Md. Code Regs. 10.01.18.07 - Additional Requirements for State Facilities
A. This regulation applies to State
facilities.
B. Screening and
Prevention Policies.
(1) The facility shall
adopt and enforce written policies and procedures for ensuring the facility
screens for, and takes reasonable steps to mitigate, an individual's risk of
being subjected to, or the perpetrator of, inappropriate sexual behavior in
accordance with the requirements set forth in this chapter.
(2) The facility shall provide training to
staff members, upon hire and annually thereafter, regarding:
(a) The policies and procedures governing the
risk screening and protection plans; and
(b) Detection and prevention of inappropriate
sexual behavior in accordance with this chapter.
(3) The Department shall utilize a uniform
risk assessment screening tool.
C. Required Processes Upon Admission to
Facility.
(1) As soon as practicable, but no
later than 3 business days after the individual's admission, the facility shall
make reasonable efforts to collect the individual's medical and treatment
records in accordance with §H of this regulation.
(2) The facility shall implement reasonable
safety precautions upon the individual's admission.
(3) Within 48 hours of the individual's
admission, clinical staff shall:
(a) Complete
a risk assessment screen of the resident, in accordance with §D of this
regulation;
(b) Complete a suicide
risk assessment; and
(c) If
necessary, modify the reasonable safety precautions to mitigate the risks
identified in the risk assessment screen.
(4) Within 5 days after the individual's
admission, the treatment team shall meet to:
(a) Review and, if appropriate, update the
risk assessment screen;
(b)
Determine if a protection plan is necessary, based upon review of the risk
assessment screen and, if so, develop a protection plan, in accordance with
§E of this regulation; and
(c)
Develop the initial plan of care in accordance with §F of this
regulation.
D. Risk Assessment Screen.
(1) To complete the risk assessment screen,
clinical staff shall:
(a) Use the form
required by the Department;
(b)
Interview the individual; and
(c)
Document the individual's responses regarding:
(i) The individual's history of trauma and
other issues relevant to the individual's risk of being subjected to, or the
perpetrator of, inappropriate sexual behavior in the facility;
(ii) Whether the individual feels safe in the
facility, including why or why not; and
(iii) What the individual believes would make
them feel safe in the facility.
(2) If the individual cannot be interviewed,
the clinical staff shall document the reason on the risk assessment screen
form.
E. Protection
Plan.
(1) The treatment team shall develop a
protection plan if the treatment team determines that it is necessary to
mitigate the risk identified in the risk assessment screen.
(2) The protection plan shall be completed on
the form required by the Department.
(3) If a protection plan is determined to not
be necessary to mitigate the risk identified in the risk assessment screen, the
rationale shall be documented in the risk assessment screen.
(4) If an individual in a State facility has
a behavior plan that includes the elements required in a protection plan, the
behavior plan shall satisfy the requirements of this regulation and shall be
labeled as a behavior and protection plan.
F. Plan of Care.
(1) When developing the initial plan of care,
the treatment team shall:
(a) Review and, if
appropriate, update the risk assessment screen based upon the information
available to the treatment team; and
(b) Include a protection plan, if
appropriate, pursuant to §E of this regulation.
(2) The initial and all subsequent plans of
care shall:
(a) Incorporate the risk
assessment screen and, if applicable, the protection plan;
(b) Include consideration of the effect of
trauma on the individual; and
(c)
Be authorized by a physician, psychiatrist, or other appropriately qualified
person under applicable legal and operational standards.
(3) The plan of care shall be reviewed at
least every 3 months and whenever an individual's risk assessment screen is
updated.
G. Review and
Update of Risk Assessment Screens and Protection Plans.
(1) The treatment team shall review the risk
assessment screen, and update if necessary, every 3 months as part of the plan
of care review.
(2) The risk
assessment may be reviewed more frequently if warranted by any new allegation
of inappropriate sexual behavior or if additional information regarding risk
factors is received by the treatment team.
(3) The plan of care shall be reviewed when
the risk assessment is updated.
(4)
The protection plan shall be reviewed and updated as needed or whenever the
risk assessment is updated and when the plan of care is reviewed.
(5) When reviewing the protection plan, the
treatment team shall consider:
(a)
Effectiveness of strategies to reduce risk;
(b) Whether new or modified strategies are
warranted; and
(c) The individual's
desires regarding the protection plan.
H. Medical and Other Records.
(1) The facility shall designate the staff
member or members responsible for collecting the individual's medical records
in accordance with this subsection.
(2) The facility shall make reasonable and
documented efforts to collect medical records from the individual's prior and
current health care providers in accordance with this subsection, including:
(a) Discharge summaries from all hospitals
where the individual received treatment in the 3 years before the individual's
admission to the facility; and
(b)
Somatic and other health assessments performed in the 3 years before the
individual's admission to the facility.
(3) The facility shall make reasonable and
documented efforts to collect any other significant records identified by the
facility that the treatment team determines are clinically necessary to develop
and implement the individual's plan of care.
(4) Facilities shall make reasonable and
documented efforts to collect information from the following sources related to
the individual's risk for being a victim or perpetrator of inappropriate sexual
behavior, provision of trauma-related care or treatment, or the individual's
reduced decision-making capacity, as authorized by law:
(a) Other State facilities;
(b) Local jails or detention centers and
facilities operated by the Department of Public Safety and Correctional
Services;
(c) The Department of
Juvenile Services;
(d) Local
Departments of Social Services, to identify other sources;
(e) Private hospitals and clinics;
and
(f) Any persons known to the
Department to have knowledge to identify other sources, including sources
indicated on the responses to the risk assessment screen.
(5) Facilities shall access records in
electronic databases whenever possible and as such data bases become
available.
(6) The facility shall
comply with applicable laws and regulations governing the confidentiality and
release of medical and other personal information pursuant to applicable State
and federal laws and regulations.
Notes
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