shall be made for return to normal environments as soon as possible.
1. Individuals shall be in contact as much as
possible with those who do not have disabilities
2. Individual program plans will be reviewed
for provisions of program services in the least restrictive environment
appropriate to the ability of the individual. Document this item with a summary
of the discussion by the entire team about the least restrictive
alternatives
3. If the person
chooses community integration or a less restrictive environment, documentation
of referral attempts for alternate placement shall be present
2. Barriers
a. Describe the conditions or barriers that
interfere with the achievement of the goal(s) or skills(s). Describe why a
particular individual's needs cannot be met or what needs to be accomplished to
meet the need.
b. Resources and/or
environment changes, adaptations or modifications necessary to attain the goal
or skill shall be listed. The person responsible for attempting to get the
service must be identified.
Note: Example of barriers are: lack of contract work, lack of funds, lack of staff individual absent due to illness, prosthetic devices, equipment space, etc. The responsible person may be staff member, individual family, etc.
c.
Documentation of efforts made to remove the identified barriers shall be noted
in the individual's progress reports.
3. Long-range goals (addressing a period of
3-5 years) and annual goals
a. The plan shall
incorporate the goals and objectives of the individual's person centered plan.
b. The planning process shall
support the individual / family in decision making and choosing options by
actively involving the individual/ family in the Individual Plan (IP)
development
4. Specific
measurable objectives.
514.2 Short-term objectives (3-6 months time
frame) shall be developed, as needed, for each of the annual goals.
A. Each objective must have criteria for
success that states what the individual must do to complete the
objective.
B. Short-term objectives
must have methods/materials for implementation and give a simple statement
describing the procedures to be used in individual training.
C. The person responsible for implementation
of each short-term and service-objective shall be specified.
Note: Utilization of title is recommended This could be the individual or parent/guardian.
D. Short-term objectives shall have an
initiation date, a target date, and, when completed, a completion
date
E. Target dates -
1. The target date shall be individualized
and noted at the same time of the initiation date and the projected date when
the individual can realistically be expected to achieve an objective.
2. The target date shall be used as a prompt
to see if expectations for the individual are realistic in relation to
attainment and appropriateness of goals and objectives. If the starting or
target dates need to be revised, the organization shall mark through, initial
and put in a new date.
3. The
ending date shall be entered in as the person completes each
objective.
514.3 Service Objectives
A. Shall be reviewed on a regular basis with
respect to expected outcomes.
B.
Shall be revised, as appropriate:
1. Based on
the satisfaction of the person served.
2. To remain meaningful to the person
served.
3. Based on the changing
needs of the person served.
C. Shall include a target date, which is a
projected date when the team thinks the individual will no longer need the
service or the service provision should be reviewed.
514.4 The following areas shall be assessed
to determine needs in the plan and shall be documented:
A. Assistive technology.
B. Reasonable accommodations.
C. Identified health and safety
risks
514.5 The
individual program plan shall be communicated in a manner that is
understandable:
A. To the person served
and/or their guardian / advocate/ representative.
B. To the persons responsible for
implementing the plan.
514.6 The organization shall ensure that
persons involved or their legal guardian/advocate understand the plans and
their own involvement in achieving the outcomes.
A. Active participation of the persons
served, or their guardian or advocate in setting goals and planning services
shall be documented. Documentation may be through interviews, records,
checklists, etc. and shall be maintained in the individual's file
B. If a person served needs services that
are not available through the organization, the organization shall make
referrals to other providers as indicated. Documentation of the referral(s)
shall be maintained in the individual's file.
NOTE: Contact DDS for a list of providers that provide the requested service.
515 Every
ninety (90) days of service delivery, the service provider shall complete a
quarterly report on the goals/objectives of the IPP. If needed, modifications
may be made with meeting of entire team. Quarterly reports must be specific to
reflect the individual's performance concerning implemented goals and
short-term objectives as specified in the individual program plan and shall be
based on the case notes for the reporting period.
A. The quarterly notes shall establish goals
or short-term objectives which are:
1.
Accomplished
2. To be
continued
3. Modified or deleted
(with statement of reason or barrier) and
4. Will be worked on for the next three
months or ninety (90) days
B. Data Collection/case notes shall be
utilized in writing progress reports.
C. Quarterly reports shall be written, dated,
and signed by persons responsible for case management. All persons responsible
for implementation of services must contribute to the report.
D. Quarterly reports shall document referral
to interdisciplinary team for modification of the annual goals as needed, in
compliance with state and federal regulations
E. Documentation of communication of
quarterly reports to the individual/parent/guardian (as appropriate) shall
occur at least every three (3) months or ninety (90) days as in compliance with
state and federal regulations.
F.
Quarterly reports must include space for individual and/or parental/guardian
evaluation of services. The organization shall document that the persons served
and/or the parent guardian has opportunity to evaluate the services received as
in accordance with state and federal guidelines.
516 Updating
A. The organization shall have policies and
procedures in place for updating individual program plans. Updates shall be
done at least annually and more often if monitoring reports indicate a need or
if federal regulations require more frequent updates.
B. The organization shall have policies and
procedures in place for revising individual program plans when goals
change.
C. Annually update -
financial, if applicable, social, medical, medical prescription for services,
evaluations as applicable, IPP's, and service needs assessment;
517 Termination of services or
alternate placement
NOTE: See the specific programming section for more detailed information (Children's services 521).
A. An exit summary shall be prepared each
time a person leaves a service, not just when the person is leaving the
organization.
1. The report shall summarize
the results of the services received by the person and makes recommendations
for future services to continue the achievement of the person's life
goals.
2. The plan may suggest
referrals to other services that are not available through the
organization
518 Data Collection Requirements
A. Data collections shall provide specific
information on annual goals and short-term objectives and should be designed to
measure and record the progress on each short-term objective.
B. Data Collection shall include date, time
and summary of each contact, signature of the individual providing services and
must be completed every time services are delivered. Data Collection shall be
filed in the individual's file at least monthly and shall be available for
review upon request.
520 The organization shall establish and
maintain each individual's daily schedule based upon the individual's program
plan. The schedule shall indicate general activities throughout the day for
each individual. As appropriate the schedule should reflect time segments for
the individual to exercise choice in the selection of activities.
521
Children's Services Individual
Program Planning
As a key element in establishing goals/objectives/ personal outcomes, the agency shall assess an individual's/family's preferences, desires, lifestyle choices, strengths, needs, skills, etc. through individual observations or interviews. Documentation of the assessment shall be maintained in the individual's file. At a minimum, the assessment must include:
A. Developmental Assessment
1. Initial evaluation shall include 2
developmental assessments; 1 standardized and 1 criterion based.
2. Documentation must include:
a. A written summary that includes standard
deviation and/or percentage of delay as determined by the test
protocols
b. An informed clinical
opinion
3. Must be in a
format that is understandable to the parent.
4. Must be signed by the evaluator.
B. An annual assessment must be
conducted using a criterion based test.
C. A Social History must be completed, signed
and dated on the approved form from DOE.
521.1 Children 3-5-The Individual Program
Plan shall include a statement of the specific services necessary to meet the
identified needs of the child/family.
A. At a
minimum the IPP must include:
1. Frequency-
Number of days or sessions that a service will be provided
2. Intensity- The length of time the service
is provided during each session, and whether the service is provided on an
individual or group basis
3.
Location- Location where the service is provided (e.g., in the child's home,
early intervention center, or other setting) as appropriate to the age and
needs of the child
4. Method- How a
service is provided
5. Dates and
duration- Projected dates of initiation of the services, a target date for
completion and/or review and the anticipated duration of those services. If
either of these dates needs to be revised, then simply mark through, initial
and put in new date.
B.
Completion of the IPP must meet all State and Federal requirements
C. In order to revise an individual's
objectives, at least three (3) members of the team must be present. Parent(s)
must be included.
521.2
Quarterly reviews must include a Family Rating which must be documented on the
appropriate form as designated by DDS.
521.3 Children reaching 5 years of age must
have a transition plan.
A. This plan must be
developed 180 days prior to age 5 as per State and Federal
guidelines.
B. The plan must be
child specific and must include specific steps to ensure a smooth transition
for the child and family, and must be in accordance with State and Federal
Guidelines.
C. The plan must
include a transition plan at kindergarten age. Children entering public schools
must have a transition plan.
D. The
individual program shall include the steps to be taken to support the
transition of the child upon reaching kindergarten age.
E. The organization must document contact
with the agency which will provide services following the transition, and must
demonstrate an attempt to involve that agency in the transition planning.
Documentation must be maintained in the individual's file.
521.4 If the organization is using the
supervising teacher model, the organization must follow all State and Federal
Guidelines and maintain appropriate documentation of supervision and direct
contact with the child on file for review.
522
Vocational Maintenance &
Monitoring
Vocational Maintenance & Monitoring
A. Case Notes
1. Case notes shall document each contact
with the individual the frequency of each contact will be determined by the
team during the development of the IPP it should include date, time and summary
of each contact.
2. Service
Objectives shall be listed in an outcome oriented manner.
A. Each service objective shall specify any
environment modification necessary to facilitate the individual's
accomplishment.
B. Each service
objective, including physical adaptations or modifications of the individual's
environment, shall be stated as a single specific outcome.
C. Service objectives shall provide
opportunities in the social environment to support community integration and
the enhancement of individual relationships.
D. Based on the individual's choice, and the
needs assessment, plans shall include facilitation of the individual's
participation in normal activities in normal settings of same-age
peers.
523
Staff Ratios
Ratios for Day Programming for Children 0-3 Years
1:4
Ratios for Day Programming for Children 3-5 Years
1:7 If non-integrated according to December 1st child count
1:9 If integrated at the December 1st child count, the center can send in documentation to DDS and use the alternative ratio of 1:9. Provider shall be required to assure DDS that the integrated status is maintained and it will be checked periodically during licensure visits.
523.3 Ratios for
Adult Day Programming
The organization shall maintain a 1:10 ratio throughout the building using the following definition.
One direct care staff person that has visual contact while ACTIVELY ENGAGED in providing support and supervision to consumers.
524
Square
Footage
A minimum of forty (40) square feet of program training area per individual served shall be required. This is program-training area only. This does not include halls, storage areas, or administrative offices.
600
FOOD
SERVICES
A. This standards section
shall be applied to all provider owned/leased/rented facilities. If the
facility contracts for food services, the organization shall ensure compliance
with DDS policies.
601 Written
procedure shall be established that addresses how food services are provided to
the individuals served by the facility:
A.
Procedure shall include how meals are provided as well as staff
responsible.
601.1 All
Day services programs shall assure that organization provided meals are
approved, adequate diets, which conform to the recommended dietary
allowance.
601.2 Licensed Group
Homes shall assure that three (3) meals a day are available for individuals
served.
A. The organization shall keep on
hand suitable food for preparing sack lunches, if appropriate.
B. All meals shall be part of an approved,
adequate diet, which conforms to the recommended dietary allowance.
C. Facilities with apartment units shall have
a mechanism for monitoring the resident's food related skills.
602 The organization shall keep
menus on file. Menu preparation should occur at least one week in advance in
order to:
A. Allow adequate time to purchase
foods to avoid too frequent menu substitutions. Meal planning shall occur so
that identical meals are not served on the same day of consecutive
weeks.
B. Serve as a reminder for
scheduling advance preparation;
C.
Allow menus to be available as a teaching tool for instruction of individuals,
to include development of menus by individuals.
Menus shall be kept on file for a minimum of three (3) months.
603 Menus shall be
prepared or approved by a registered dietitian/nutritionist. Organizations may
contract with a dietitian/nutritionist.
A.
Dietitian/nutritionist shall check for nutritional adequacy of menus and
acceptable food safety and sanitation practices. This must be documented by a
written report at least
B. DDS
shall accept Arkansas Nutrition Program approval, or site monitoring reports,
as adequate approval for Centers that participate in the free/reduced lunch
program.
604 The
organization shall develop and implement written procedures that address
provisions for special diets.
A. Special
diets pertain to allergies, weight control, diabetes, religion, hypertension,
and other medical conditions as documented in the consumers file.
605 Food items and toxic items
shall not be stored together.
700
TRANSPORTATION
A. The organization shall establish written
procedures that address how transportation services are provided to individuals
served by the program.
B. The
procedures shall address transportation to the persons served, as well as staff
responsible.
C. The organization
shall ensure that all individuals receiving services are provided with a copy
of the transportation policies and shall document receipt of this information
in the individual's file.
701 The
organization shall assure safety for all persons being transported. For all
transportation services provided for the persons served by the organization,
the organization shall ensure:
A. For all
vehicles owned or operated by the organization:
1. Compliance with all applicable federal,
state, county, and city requirements.
a. All
vehicles shall be properly licensed by the State of Arkansas.
2. Appropriate licensing of all
drivers.
a. All drivers must be licensed
according to state requirements for providers of public
transportation.
3.
Review of driving records of all drivers on an initial and annual
basis.
4. Insurance requirements
for vehicles and personnel.
a. The
organization shall maintain insurance coverage providing a minimum of
$1,000,000 comprehensive, liability, and property damage.
5. Safety equipment / features in vehicle(s).
a. Fire extinguisher in every program vehicle
used to transport consumers.
b.
Each vehicle shall utilize seat belts or suitable restraints when in motion in
accordance with Ark Code
27-37-702
"Seat Belt Use Required" and
27-34-101 -107
"The Child Passenger Protection Act"
c. The organization shall establish policy
and procedure to ensure Child Safety Alarms on every vehicle required under Ark
Code
20-78-225
(all vehicles designed or used to transport more than 7 passengers and 1 bus
driver)
6.
Accessibility based on the individual's needs and reasonable
requests.
7. Training of drivers in
the organization's transportation requirements.
8. Written emergency procedures.
a.
Each vehicle used
in transporting clients shall have a documented emergency drill once every six
months.
9. Availability
of communication devices (i.e., cell phones 2-way radios, etc.).
10. Road warning/hazard equipment (i.e.,
safety cones, flairs, reflector signs, etc.)
11. First aid supplies.
a. Every program vehicle used to transport
consumers shall maintain a First Aid kit.
12. Maintenance of vehicles owned or operated
by the organization according to manufacturers' recommendations.
a. The organization shall establish/implement
procedures that ensures a vehicle maintenance log is kept up to date for all
vehicles used to transport consumers.
1. The
procedure shall establish who is responsible for upkeep of vehicle and who is
responsible for documentation and update of log.
b. The maintenance log shall document the
following:
1. Oil changes
2. Tires and brakes
repair/inspection
3. Head and tail
lights and turn signals repair/inspection
4. Windshield washer and wiper blades
repair/inspection
5. Air
conditioner (if any), and defroster inspection/repair
6. Hoses and fan belts
inspection/replacement
7. Fluid
levels inspection and replacement
8. Exhaust system inspection/repair
9. Emergency warning system
inspection/repair
10. Steering
assemblage inspection/repair
13. If services are contracted:
a. An annual review of the contract against
elements 1-12 of this standard shall be performed by the
organization.
b. Personnel or
contractors shall provide transportation services for the persons served in a
safe manner, with drivers having knowledge of unique needs of persons served,
and consistent with the regulations of the local authorities.
1. This standard shall apply when any
vehicle, including a personal vehicle, is used to provide transportation for
persons served.
702 The organization shall establish written
policy and procedure to address apparent abandonment of consumer by family
and/or guardian.
A. The organization shall
develop a procedure to be followed by transportation staff when unable to leave
individuals at home or alternate sites as specified by family that ensure the
safety of the individual at all times.
703 At least one responsible person, in
addition to the driver, shall be present in the vehicle if any of the following
conditions apply:
A. Any person being
transported has medical conditions as defined by the organization
guidelines.
B. Any person being
transported has a severe disability as defined by the organization's
guidelines.
NOTE: 'Responsible person' shall be defined by the organization's policy.
704 Organizations operating vehicles
transporting children shall comply with the child:staff ratio specified by the
Child Care Licensing Standards for Transportation
705 Organizations operating vehicles
transporting adults shall establish/implement policies related to adult:staff
ratios.
NOTE: DDS recommends a 1 to 10 Ratio at all times.
800
Physical Plant, Accessibility and
Safety
A. The organization shall
provide a physical plant compatible with services provided and with the needs
of the individuals and staff; provide an accessible and safe environment and be
in compliance with U.S.C. § 12101 et. seq. "American with Disabilities Act
of 1990" at all owned, leased, and/or rented program site(s).
801 The organization shall promote
accessibility in all settings. The organization shall assess all physical sites
to ensure accessibility for individuals and their families and shall remove all
identified barriers.
A. Organizations shall
ensure that all physical sites address accessibility issues in order to:
1. Enhance the quality of life for those
served in their programs and services.
2. Meet legal and regulatory
requirements.
3. Meet the
expectations of stakeholders in the area of accessibility.
801.1 Accessibility Requirements
A. The organization shall ensure
architectural accessibility at each facility based on the individual's needs.
1. Ramps, doors, corridors, toileting and
bathing facilities, furnishings, and equipment are designed to meet the
individual's needs.
B.
The organization shall ensure that all their facilities are in compliance with
29 U.S.C. §§
706(8),
794
-
794(b)
"Disability Rights of 1964" and U.S.C. § 12101 et. seq. "American with
Disabilities Act of 1990". Compliance with the aforementioned laws is required
to receive federal monies. Admissions criteria of who can be served shall
identify any persons the facility or staff would be prevented from serving due
to accessibility issues.
801.2 Accessibility Assessment and Planning
A. The organization shall assess all
facilities. The assessment shall identify all barriers and shall develop a plan
for removal of barriers in the following areas:
1. Architecture
a.
Architectural or physical barriers which may include steps that prevent access
to a building for an individual who uses a wheelchair, narrow doorways that
need to be widened, bathrooms that need to be made accessible, the absence of
light alarms for individuals who have a hearing impairment, and the absence of
signs in Braille for individuals who have visual impairments.
2. Environment
a. Any location or characteristic of the
setting that compromises, hinders, or impedes service delivery and the benefits
to be gained.
802 Physical Plant Structure
802.1 Architecture
A. All water, food service, and sewage
disposal systems must meet all local, state, and federal regulatory agencies,
as applicable. The organization shall maintain documentation of all approved
inspections for review by DDS.
1. Sewer
inspections are not required if the site is on city water and sewage
lines.
2. Sites using a well and/or
septic tank, shall be obtain an inspection by the Division of Health
documenting compliance with the DOH and local regulations.
B. Floor furnaces, gas heaters, electric
heaters, hot radiators, and exposed water heaters must be protected by screens
or guards that are without sharp corners and are attached to floor or wall to
prevent persons from falling against the guard and knocking it over.
C. Enclosed gas heaters must be properly
vented to the outside, and installed with permanent connection that includes a
cut-off valve in the rigid part of the gas supply pipe.
Note: DDS recommends gas heaters with a pilot light and automatic cut-off valve which automatically cuts off gas to the main burner when the pilot light goes out
D. Restroom facilities used by individuals
must provide for individual privacy and be appropriate for the individuals
served regarding size and accessibility.
802.2 Environment
A. Temperature of each facility must be
maintained within a normal comfort range for the climate. Recognizing that
there may be variances within a building, the organization shall make
reasonable efforts to maintain a comfortable temperature range throughout the
facility.
Note: The recommended standard for range of comfort is from 65 to 80 degrees F (U.S. Atmospheric Standards 29.1)
B. All areas of the facility shall be
sufficiently lighted to meet the needs of the individuals being served and the
usage of the area.
C. The
organization shall maintain the interior and exterior of the building in a
sanitary and repaired condition.
D.
The premises shall be free of offensive odors.
E. The grounds and all buildings on the
grounds shall be maintained in a clean and repaired condition.
1. Play and activity areas shall be free of
dense undergrowth and refuse accumulations. All landscape plantings and the
lawn shall be well groomed.
F. The facility shall be maintained free of
infestations of insects and rodents.
1. The
organization shall maintain a contract for pest control that is administered by
appropriately licensed professionals.
G. The organization shall establish written
procedures regarding smoking that is in accordance with The Clean Air Indoor
Act (Act 8 of 2006).
1. For all congregate,
day-hab settings, and licensed group homes, smoking will not be permitted in
the following areas:
a. Common Work
Areas
b. Auditoriums
c. Classrooms
d. Conference and Meeting Rooms
e. Private Offices
f. Elevators
g. Hallways
h. Health Care Facilities
i. Cafeterias
j. Employee Lounges
k.
Stairs
l. Restrooms
m. All other enclosed areas.
2. Approved Exemptions:
a. Private residences or health care
facility
b. All workplaces of any
employer with fewer than three (3) employees. (Note: This exemption does not
apply to any public place)
c.
Outdoor areas of places of employment or group homes
H. All materials and
equipment and supplies shall be stored and maintained in a safe condition.
Cleaning fluids and detergents must be stored in original containers with
labels describing contents.
1. The
organization shall maintain an MSDS manual in a location that is accessible to
all employees. All MSDS sheets must be on file and current.
803 Safety Inspections
803.1 The organization shall ensure that
annual safety inspections are completed by qualified individuals to enhance and
maintain the organization's health and safety practices.
A. All applicable inspections shall be
maintained on file, and current within one year or as specified by
law/regulation (i.e., Annual Fire Department, Local Health Department, Safety
Engineer, OSHA, Safety Specialist, and Insurance Carrier).
B. A comprehensive inspection shall be
conducted annually at all facilities where the organization delivers services
or provides administration on a regular and consistent basis. Inspections shall
be conducted by a qualified external authority(ies).
1. Results of each inspection shall contain
written documentation that:
a. Identifies the
areas inspected.
b. Identifies
recommendations for areas needing improvement.
c. Identifies actions taken to respond to the
recommendation(s).
C. All applicable licenses, inspections,
etc., shall be current. This shall include health inspections for food service
preparation, if applicable. Residential facilities with more than ten (10)
residents must have a Division of Health inspection.
803.2 Regular self-inspections shall be
completed to assist personnel in internalizing current health and safety
requirements into everyday practices.
A. The
organization may designate professional personnel (managers, supervisors,
direct service employees, maintenance personnel) or internal groups (safety
committees, safety circles, operation teams, consumers or advocates) within the
organizational structure to conduct self- inspections. The organization shall
ensure that all staff involved in self-inspections have received training in
conducting inspections prior to participation.
B. The organization shall maintain a schedule
of when self-inspections will be conducted.
1. At a minimum, self-inspections must be
conducted:
a. At least twice a
year.
b. At all facilities where
the organization delivers services or provides administration on a regular and
consistent basis.
2.
Results of self-inspections shall contain written documentation that:
a. Identifies the areas inspected.
b. Identifies recommendations for areas
needing improvement.
c. Identifies
actions taken to respond to the recommendation(s).
804
Emergency Procedures
804.1 The organization
shall establish emergency procedures that detail actions to be taken in the
event of emergency and to promote safety for the individuals served.
A. Emergency procedures shall be in written
form, and shall be available and communicated to all members of the staff and
other supervisory personnel.
1. At a minimum,
emergency procedures shall be implemented for:
a. Fires.
b. Bomb threats
c. Natural disasters.
d. Utility failures
e. Medical emergencies
f. Safety during violent or other
threatening situations (i.e., intruders)
2. Written emergency procedures shall:
a. Meet the requirements of all applicable
authorities.
b. Implement practices
appropriate for the locale (i.e., Arkansas Chemical Stockpile Emergency
Preparedness Program/CSEPP)
B. The organization shall maintain an
emergency alarm system for each type of drill (fire and tornado).
C. The organization shall ensure that persons
served, as appropriate, are be educated and trained about emergency and
evacuation procedures.
D. The
organization shall evaluate and consider modification of all emergency
procedures during the following times:
a.
Training.
b. After training
drills.
c. As risks increase.
d. After actual
emergencies.
e. When responsibility
is reassigned.
f. When changes are
made to the physical plant.
g. When
changes occur in the physical plant proximity.
h. When a policy or procedure is
revised.
i. When briefing personnel
on emergency plan changes.
E. The organization shall analyze tests of
the emergency and evacuation procedures annually and shall use the results of
the analysis to improve or to affirm satisfactory current practices.
804.2 For all facilities where the
organization delivers services or provides administration on a regular and
consistent basis, the organizations shall establish/implement written
procedures for evacuations.
A. Evacuation
procedures shall address:
1. When evacuation
is appropriate.
2. Complete
evacuation from the physical facility.
3. The safety of evacuees.
4. Accounting for all persons
involved.
5. Temporary shelter,
when applicable.
6. Identification
of essential services.
7.
Continuation of essential services.
8. Emergency phone numbers.
9. Notification of the appropriate emergency
authorities.
B.
Evacuation routes must be posted in conspicuous places, except in residential
settings and must be easily understandable to the individuals
served.
804.3 As a part
of an organization's performance improvement activities shall include emergency
procedure testing.
A. A tornado drill must be
held monthly.
1. Written reports telling
date, hour of day, evacuation time, and other areas of concern shall be
maintained.
B. A fire
drill must be held monthly.
1. Written reports
telling date, hour of day, evacuation time, and other areas of concern shall be
maintained.
804.4 Detectors
Battery operated or electronic smoke detectors, heat sensors, carbon monoxide detectors and/or sprinklers shall be provided in all buildings where services are provided and shall meet life safety codes.
A. Fire Marshall's report shall be followed
as to placement of these devices.
B. Equipment shall be tested at least
quarterly or more frequently if recommended by the manufacturer.
804.5 Fire Extinguishers
Fire extinguishers shall be required to the extent specified by the State Fire Marshall or his designee and shall be checked annually.
A. The Fire Marshall uses Ark. Code Ann.
§§
12-13-101 -
12-13-116
"Fire Prevention Act" that follows the Life Safety Code 101 and additional
National Fire Prevention Agency publications.
804.6 Emergency Lighting
The organization shall maintain emergency lighting, (i.e., flashlight or other battery operated lights) as required by the life safety codes.
804.7 First Aid
The organization shall maintain a first aid kit and current first aid manual at all sites where services are provided on a regular, consistent basis.
A. Antidote charts and the
telephone numbers of poison control centers shall be readily accessible to
staff and individuals served.
Note: This can be obtained through Poison Control Center at University of Arkansas Medical Science Center in Little Rock if you cannot get locally
804.8 Water Temperatures
Provisions shall be made to control water temperature at facilities where services are provided on a regular, consistent basis.
A. To ensure the safety of individuals
served, each organization shall develop/implement policy and procedure
concerning water temperature adhering to current literature regarding water
safety with a maximum temperature of 120 degrees. If the thermostat of the hot
water heater is set above 120 degrees, a mixer must be to the lavatories and
bathing facilities to maintain safety.
Note: This standard shall apply only to service areas and where consumers are working.
APPENDIX A
SUGGESTED BOARD/ORGANIZATION TRAINING TOPICS
Policy Development and Implementation
Planning and Evaluation
Equal Employment Opportunity/Affirmative Action
Employee Performance Evaluation
Team Building
Performance Management
Effective meetings
Due Process
Freedom of Information
Overview of Department of Human Services
Overview of Developmental Disabilities Services
Philosophy and Goals
Programs, Practices, Policies and procedures of Local Organizations
Overview of Community Integration
History, Philosophy, Causes and Types, Functional Levels, Severity Levels, Prevention and Program Issues in Mental Retardation and Other Developmental Disabilities.
Introduction to Principles of Normalization
Legal rights of Individuals with a Developmental Disability
Interdisciplinary Approach Overview
Age Appropriate Programming
Medications - Implications, Side Effects, legality of Administering
Overview of Federal and State Laws related to serving people with Developmental Disabilities (see index):
U.S.C. S2000a - 2000 h-6; Ark. Code Ann. SS 6-41-222; 20 U.S.C S 14000 et. seq. (Part B & Part H); 29 U.S.C SS 706(8), 794-794(b); 5 U.S.C S 552a; 42 U.S.C SS 6000-6083; Ark. Code Ann. SS 20-48-201 - 20-48-211; Ark. Code Ann. SS 28-65-101 - 28-65-109; Ark. Code Ann. SS 5-28-101 - 5-28-109; Ark. Code Ann. SS 12-12-501 - 12-12-515; Ark. Code Ann. SS 25-2-104, 25-2-105, 25-2-107, Ark. Code Ann. SS 25-10-102 - 25-10-116; Ark. Code Ann. SS 20-18-215; U.S.C. S 12101 et. Seq.; DHS Administrative Policy 3002-I (Revised) and DDS Service Policy 3016, Prevention of Transmission of Disease Borne by Blood or other Body Fluids such as AIDS and Hepatitis B; DDS Administrative Policy 1077 Chemical Right to Know; DDS Service Policy 3004-I Maltreatment Prevention, Reporting and Investigation.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.