13-007 Code Vt. R. 13-150-007-X - OPERATION OF INTERMEDIATE CARE FACILITIES FOR THE MENTALLY RETARDED

Section 1.1 Overview

The goal of ICF/MR services is to provide habilitation services for mentally retarded people and persons with related conditions, in settings which are normative and least restrictive of personal freedom. Considerable empirical evidence has clearly established the advantages of small, integrated residential facilities which provide normalizing atmospheres and practices. n1 Such residential environments contribute to a reduction in an individual's need for life-long supervised living arrangements and facilitate movement to more independent living arrangements as a resident acquires new skills.

n1 Wolfensberger, W. - Principle of Normalization in Human Services, Toronto, NIMR, 1972.

Physical characteristics of a normal environment dictate that the residence be physically integrated within the community and have exterior and interior features that are similar to a majority of other homes in the neighborhood. Determination of location of the residence should consider several factors, including:

(1) whether the proximity of the building to other facilities providing services to individuals who are impaired or devalued creates a climate of deviance which would have a detrimental effect upon community response to the resident, and;

(2) whether the location of the residence affords easy access to community services and recreational facilities to foster maximum social integration of the residents.

The interior design of each residence should simulate the functional arrangements of a typical home and should accommodate the needs for personal space. Design and construction of the residence should provide for areas affording privacy to residents when desired, while also providing common use areas which would accommodate all occupants of the home.

The residential program adopting the normalization principle follows a daily schedule which is common to a normal life style, including, but not limited to:

(a) a normal rhythm of the day with respect to arising, participating in work/educational/play activities, eating and retiring;

(b) a normal rhythm of the week with differentiation of schedules for weekdays/weekends, and;

(c) a normal rhythm of the year, including the observance of holidays, days with personal significance, and vacations. To the extent that a resident is capable of handling the responsibilities involved, he/she should be allowed to come and go from the group residence, entertain visitors, have appropriate contact with members of the opposite sex, experience the normal role of child or adult and take those risks appropriate to his/her age. In addition to the appropriate physical design and life-style model, individualized programming and qualified staff to carry out that programming are essential components in providing for maximum development of each resident.

Section 1.2 General Requirements for Community ICF/MR's

Physical characteristics of a normal environment dictate that the residence be physically integrated within the community and have exterior and interior features that are similar to a majority of other homes in the neighborhood. In recognition of the preceding principles, the State has established the following general requirements which apply to all ICF/MR facilities beginning operation after July 1, 1977.

1.2.1 Residential Location - All ICF/MR programs shall be located in residential neighborhoods. This shall be construed to mean that 75% of the structures within 0.1 miles of the proposed facility are denoted to primarily residential use.

1.2.2 Conformance - The exterior design of any ICF/MR shall be such so as not to call undue attention to the structure. The maximum height of the structure shall not exceed by more than 25% the average height of residences on abutting properties. Exterior finish materials shall be selected so as to conform to neighborhood standards. It is not the purpose of this program to encourage exterior designs or finishes which are unique to a neighborhood. This is not intended to inihibit [inhibit] the use of solar panels or other tested energy-saving devices.

1.2.3 Size - No ICF/MR regulated hereunder shall serve, or be designed to serve, more than six (6) mentally retarded persons. Proposals for projects to serve four (4) or five (5) persons may be considered, subject to cost considerations.

1.2.4 Regulatory Conflict - The State of Vermont is committed to the principle of normalization. In the event a provider hereunder, or a proposed provider, believes that mandated regulations conflict with the principles of normalization, the following procedure is to be followed:

a. Follow the regulation as written.

b. Send documentation of the alleged conflict to the Commissioner of Mental Health.

Disregard of written regulations may be cause for denial of Medicaid reimbursement.

1.2.5 Density - In no event shall an ICF/MR be located within 1,000 feet of another group residence for developmentally disabled persons. No ICF/MR shall be located in any community where such facility would increase the number of mentally retarded persons served in group residences in that community beyond 0.5% of that community's population.

Section 2.1 Definition of Persons to be Served

A. ICF/MR facilities in Vermont are intended to serve individuals whose primary handicapping condition is mental retardation, or other related conditions. In particular, an ICF/MR may be an appropriate environment for a mentally retarded person with multiple, significant skill deficits. The service needs of every person are unique; it is not possible to state precisely the behavioral characteristics which would best be served in an ICF/MR. In general, however, a mentally retarded individual would likely not be best served in an ICF/MR unless that person has significant deficits in most of the following areas:

2.1.1 Nutrition - including ability to purchase and prepare nutritious meals. Also included here are self-feeding skills.

2.1.2 Grooming - including personal hygiene and the ability to dress appropriately.

2.1.3 Communication - including the ability to communicate needs to other than mental retardation professionals.

2.1.4 Health Status - especially with respect to chronic conditions.

2.1.5 Personal Health Care Management - including ability to manage typical health-related problems.

2.1.6 Social Skills - including those needed to procure needed goods and services and to participate in appropriate recreational activities.

2.1.7 Emergency Safety Skills - including ability to safely evacuate in time of fire.

The preceding list is not intended to be all-inclusive, but is provided for guidance only.

Section 3.1 Functional Record Keeping for Individual Program Planning

The residential program record keeping system shall provide for the compilation of data that will be used in implementing each individual's program plan and for reviewing and revising the plan on the basis of the individual's response to it. Individual program plan records shall:

a. Contain a comprehensive list of the resident's developmental needs with accompanying supportable data.

b. Identify supportable short and long term goals and projected time frames for their completion.

c. Record and date resident's progress toward goal attainment.

d. Identify staff person responsible for implementing specific objectives and strategy to be used.

e. Contain standard record charts for recording progress.

f. Follow standard procedures for maintenance of the record by staff.

g. Provide a format for identifying support elements and/or staff training which would be necessary for the resident to acquire new skills.

h. Indicate client or guardian approval of the goals and strategies defined in the plan.

Results, recommendations and actions of the interdisciplinary assessment process shall be recorded. Each individual record shall additionally contain:

a. Date of admission.

b. Records of support services provided, attendance and individual response to service.

c. Reports of accidents, seizures, illnesses, and treatments thereof, and immunizations.

d. Records of significant behavior incidents.

e. Records of contacts with the individual's family or guardian.

Where particular professional services require the maintenance of separate records, a summary of the information contained therein shall be entered in the individual's residential record.

All information contained in the resident's record shall be considered privileged and confidential. Written consent of the resident or his parent or guardian shall be required for the release of information to persons other than residential staff for programming purposes, or Agency of Human Services personnel for certification and inspection purposes.

When it is necessary for facility staff to supervise the use of personal funds, a record of such shall be maintained as part of the resident's record.

Section 3.2 Record Keeping for Medical Records

Medical records shall include:

a. Name of the resident's physician, dentist, or clinic.

b. Dates of examinations and treatments.

c. Any special instructions for care or treatment that were recommended.

d. When a resident receives specialized therapeutic services, a record of therapies provided and the resident's progress in these therapies shall be maintained.

e. Medical history.

When a resident receives a medication, a record of the prescription and administration of the medication shall be maintained. Adverse reactions to medication, and the report to the physician of the same, shall be recorded.

When a resident is hospitalized, a summary of the hospitalization shall be requested. The summary shall include a listing of medications and treatment recommended at discharge, as well as directions for follow-up care and further examination.

All entries in the resident's record shall be legible, dated and authenticated by the signature and identification of the individual making the entry

Section 3.3 Record Keeping Relative to Skill Areas

When appropriate to the identified needs of the resident, and as set forth in the individual program plan, the residential staff shall conduct and record training and periodic evaluation of the resident's skills in the areas specified below:

3.3.1 Eating and Drinking Skills - including table manners, use of adaptive equipment and independent use of drinking units.

3.3.2 Toileting Skills - every resident who does not eliminate appropriately and independently shall be engaged in a prescribed toilet training program such as Foxe-Azrin. Residents who are incontinent shall be immediately cleansed and changed upon soiling, unless specifically contraindicated by a plan for toilet training.

3.3.3 Dressing Skills - including selecting daily clothing appropriate to the season, weather and activity to be engaged in; the use of prosthetic devices as needed and the purchasing of clothing as independently as possible using community stores.

3.3.4 Grooming Skills - each resident shall be assisted in learning normal grooming practices with individual toilet articles which are readily accessible:

a. Dental.

b. Shaving.

c. Receiving hair cutting and styling in an individualized manner consistent with current style.

d. Care of fingernails and toenails.

e. Bathing/showering conducted as needed, at the most independent level possible with due regard for privacy.

f. Female residents shall be instructed in attaining independence in caring for menstrual needs.

3.3.5 Health Care Skills - including those related to nutrition, use of and self-administration of medication, first aid, care and use of prosthetic devices, preventive health care, safety, and birth control.

3.3.6 Communication Skills - including language stimulation and use of signing.

3.3.7 Interpersonal Skills - such as sharing, courtesy, cooperation, and responsibility.

3.3.8 Home Management Skills - including laundering and mending own clothing, meal planning and preparation and housekeeping.

3.3.9 Mobility Skills - including ambulation, use of mobility equipment, orientation to community.

3.3.10 Time Management Skills.

3.3.11 Money Management Skills - including normal possession and use of money.

3.3.12 Transportation Skills - all residents shall receive instruction, where appropriate, in the independent use of transportation services. Depending on functioning level, this may mean developing the skills to board a school bus independently, or may mean using community public transportation services unaided.

3.3.13 Community Service Skills - all residents shall receive training in the proper use of community services (restaurant, laundry, bank, clothing and grocery stores, pharmacy, post office, etc.) and recreational (bowling alley, swimming pool, public beaches, etc.) facilities.

3.3.14 Leisure Time Skills.

Each training program shall identify for the resident:

a. Behaviorally-stated objectives.

b. Strategies to be used to achieve objectives.

c. Anticipated schedule.

d. Person responsible for conducting the training.

e. Collection of data to assess progress.

f. The instructional materials and techniques to be used which are appropriate to the chronological age of the individual.

Because it may not be possible to attempt to fulfill simultaneously all of the individual's developmental needs, it may be necessary to identify those needs and objectives that have priority, and to arrange the individual's program accordingly.

The residential program may either provide the training in any of the above areas directly, or may, for certain skills such as communication or mobility, seek consulting services from other community agencies. The individual's program plan designates responsibility for provision of each service need.

Section 4.1 Dental Services

4.1.1 Diagnostic Services

a. The ICF/MR must provide each resident with comprehensive diagnostic dental services that include a complete extra-oral and intraoral examination, using all diagnostic aids necessary to properly evaluate the resident's oral condition, not later than one (1) month after a resident's admission to the ICF/MR, unless he received the examination within six (6) months before admission.

b. The ICF/MR must review the results of the examination and enter them in the resident's record.

4.1.2 Treatment - The ICF/MR must provide each resident with comprehensive dental treatment that includes:

a. Provision for emergency dental treatment on a 24-hour-a-day basis by a qualified dentist.

b. A system that assures that each resident is re-examined as needed, but at least once a year.

4.1.3 Education and Training - The ICF/MR must provide education and training in the maintenance of oral health that includes:

a. A dental hygiene program that informs residents and all staff on nutrition and diet control measures and residents and living unit staff on proper oral hygiene methods.

b. Instruction of parents or guardians in the maintenance of proper oral hygiene in appropriate instances, for example when a resident leaves the ICF/MR.

4.1.4 Records - The ICF/MR must:

a. Keep a permanent dental record for each resident.

b. Enter a summary dental progress report at stated intervals in each resident's record kept in the living unit.

c. Provide a copy of the permanent dental record to any facility to which the resident is transferred.

4.1.5 Formal Arrangements - The ICF/MR must have a formal arrangement for providing each resident with the dental services required under this subpart. All dentists and dental hygienists providing services to the facility must be licensed to practice in Vermont.

Section 4.2 Training and Habilitation Services

4.2.1 Required Services

a. The ICF/MR must provide training and habilitation services to all residents, regardless of age, degree of retardation, or accompanying disabilities or handicaps.

b. Individual evaluations of residents must:

1. Be based upon the use of empirically reliable and valid instruments, whenever these instruments are available.

2. Provide the basis for prescribing an appropriate program of training experiences for the resident.

c. The ICF/MR must have written training and habilitation objectives for each resident that are:

1. Based upon complete and relevant diagnostic and prognostic data.

2. Stated in specific behavioral terms that permit the progress of each resident to be assessed.

d. The ICF/MR must provide evidence of services designed to meet the training and habilitation objectives for each resident.

e. The training and habilitation staff must:

1. Maintain a functional training and habilitation record for each resident.

2. Provide training and habilitation services to residents with hearing, vision, perceptual, or motor impairments.

4.2.2 Staff - The ICF/MR must have enough qualified training and habilitation personnel and support staff, supervised by a qualified mental retardation professional, to carry out the training and habilitation program.

Section 4.3 Food and Nutrition Services

4.3.1 Required Services - The ICF/MR's food services must include:

a. Menu planning.

b. Initiating food orders or requisitions.

c. Establishing specifications for food purchases and insuring that the specifications are met.

d. Storing and handling food.

e. Preparing and serving food.

f. Maintaining sanitary standards in compliance with State and local regulations.

g. Orienting, training, and supervising food service personnel.

4.3.2 Diet Requirements

a. The ICF/MR must provide each resident with a nourishing, well-balanced diet.

b. Modified diets must be:

1. Prescribed by the resident's interdisciplinary team with a record of the prescription kept on file.

2. Planned, prepared, and served by individuals who have received adequate instruction.

3. Periodically reviewed and adjusted as needed.

c. The ICF/MR must furnish a nourishing, well-balanced diet in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences, adjusted for age, sex, activity, and disability, unless otherwise required by medical needs. (Recommended Dietary Allowances (8th ed., 1974) is available from the Printing and Publication Office, National Academy of Sciences, Washington, D.C. 20418.)

d. A resident may not be denied a nutritionally adequate diet as a form of punishment.

4.3.3 Meal Service

a. The ICF/MR must serve at least three meals daily, at regular times comparable to normal mealtimes in the community with:

1. Not more than 14 hours between a substantial evening meal and breakfast of the following day.

2. Not less than 10 hours between breakfast and the evening meal of the same day.

b. Food must be served:

1. In appropriate quantity.

2. At appropriate temperature.

3. In a form consistent with the developmental level of the resident.

4. With appropriate utensils.

c. Food served and uneaten must be discarded.

4.3.4 Menus

a. Menus must:

1. Be written in advance.

2. Provide a variety of foods at each meal.

3. Be different for the same days of each week and adjusted for seasonal changes.

b. The ICF/MR must keep on file, for at least thirty (30) days, records of menus as served and of food purchased.

4.3.5 Food Storage - The ICF/MR must store:

a. Dry or staple food items at least 12 inches above the floor, in a ventilated room not subject to sewage or waste water backflow or contamination by condensation, leakage, rodents, or vermin.

b. Perishable foods at proper temperatures to conserve nutritive values.

4.3.6 Work Areas - The ICF/MR must:

a. Have effective procedures for cleaning all equipment and work areas.

b. Provide handwashing facilities, including hot and cold water, soap, and paper towels adjacent to work areas.

4.3.7 Dining Areas and Service - The ICF/MR must:

a. Serve meals for all residents, including the mobile and nonambulatory, in dining rooms, unless otherwise required for health reasons or by decision of the team responsible for the resident's program.

b. Provide table service for all residents who can and will eat at a table, including residents in wheelchairs.

c. Equip areas with table, chairs, eating utensils, and dishes designed to meet the developmental needs of each resident.

d. Supervise and staff dining rooms adequately to direct self-help dining procedures and to assure that each resident receives enough food.

4.3.8 Training of Residents and Direct Care Staff

a. The ICF/MR must provide residents with systematic training to develop appropriate eating skills, using special eating equipment and utensils if it serves the developmental process.

b. Direct care staff must be trained in and use proper feeding techniques.

c. The ICF/MR must insure that residents eat in an upright position, unless medically contraindicated, and in a manner consistent with their developmental needs.

4.3.9 Staff

a. The ICF/MR must have enough competent personnel to meet the food and nutrition needs of residents.

b. The ICF/MR must designate a staff member who is trained or experienced in food management or nutrition to direct food and nutrition services.

Section 4.4 Medical Services

4.4.1 Required Services - The ICF/MR must:

a. Provide medical services through direct contact between physicians and residents and through contact between physicians and individuals working with the residents.

b. Provide health services including treatment, medications, diet, and any other health service prescribed or planned for the resident, 24 hours a day.

c. Provide evidence, such as utilization review committee records, that hospital and laboratory services are used in accordance with professional standards.

4.4.2 Goals and Evaluations

a. Physicians must participate, when appropriate, in:

1. The continuing interdisciplinary evaluation of individual residents for the purposes of beginning, monitoring, and following up on individualized habilitation programs.

2. The development for each resident of a detailed, written statement of:

- case management goals for physical and mental health, education, and functional and social competence.

- a management plan detailing the various habilitation or rehabilitation services to achieve those goals, with clear designation of responsibility for implementation.

b. The ICF/MR must review and update the statement of treatment goals and management plans as needed, but at least annually, to insure:

1. Continuing appropriateness of the goals.

2. Consistency of management methods with the goals.

3. The achievement of progress toward the goals.

4.4.3 Arrangements with Outside Resources: - The ICF/MR must:

a. Have a formal arrangement for providing each resident with medical care that includes care for medical emergencies on a 24-hour-a-day basis.

b. Designate a physician, licensed to practice medicine in the State, to be responsible for maintaining the general health conditions and practices of the ICF/MR.

c. Maintain effective arrangements for residents to receive prompt medical and remedial services that they require but that the ICF/MR does not regularly provide.

d. Where appropriate in community ICF/MR's, have a formal arrangement for providing licensed practical nurses as needed to carry out resident's programs.

4.4.4 Preventive Health Services - The ICF/MR must have preventive health services for residents that include:

a. Means for the prompt detection and referral of health problems, through adequate medical surveillance, periodic inspection, and regular medical examinations.

b. Annual physical examinations that include:

1. Examination of vision and hearing.

2. Routine screening, laboratory examinations as determined necessary by the physician, and special studies when needed.

c. Immunizations, using as a guide, the recommendations of the Public Health Service Advisory Committee on Immunization Practices and of the Committee on the Control of Infectious Diseases of the American Academy of Pediatrics.

d. Tuberculosis control, appropriate to the ICF/MR's population, in accordance with the recommendations of the American College of Chest Physicians, or the section on diseases of the chest of the American Academy of Pediatrics, or both.

e. Reporting of communicable diseases and infections in accordance with law.

4.4.5 Required Services - The ICF/MR must provide residents with nursing services, in accordance with their needs, that include, as appropriate, the following:

a. Registered nurse participation in:

1. The preadmission evaluation study and plan.

2. The evaluation study, program design, and placement of the resident at the time of admission.

3. The periodic re-evaluation of the type, extent, and quality of services and programming.

4. The development of the discharge plan.

5. The referral to appropriate community resources.

b. Training in habits of personal hygiene, family life, and sex education that includes, but is not limited to, family planning and venereal disease counseling.

c. Control of communicable diseases and infections through:

1. Identification and assessment.

2. Reporting to medical authorities.

3. Implementation of appropriate protective and preventive measures.

4. Development of a written nursing services plan for each resident as part of the total habilitation program.

5. Modification of the nursing plan, in terms of the resident's daily needs, at least annually for adults and more frequently for children, in accordance with developmental changes.

4.4.6 Training

a. A registered nurse must participate, as appropriate, in the planning and implementation of training of the ICF/MR's personnel.

b. The ICF/MR must have direct care personnel trained in:

1. Detecting signs of illness or dysfunction that warrant medical or nursing intervention.

2. Basic skills required to meet the health needs and problems of the residents.

3. First aid for accident or illness.

4.4.7 Supervision of Health Services in Community ICF/MR's

a. Contracting for the services of a public health nurse or other registered nurse to care for minor illnesses, injuries, or emergencies, and to consult on the health aspects of the individual plan of care.

b. Having a responsible staff member on duty 24-hour-a-day who is immediately accessible to the residents to take reports of injuries, symptoms of illness, and emergencies.

c. The health services supervisor is responsible for developing, supervising the implementation of, reviewing and revising a written health care plan for each resident that is:

1. Developed and implemented according to the instructions of the attending or staff physician.

2. Reviewed and revised as needed, but not less often than quarterly.

Section 4.5 Pharmacy Services

4.5.1 Required Services - The ICF/MR must:

a. Make formal arrangements for qualified pharmacy services, including provision for emergency service.

b. Have a current pharmacy manual that:

1. Includes policies and procedures and defines the functions and responsibilities relating to pharmacy services.

2. Is revised annually to keep abreast of current developments in services and management techniques.

c. Have a formulary system approved by a responsible physician and pharmacist and other appropriate staff. Copies of the ICF/MR's formulary system and of the American Hospital Formulary Service must be located and available in the facility.

4.5.2 Pharmacist

a. Pharmacy services must be provided under the direction of a qualified, licensed pharmacist.

b. The pharmacist must:

1. When a resident is admitted, obtain, if possible, a history of prescription and nonprescription drugs used and enter this information in the resident's record.

2. Receive the original, or a direct copy, of the physician drug treatment order.

3. Maintain for each resident an individual record of all prescription and nonprescription medications dispensed, including quantities and frequency of refills.

4. Participate, as appropriate, in the continuing interdisciplinary evaluation of individual residents for the purposes of beginning, monitoring, and following up on individualized habilitation programs.

5. Establish quality specifications for drug purchases and insure that they are met.

c. A pharmacist or registered nurse must regularly review the medication record of each resident for potential adverse reactions, allergies, interactions, contraindications, rationality and laboratory test modifications and advise the physician of any recommended changes with reasons and with an alternate drug regimen.

d. As appropriate to the ICF/MR, the responsible pharmacist, physician, nurse and other professional staff must write policies and procedures that govern the safe administration and handling of all drugs. The following policies and procedures must be included:

1. There must be a written policy governing the administration (including self-administration) of drugs, whether prescribed or not.

2. The pharmacist or an individual under his supervision must compound, package, label, and dispense drugs including samples and investigational drugs. Proper controls and records must be kept of these processes.

3. Each drug must be identified up to the point of administration.

4. Whenever possible, the pharmacist must dispense drugs that require dosage measurements in a form ready to be administered to the resident.

4.5.3 Drugs and Medications

a. A medication must be used only by the resident for whom it is issued.

b. Any drug that is discontinued or outdated and any container with a worn, illegible, or missing label must be returned to the pharmacy for proper disposition.

c. The ICF/MR must have:

1. An automatic stop order on all drugs.

2. A drug recall procedure that can be readily used.

3. A procedure for reporting adverse drug reactions to the Food and Drug Administration.

4. An emergency kit available and appropriate to the needs of its residents.

d. Medication errors and drug reactions must be recorded and reported immediately to the practitioner who ordered the drug.

4.5.4 Drug Storage - The ICF/MR must:

a. Store drugs under proper conditions of sanitation, temperature, light, moisture, ventilation, segregation, and security.

b. Store poisons, drugs used externally, and drugs taken internally on separate shelves or in separate cabinets, at all locations.

c. Keep medication that is stored in a refrigerator containing other items in a separate compartment with proper security.

d. If there is a drug storeroom separate from the pharmacy, keep a perpetual inventory of receipts and issues of all drugs from that storeroom.

e. Meet the drug security requirements of Federal and State laws that apply to storerooms, pharmacies, and living units.

Section 4.6 Physical and Occupational Therapy Services

4.6.1 Required Services

a. The ICF/MR must provide physical and occupational therapy services through direct contact between therapists and residents and through contact between therapists and individuals involved with the residents.

b. Physical and occupational therapy staff must provide treatment training programs that are designed to:

1. Preserve and improve abilities for independent function, such as range of motion, strength, tolerance, coordination and activities of daily living.

2. Prevent, insofar as is possible, irreducible or progressive disabilities through means such as the use of orthotic and prosthetic appliances, assistive and adaptive devices positioning, behavior adaptations, and sensory stimulation

c. The therapist must:

1. Work closely with the resident's primary physician and with other medical specialists.

2. Record regularly and evaluate periodically the treatment training progress.

3. Use the treatment training progress as the basis for continuation or change in the resident's program.

4.6.2 Records and Evaluations - The ICF/MR must have evaluation results treatment objectives, plans and procedures, and continuing observations of treatment progress:

a. Recorded accurately, summarized, and communicated to all relevant parties.

b. Used in evaluating progress.

c. Included in the resident's record kept in the living unit.

Section 4.7 Psychological Services

4.7.1 Required Services - The ICF/MR must:

a. Provide psychological services through personal contact between psychologists and individuals involved with the resident and provide:

1. Psychological services for residents, including evaluation, consultation, therapy, and program development.

2. Administration and supervision of psychological services

3. Staff training.

Section 4.8 Recreation Services

4.8.1 Required Services - The ICF/MR must:

a. Coordinate recreational services with other services and programs provided to each resident, in order to:

1. Make the fullest possible use of the ICF/MR's resources.

2. Maximize benefits to the residents.

b. Design and construct or modify recreation areas and facilities so that all residents, regardless of their disabilities, have access to them.

c. Provide recreation equipment and supplies in a quantity and variety that is sufficient to carry out the stated objectives of the activities programs.

4.8.2 Records - The ICF/MR's resident records must include:

a. Periodic surveys of the residents' recreation interests.

b. The extent and level of the residents' participation in the the recreation program.

Section 4.9 Speech Pathology and Audiology Services

4.9.1 Required Services:

a. The ICF/MR must provide speech pathology and audiology services through direct contact between speech pathologists and audiologists and residents, and working with other personnel, including, but not limited to, teachers and direct care staff.

b. Speech pathology and audiology services available to the ICF/MR must include:

1. Screening and evaluation of residents with respect to speech and hearing functions.

2. Comprehensive audiological assessment of residents as indicated by screening results, that include tests of puretone air and bone conduction, speech audiometry, and other procedures, as necessary, and the assessment of the use of visual cues.

3. Assessment of the use of amplification.

4. Provision for procurement, maintenance, and replacement of hearing aids, as specified by a qualified audiologist.

5. Comprehensive speech and language evaluation of residents, as indicated by screening results, including appraisal of articulation, voice, rhythm, and language.

6. Participation in the continuing interdisciplinary evaluation of individual residents for purposes of beginning, monitoring, and following up on individualized habilitation programs.

7. Treatment services as an extension of the evaluation process, that include:

- direct counseling with residents.

- consultation with appropriate staff for speech improvement and speech education activities.

- work with appropriate staff to develop specialized programs for developing each resident's communication skills in comprehension, including speech, reading, auditory training, and hearing aid utilization and skills in expression, including improvement in articulation, voice, rhythm, and language.

- parti cipation in inservice training programs for direct care and other staff.

4.9.2 Evaluations and Assessments

a. Speech pathologists and audiologists must accurately and systematically report evaluation and assessment results in order to:

1. Provide information, when appropriate, that is useful to other staff working directly with the resident.

2. Include evaluative and summary reports in the resident's record kept in the living unit.

b. Continuing observations of treatment progress must be:

1. Recorded accurately, summarized, and communicated.

2. Used in evaluating progress.

Section 4.10 Social Services

4.10.1 Required Services - The ICR/MR must provide, as part of an interdisciplinary set of services, social services to each resident directed toward:

a. Maximizing the social functioning of each resident.

b. Enhancing the coping capacity of each resident's family.

c. Asserting and safeguarding the human and civil rights of the retarded and their families.

d. Fostering the human dignity and personal worth of each resident.

4.10.2 Social Workers

a. During the evaluation process to determine whether or not admission to the ICF/MR is necessary, social workers must help the resident and his family:

1. Consider alternative services, based on the retarded individual's status and important family and community factors.

2. Make a responsible choice as to whether and when residential placement is indicated.

b. Social workers must participate, when appropriate, in the continuing interdisciplinary evaluation of individual residents for the purposes of beginning, monitoring, and following up on individualized habilitation programs.

c. During the retarded individual's admission to, and residence in the facility, or while he is receiving services from the facility, social workers must, as appropriate, provide liasion between him, the ICF/MR, the family, and the community, in order to:

1. Help the staff:

- individualize and understand the needs of the resident and his family in relation to each other.

- understand social factors in the resident's day-to-day behavior, including staff-resident relationships.

- prepare the resident for changes in his living situation.

2. Help the family develop constructive and personally meaningful ways to support the resident's experience in the ICF/MR through:

- counseling concerning the problems of changes in family structure and functioning.

- referral to specific services, as appropriate.

3. Help the family participate in planning for the resident's return to home or other community placement.

d. After the resident leaves the ICF/MR, social workers must provide systematic followup to assure referral to appropriate community agencies.

Section 5.1 Safety and Sanitation

5.1.1 Emergency Plan and Procedures

a. The ICF/MR must have a written staff organization plan and detailed written procedures to meet all potential emergencies and disasters such as fire, severe weather and missing residents.

b. The ICF/MR must:

1. Clearly communicate and periodically review the plan and procedures with the staff.

2. Post the plan and procedures at suitable locations through the facility.

5.1.2 Evacuation Drills

a. The ICF/MR must hold evacuation drills at least quarterly for each shift of personnel and under varied conditions to:

1. Insure that all personnel on all shifts are trained to perform assigned tasks.

2. Insure that all personnel on all shifts are familiar with the use of the ICF/MR's firefighting equipment.

3. Evaluate the effectiveness of emergency and disaster plans and procedures.

b. The ICF/MR must:

1. Actually evacuate residents to safe areas during at least one evacuation drill each year, on each shift.

2. Make special provisions for the evacuation of the physically handicapped, such as fire chutes and mattress loops with poles.

3. Write and file a report evaluating each evacuation drill.

4. Investigate all accidents and take corrective action to prevent similar accidents in the future.

5.1.3 Fire Prevention

a. The State survey agency shall apply the lodgings or roomings section of the 1973 N.F.P.A. Life Safety Code (101) provided that all residents are:

1. Receiving active treatment.

2. Capable of following directions and taking appropriate action for self-preservation under emergency conditions:

- a licensed physician or a Q.M.R.P. (as defined herein) shall provide written certification regarding the above two items for all residents.

b. Where the certifications required under the above are not available, the State survey agency shall apply the institutional section of the 1973 N.F.P.A. Code (101).

5.1.4 Paint - The ICF/MR must:

a. Use lead-free paint inside the facility.

b. Remove or cover old paint or plaster containing lead so that it is not accessible to residents.

5.1.5 Building Accessibility and Use

a. The ICF/MR must:

1. Be accessible to and usable by all residents, personnel, and the public, including individuals with disabilities.

2. Meet the requirements of American National Standards Institute (A.N.S.I.) Standard No. A117.1 (1961) American Standard Specifications for Making Buildings and Facilities Accessible to and Usable by the Physically Handicapped.

b. The State survey agency may waive, for as long as it considers appropriate, specific provisions of A.N.S.I. Standard No. A117.1 (1961) if:

1. The provision would result in unreasonable hardship on the ICF/MR if strictly enforced.

2. The waiver does not adversely affect the health and safety of the residents.

5.1.6 Sanitation Records and Reports - The ICF/MR must keep:

a. Records that document compliance with the sanitation, health, and environmental safety codes of the State or local authorities having primary jurisdiction over the ICF/MR.

b. Written reports of inspections by State or local health authorities, and records of action taken on their recommendations.

5.1.7 Grouping and Organization of Living Units

a. The ICF/MR may not house residents of grossly different ages, developmental levels, and social needs in close physical or social proximity unless the housing is planned to promote growth and development of all those housed together.

b. The ICF/MR may not segregate residents on the basis of their physical handicaps. It must integrate residents who are mobile nonambulatory, deaf, blind, epileptic, and so forth, with others of comparable social and intellectual development

5.1.8 Resident Living Staff

a. Each resident living unit must have sufficient, appropriately qualified, and adequately trained personnel to conduct the resident living program as required.

b. The ICF/MR must have an individual, whose training and experience is appropriate to the program, who is administratively responsible for resident living personnel.

5.1.9 Resident Living Areas - The ICF/MR must design and equip the resident living areas for the comfort and privacy of each resident.

5.1.10 Resident Bedrooms: Space and Occupancy

a. Bedrooms must:

1. Be at or above street grade level.

2. Be outside rooms.

3. Be equiped with or located near adequate toilet and bathing facilities.

4. Measure at least 60 square feet per resident in multiple resident bedrooms and at least 80 square feet in single resident bedrooms.

5. Accommodate no more than two residents in community ICF/MR's.

6. Accomodate no more than four residents in ICF/MR's serving more than 15.

7. Accommodate no more than 24 residents per unit or dormitory in ICF/MR's serving more than 15.

5.1.11 Resident Bedrooms: Furniture and Bedding - The ICF/MR must provide each resident with:

a. A separate bed of proper size and height for the convenience of the resident.

b. A clean, comfortable mattress.

c. Bedding appropriate to the weather and climate.

d. Appropriate furniture, such as a chest of drawers, a table or desk, and an individual closet with clothes racks and shelves accessible to the resident.

5.1.12 Storage Space in Living Units - The ICF/MR must provide:

a. Space for equipment for daily out-of-bed activity for all residents who are not yet mobile, except those who have a a short-term illness or those few residents for whom out-of-bed activity is a threat to life.

b. Suitable storage space, accessible to the resident, for personal possessions, such as toys and prosthetic equipment.

c. Adequate clean linen and dirty linen storage areas for each living unit.

5.1.13 Resident Bathrooms in Community ICF/MR's

a. The ICF/MR shall have two bathrooms for resident use. Each bathroom shall have a tub and/or shower, a toilet, a lavatory, and mirror placed to facilitate dressing:

1. At least one such bathroom shall be fully accessible and usable by physically handicapped persons:

- the above requirement shall not be construed to mean that every bathroom need accommodate persons with all types of handicaps. Rather, bathrooms should be designed so that adaptations can be made to insure individual accessibility.

2. Unless otherwise dictated by written training program requirements, the temperature at hot water taps accessible by residents shall not exceed 110 [degrees] F.

5.1.14 Resident Bathrooms in Facilities Serving More Than 15 Residents

a. The ICF/MR shall have toilets, bathtubs, and showers appropriate to the number, size, and design of the facility.

b. Individual privacy must be provided for residents while using bathroom facilities.

c. Bathrooms must be equipped to accommodate individuals with physical handicaps.

d. Unless otherwise dictated by written program requirements, the temperature at hot water taps which are accessible to residents shall not exceed 110 [degrees] F.

5.1.15 Heating and Ventilation in Living Units

a. Each habitable room in the ICF/MR must have:

1. At least one window.

2. Direct outside ventilation by means of windows, louvers, air conditioning, or mechanical ventilation horizontally and vertically.

b. The ICF/MR must:

1. Maintain the temperature and humidity within a normal comfort range by heating, air conditioning, or other means.

2. Use a heating apparatus that does not constitute a burn hazard to residents.

5.1.16 Floors in Living Units - The ICF/MR must have:

a. Floors that have a resilient, nonabrasive, and slip-resistant surface.

b. Nonabrasive carpeting, if the living unit is carpeted and serves residents who crawl.

5.1.17 Emergency Lighting in Community ICF/MR's - Emergency lighting, if used, shall be unobtrusive in nature and not call attention to itself in any way. Such lighting shall not be required.

5.1.18 Emergency Lighting in Facilities Serving More Than 15 Residents - ICF/MR's serving more than 15 residents must have emergency lighting with automatic switching for stairs and exits.

Section 6.1 Definitions

As used in this regulation:

6.1.1 "Ambulatory" means able to walk without assistance.

6.1.2 "Living unit" means a resident living unit that includes sleeping areas and may include dining and activity areas.

6.1.3 "Mobile nonambulatory" means unable to walk without assistance, but able to move from place to place with the use of a device such as a walker, crutches, a wheelchair, or a wheeled platform.

6.1.4 "Nonambulatory" means unable to walk without assistance.

6.1.5 "Nonmobile" meals unable to move from place to place.

6.1.6 "Qualified Mental Retardation Professional" means a person who has specialized training or one year of experience in treating or working with the mentally retarded and is one of the following:

a. A psychologist with a master's degree from an accredited program.

b. A licensed doctor of medicine or osteopathy.

c. An educator with a degree in education from an accredited program.

d. A social worker with a bachelor's degree in:

1. A field other than social work and at least three years of social work experience under the supervision of a qualified social worker.

e. A physical or occupational therapist as defined earlier in this document.

f. A speech pathologist or audiologist as defined earlier in this document.

g. A registered nurse.

h. A therapeutic recreation specialist who:

1. Is a graduate of an accredited program.

2. If the State has a licensing or registration procedure, is licensed or registered in the State.

i. A rehabilitation counselor who is certified by the Committee on Rehabilitation Counselor Certification.

6.1.7 "Resident living" means pertaining to residential services provided by an ICF/MR.

6.1.8 "Training and habilitation services" means those intended to aid the intellectual, sensorimotor, and emotional development of a resident.

Section 6.2 Administrative Policies and Procedures

6.2.1 Philosophy, Objectives, and Goals

a. The ICF/MR must have a written outline of the philosophy, objectives, and goals it is striving to achieve that includes at least:

1. The ICF/MR's role in the State comprehensive program for the mentally retarded.

2. The ICF/MR's goals for its residents.

3. The ICF/MR's concept of its relationship to the parents or legal guardians of its residents.

b. The outline must be available for distribution to staff, consumer representatives, and the interested public.

6.2.2 Resident's Civil Rights - The ICF/MR must have written policies and procedures that insure the civil rights of all residents.

6.2.3 Resident's Bill of Rights - The ICF/MR must have written policies and procedures that insure the following rights for each resident:

a. Information:

1. Each resident must be fully informed, before or at admission, of his rights and responsibilities and of all rules governing resident conduct.

2. If the ICF/MR amends its policies on resident's rights and responsibilities and its rules governing conduct, each resident in the ICF/MR at that time must be informed.

3. Each resident must acknowledge, in writing, receipt of the information and any amendments to it. A mentally retarded resident's written acknowledgment must be witnessed by a third person.

4. Each resident must be fully informed, in writing, of all services available in the ICF/MR and of the charges for these services including any charges for services not paid for my Medicaid or not included in the ICF/MR's basic rate per day. The ICF/MR must provide this information either before, or at the time of admission and on a continuing basis as changes occur in services or charges during the resident's stay.

b. Medical condition and treatment:

1. Each resident must:

- be fully informed by a physician of his health and medical condition unless the physician decides that informing the resident is medically contraindicated.

- be given the opportunity to participate in planning his total care and medical treatment.

- be given the opportunity to refuse treatment.

- give informed, written consent before participating in experimental research.

2. If the physician decides that informing the resident of his health and medical condition is medically contraindicated, he must document this decision in the resident's record.

c. Transfer and discharge:

1. Each resident must be transferred or discharged only for:

- medical reasons.

- his welfare or that of the other residents.

- nonpayment except as prohibited by the Medicaid program.

d. Exercising rights:

1. Each resident must be:

- encouraged and assisted to exercise his rights as a resident of the ICF/MR and as a citizen.

- allowed to submit complaints or recommendations concerning the policies and services of the ICF/MR to staff or to outside representatives of the resident's choice or both, free from restraint, interference, coercion, discrimination, or reprisal.

e. Financial affairs:

1. Each resident must be allowed to manage his personal financial affairs. If a resident requests assistance from the ICF/MR in managing his personal financial affairs:

- the request must be in writing.

- the ICF/MR must comply with the record keeping requirements.

f. Freedom from abuse and restraints:

1. Each resident must be free from mental and physical abuse.

2. Each resident must be free from chemical and physical restraints unless the restraints are:

- authorized by a physician in writing for a specified period of time.

- used in an emergency under the following conditions:

- the use is necessary to protect the resident from injuring himself or others.

- the use is authorized by a professional staff member identified in the written policies and procedures of the facility as having authority to do so.

- the use is reported promptly to the resident's physician by that staff member.

- used during a behavior modification session for a mentally retarded resident under the following conditions:

- the use is authorized in writing by a physician or a qualified mental retardation professional.

- the parent or legal guardian of the mentally retarded resident gives his informed consent to the use of restraints or aversive stimuli.

g. Privacy:

1. Each resident must be treated with consideration, respect and full recognition of his dignity and individuality.

2. Each resident must be given privacy during treatment and care of personal needs.

3. Each resident's records, including information in an automatic data bank, must be treated confidentially.

4. Each resident must give written consent before the ICF/MR may release information from his record to someone not otherwise authorized by law to receive it.

5. A married resident must be given privacy during visits by his spouse.

6. If both husband and wife are residents of the ICF/MR, they must be permitted to share a room.

h. Work:

1. No resident may be required to perform services for the ICF/MR.

i. Freedom of association and correspondence:

1. Each resident must be allowed to:

- communicate, associate, and meet privately with individuals of his choice, unless this infringes on the rights of another resident.

- send and receive personal mail unopened.

j. Activities:

1. Each resident must be allowed to participate in social, religious, and community group activities unless a qualified mental retardation professional:

- determines that these activities are contraindicated for a mentally retarded resident.

- documents that determination in the resident's record.

k. Personal possessions:

1. Each resident must be allowed to retain and use his personal possessions and clothing as space permits.

6.2.4 Delegation of Rights and Responsibilities

a. The ICF/MR must have written policies and procedures that provide that all rights and responsibilities of a resident pass to the resident's guardian, next-of-kin, or sponsoring agency or agencies, if the resident is:

1. Adjudicated incompetent under State law.

2. Determined by a qualified mental retardation professional to be incapable of understanding his rights and responsibilities; the qualified mental retardation professional who made the determination must record the specific reason in the resident's record.

6.2.5 Resident Finances

a. The ICF/MR must have written policies and procedures that protect the financial interest of each resident.

b. If large sums accrue to a resident, the policies and procedures must provide for appropriate protection of these funds and for counseling the resident concerning their use.

c. Each resident must be allowed to possess and use money in normal ways or be learning to do so.

d. The ICF/MR must maintain a current, written financial record for each resident that includes written receipts for:

1. All personal possessions and funds received by or deposited with the ICF/MR.

2. All disbursements made to or for the resident.

e. The financial record must be available to the resident and his family.

6.2.6 Policy and Procedure Manuals - The ICF/MR must have manuals that:

a. Describe the policies and procedures in the major operating units of the ICF/MR.

b. Are current, relevant, and available.

c. Are complied with within the units.

6.2.7 Management Audit Plan - The ICF/MR must have a plan for a continuing management audit to insure that the ICF/MR:

a. Complies with State laws and regulations.

b. Effectively implements its policies and procedures.

6.2.8 Governing Body

a. The ICF/MR must have a governing body that:

1. Exercises general direction over the affairs of the ICF/MR.

2. Establishes policies concerning the operation of the ICF/MR and the welfare of the individuals it serves.

3. Establishes qualifications for the chief executive officer in the following areas:

- education.

- experience.

- personal factors.

- skills.

4. Appoints the chief executive officer.

b. The governing body may consist of one individual or a group.

6.2.9 Chief Executive Officer

a. The chief executive officer must:

1. Act for the governing body in the overall management of the ICF/MR.

2. Arrange for one individual to be responsible for the administrative direction of the ICF/MR at all times.

b. The chief executive officer must be a qualified mental retardation professional.

6.2.10 Qualified Mental Retardation Professional - The ICF/MR must have a qualified mental retardation professional who is responsible for:

a. Supervising the delivery of each resident's individual plan of care.

b. Supervising the delivery of training and habilitation services.

c. Integrating the various aspects of the ICF/MR's program.

d. Recording each resident's progress.

e. Initiating a periodic review of each individual plan of care for necessary changes.

6.2.11 Organization Chart - The ICF/MR must have an organization chart that shows:

a. The major operating programs of the ICF/MR.

b. The staff divisions of the ICF/MR.

c. The administrative personnel in charge of the programs and divisions.

d. The lines of authority, responsibility, and communication for administrative personnel.

6.2.12 Staff-Resident Communications - The ICF/MR must provide for effective staff and resident participation and communication in the following manners:

a. The ICF/MR must establish appropriate standing committees such as human rights, research, review, and infection.

b. The committees must meet regularly and include direct care staff whenever appropriate.

c. Reports of staff meetings, standing, and ad hoc committee meetings must include recommendations and their implementation and be filed.

6.2.13 Communication with Residents and Parents

a. The ICF/MR must have an active program of communication with the residents and their families that includes:

1. Keeping resident's families or legal guardians informed of resident activities that may be of interest to them or of significant changes in the resident's condition.

2. Answering communications from resident's relatives promptly and appropriately.

3. Allowing close relatives and guardians to visit at any reasonable hour, without prior notice, unless the resident's needs limit visits.

4. Allowing parents to visit any part of the ICF/MR that provides services to residents.

5. Encouraging frequent and informal visits home by the residents.

6. Having rules that make it easy to arrange visits home.

b. The ICF/MR must insure that individuals allowed to visit the ICF/MR under the above-mentioned paragraph do not infringe on the privacy and rights of other residents.

6.2.14 Health and Safety Laws - The ICF/MR must meet all Federal, State and local laws, regulations, and codes pertaining to health and safety, such as provisions regulating:

a. Buying, dispensing, safeguarding, administering, and disposing of medications and controlled substances.

b. Construction, maintenance, and equipment for the ICF/MR.

c. Sanitation.

d. Communicable and reportable diseases.

e. Post-mortem procedures.

6.2.15 Agreements with Outside Resources

a. If the ICF/MR does not employ a qualified professional to furnish a required institutional service, it must have in effect a written agreement with a qualified professional outside the ICF/MR to furnish the required service.

b. The agreement must:

1. Contain the responsibilities, functions, objectives and other terms agreed to by the ICF/MR and the qualified professional.

2. Be signed by the administrator or his representative and by the qualified professional.

Section 6.3 Administrative Services

6.3.1 Support Services

a. The ICF/MR must provide adequate, modern administrative support to efficiently meet the needs of residents and facilitate attainment of the ICF/MR's goals and objectives.

b. The ICF/MR must:

1. Document its purchasing process.

2. Adequately operate its inventory control system and stockroom.

3. Have appropriate storage facilities for all supplies and surplus equipment.

4. Have enough trained and experienced personnel to do purchase, supply, and property control functions.

6.3.2 Communication System

a. The ICF/MR must have an adequate communication system, including telephone service, that insures:

1. Prompt contact of on-duty personnel.

2. Prompt notification of responsible personnel in an emergency.

6.3.3 Engineering and Maintenance - The ICF/MR must have:

a. An appropriate preventive maintenance program.

b. Enough trained and experienced personnel for engineering and maintenance functions.

6.3.4 Laundry Services - The ICF/MR must manage its laundry services so that it meets daily clothing and linen needs without delay.

Section 6.4 Admission and Release

6.4.1 Admission Criteria and Evaluations

a. Except as provided in Paragraph c. of this section, an ICF/MR may not admit an individual as a resident unless his needs can be met and an interdisciplinary professional team has determined that admission is the best available plan for that individual.

b. The team must:

1. Conduct a comprehensive evaluation of the individual covering physical, emotional, social, and cognitive factors.

2. Before the individual's admission:

- define his need for service without regard to the availablility of those services.

- review all available and applicable programs of care, treatment, and training and record its findings.

c. If admission is not the best plan but the individual must be admitted nevertheless, the ICF/MR must:

1. Clearly acknowledge that the admission is inappropriate.

2. Initiate plans to actively explore alternatives.

6.4.2 Availability of Rules and Procedures - The facility must make available for distribution a summary of the laws, regulations, and procedures concerning admission, readmission, and release of a resident.

6.4.3 Review of Preadmission Evaluation - Within one month after admission, the interdisciplinary professional team must:

a. Review and update the preadmission evaluation with the participation of direct care personnel.

b. Develop, with the participation of direct care personnel, a prognosis that can be used for programming and placement.

c. Record the results of the evaluation in the resident's record kept in the living unit.

d. Write an interpretation of the evaluation in terms of specific actions to be taken for:

1. The direct care personnel and the special services staff responsible for carrying out the resident's program.

2. The resident's parents or legal guardian.

6.4.4 Annual Review of Resident's Status

a. All relevant personnel of the ICF/MR, including personnel in the living unit, must jointly review the status of each resident at least once a year and produce program recommendations.

b. This review must include consideration of the following:

1. The advisability of continued residence and alternative programs.

2. When the resident legally becomes an adult:

- the need for guardianship.

- how the resident may exercise his civil and legal rights.

6.4.5 Record and Reports of Reviews - The results of the reviews required above must be:

a. Recorded in the resident's record kept in the living unit.

b. Made available to personnel involved in the direct care of the resident.

c. Interpreted to the resident's parents or legal guardian who are involved in planning and decision making.

d. Interpreted to the resident, when appropriate.

6.4.6 Release from the ICF/MR

a. The ICF/MR must establish procedures for counseling a parent or guardian who requests the release of a resident concerning the advantages or disadvantages of the release.

b. Planning for release of a resident must include providing for appropriate services in the resident's new environment, including protective supervision and other follow up services.

c. When a resident is permanently released, the ICF/MR must prepare and place in the resident's record a summary of findings, progress and plans.

6.4.7 Transfer to Another Facility

a. Except as provided in Paragraph b. of this section, the ICF/MR must have in effect a transfer agreement with one or more hospitals sufficiently close by to make feasible the prompt transfer of the resident and his records to the hospital and to support a working arrangement between the ICF/MR and the hospital for providing inpatient hospital services to residents when needed.

b. If the survey agency finds that the ICF/MR tried in good faith to enter into an agreement but could not, the ICF/MR will be considered to meet the requirements of Paragraph a., as long as the survey agency finds that it is in the public interest and essential to assuring ICF/MR services for eligible individuals in the community.

c. When a resident is transferred to another facility, the ICF/MR making the transfer must:

1. Record the reason for the transfer and a summary of findings, progress and plans.

2. Except in an emergency, inform the resident and his parent or guardian in advance and obtain their written consent to the transfer.

6.4.8 Emergencies or Death of a Resident

a. The ICF/MR must notify promptly, the resident's next-of-kin or guardian of any unusual occurrence concerning the resident, including serious illness, accident, or death.

b. If any autopsy is performed after a resident's death:

1. A qualified physician who has no conflict of interest or loyalty to the ICF/MR must perform the autopsy.

2. The resident's family must be told of the autopsy findings if they so desire.

Section 6.5 Personnel Policies

6.5.1 Written Policies - The ICF/MR must:

a. Have written personnel policies that are available to all employees.

b. Make written job descriptions available for all positions.

c. Have written policies that prohibit employees with symptoms or signs of a communicable disease from working.

6.5.2 Licensure and Professional Standards - The ICF/MR must:

a. Require the same licensure, certification, or standards for positions in the facility as are required for comparable positions in community practice.

b. Take into account in its personnel activities the ethical standards of professional conduct developed by professional societies.

6.5.3 Suspension and Dismissal - The ICF/MR must have an authorized procedure, consistent with due process, for suspending or dismissing an employee.

6.5.4 Staff Treatment of Residents

a. The ICF/MR must have written policies that prohibit mistreatment, neglect, or abuse of a resident by an employee of the ICF/MR.

b. The ICF/MR must insure that all alleged violations of these policies are reported immediately.

c. The ICF/MR must have evidence that:

1. All violations are investigated thoroughly.

2. The results of the investigation are reported to the chief executive or his designated representative within 24 hours of the report of the incident.

3. If the alleged violation is verified, the chief executive officer imposes an appropriate penalty.

6.5.5 Sufficient Staffing and Resident Work

a. The ICF/MR must have a staff of sufficient size that the ICF/MR does not depend on residents or volunteers for services

b. The ICF/MR must have a written policy to protect residents from exploitation if they engage in productive work.

6.5.6 Staff Training Program

a. The ICF/MR must have a staff training program, appropriate to the size and nature of the ICF/MR, that includes:

1. Orientation for each new employee to acquaint him with the philosophy, organization, program, practices, and goals of the ICF/MR.

2. Inservice training for any employee who has not achieved the desired level of competence.

3. Continuing inservice training for all employees to update and improve their skills.

4. Supervisory and management training for each employee who is in, or a candidate for, a supervisory position.

b. If appropriate to the size and nature of the ICF/MR, it must have someone designated to be responsible for staff development and training.

Section 6.6 Resident Living

6.6.1 Responsibilities of Living Unit Staff

a. The living unit staff must make care and development of the residents their primary responsibility. This includes training each resident in the activities of daily living and in the development of self-help and social skills.

b. The ICF/MR must insure that the staff are not diverted from their primary responsibilities by excessive housekeeping of clerical duties or other activities not related to resident care.

c. Members of the living unit staff from all shifts must participate in appropriate activities relating to the care and development of the resident including, at least, referral, planning, initiation, coordination, implementation, follow through, monitoring, and evaluation.

6.6.2 Resident Evaluation and Program Plans - The ICF/MR must have specific evaluation and program plans for each resident that are:

a. Available to direct care staff in each living unit.

b. Reviewed by a member or members of an interdisciplinary professional team at least monthly with documentation of the review entered in the resident's record.

6.6.3 Resident Activities

a. The ICF/MR must develop an activity schedule for each resident that:

1. Does not allow periods of unscheduled activity to extent longer than three continuous hours.

2. Allows free time for individual or group activities using appropriate materials, as specified by the program team.

3. Includes planned outdoor periods all year round.

b. Each resident's activity schedule must be available to direct care staff and be carried out daily.

c. The ICF/MR must insure that a multihandicapped or non-ambulatory resident:

1. Spends a major portion of the waking day out of bed.

2. Spends a portion of the waking day out of his bedroom area.

3. Has planned daily activity and exercise periods.

4. Moves around by various methods and devices whenever possible.

6.6.4 Personal Possessions - The ICF/MR must allow the residents to hay personal possessions, such as toys, books, pictures, games, radio arts and crafts materials, religious articles, toiletries, jewelr and letters.

6.6.5 Control and Discipline of Residents

a. The ICF/MR must have written policies and procedures for the control and discipline of residents that are available in each living unit and to parents and guardians.

b. If appropriate, residents must participate in formulating these policies and procedures.

c. The ICF/MR may not allow:

1. Corporal punishment of a resident.

2. A resident to discipline another resident, unless it is done as part of an organized self-government program conducted in accordance with written policy.

3. A resident to be placed alone in a locked room.

6.6.6 Physical Restraint

a. The ICF/MR may not use physical restraint:

1. As punishment.

2. For the convenience of the staff.

3. As a substitute for activities or treatment.

b. The ICF/MR must have a written policy that specifies:

1. How and when physical restraint may be used.

2. The staff members who must authorize its use.

3. The method for monitoring and controlling its use.

c. An order for physical restraint may not be in effect longer than twelve hours.

d. Appropriately trained staff must check a resident placed in a physical restraint at least every thirty minutes and keep a record of these checks.

e. A resident who is in a physical restraint must be given an opportunity for motion and exercise for a period of not less than ten minutes during each two hours of restraint.

6.6.7 Mechanical Devices Used for Physical Restraint

a. Mechanical devices used for physical restraint must be designed and used in a way that causes the resident no physical injury and the least possible physical discomfort.

b. A totally enclosed crib or a barred enclosure is a physical restraint.

c. Mechanical supports used to achieve proper body position and balance are not physical restraints. However, mechanical supports must be designed and applied:

1. Under the supervision of a qualified professional.

2. In accordance with principles of good body alignment, concern for circulation, and allowance for change of position.

6.6.8 Chemical Restraint of Residents - The ICF/MR may not use chemical restraint:

a. Excessively.

b. As punishment.

c. For the convenience of the staff.

d. As a substitute for activities or treatment.

e. In quantities that interfere with a resident's habilitation program.

6.6.9 Resident Clothing - The ICF/MR must insure that each resident:

a. Has enough neat, clean, suitable, and seasonable clothing.

b. Has his own clothing marked with his name when necessary.

c. Is dressed daily in his own clothes, unless this is contraindicated in written medical orders.

d. Is trained and encouraged, as appropriate, to:

1. Select his daily clothing.

2. Dress himself.

3. Change his clothes to suit his activities.

e. Has storage space for his clothing that is accessible to him even if he is in a wheelchair.

6.6.10 Behavior Modification Programs

a. For the purposes of this section:

1. "Aversive stimuli" means things or events that the resident finds unpleasant or painful that are used to immediately discourage undesired behavior.

2. "Time out" means a procedure designed to improve a resident's behavior by removing positive reinforcement when his behavior is undesirable.

b. Behavior modification programs involving the use of aversive stimuli or time out devices must be:

1. Reviewed and approved by the ICF/MR's human rights committee or the qualified mental retardation professional

2. Conducted only with the consent of the affected resident's parents or legal guardian.

3. Described in written plans that are kept on file in the ICF/MR.

c. A physical restraint used as a time out device may be applied only during behavior modification exercises and only in the presence of the trainer.

d. For time out purposes, time out devices and aversive stimuli may not be used for longer than one hour, and then only during the behavior modification program and only under the supervision of the trainer.

6.6.11 Health, Hygiene, Grooming, and Toilet Training

a. Each resident must be trained to be as independent as possible in health, hygiene, and grooming practices, including bathing, brushing teeth, shampooing, combing and brushing hair, shaving and caring for toenails and fingernails.

b. Each resident who does not eliminate appropriately and independently must be in a regular, systematic toilet training program and a record must be kept of his progress in the program.

c. The ICF/MR must establish procedures for:

1. Weighing each resident monthly, unless the special needs of the resident require more frequent weighing.

2. Measuring the height of each resident every three months until the resident reaches the age of maximum growth.

3. Maintaining weight and height records for each resident

4. Insuring that each resident maintains a normal weight.

d. At least every three days, a physician must review orders prescribing bed rest or prohibiting a resident from being outdoors.

e. The ICF/MR must furnish, maintain in good repair, and encourage the use of dentures, eyeglasses, hearing aids, braces, and other aids prescribed for a resident by an appropriate specialist.

Section 7.1 Allowable Costs

Allowable costs are defined as those necessary and ordinary costs related to resident care. They must be costs that prudent and cost-conscious management would pay for a given item or service. It should be noted, however, that allowable costs will not be considered for inclusion in reimbursement rate determination unless they have undergone prior budgetary review and have been approved by the Administrative Agency. The following, although not intended as an all-inclusive listing, are presented as specifics to clarify some anticipated areas of misunderstanding.

7.1.1 Depreciation - Depreciation will be an allowable cost when the following guidelines are followed:

a. Method: straight line.

b. Minimum asset life for new facilities and equipment:

1. Buildings - 25 years.

2. Building improvement - remaining life of building but not less than 15 years.

3. Equipment - 5 years.

4. Vehicles - 3 years.

5. Land improvement - 25 years.

6. Leasehold improvements - the useful life of the improvement or the remaining term of the lease, whichever is shorter.

c. Asset life for used facilities and equipment: reasonable life expectancy.

d. Basis when purchased new: actual cost (which includes legal fees, shipping charges, etc.).

e. Basis when purchased used: actual cost.

f. Basis limitations: all assets with a life expectancy in excess of one year and an individual cost in excess of $ 500 must be capitalized and depreciated.

7.1.2 Gains and Losses on Disposition of Equipment - Gains and losses on the sale or abandonment of equipment are includable in computing allowable costs. A gain shall be an offset to depreciation expense to the extent that such gain resulted from depreciation reimbursed under these regulations. Gains or losses on trade-ins should be reflected in the basis of the acquired asset.

7.1.3 Costs of Residency - The costs of residence in the facility for administrators and key staff are allowable costs if such costs together with other compensation, are reasonable.

7.1.4 Cost of Purchases from Related Organizations - The cost of purchases from related organizations are allowable to the extent that they do not exceed the cost to the related organization or the price of comparable services, facilities, or supplies purchased elsewhere, whichever is lower.

7.1.5 Employee Training and Education Costs - Employee training and eucation costs pertaining to providing or improving patient care are allowable.

7.1.6 One Time, Pre-opening Costs of New Facilities - One time, pre-opening costs of new facilities incurred more than seven days prior to admittance of residents are allowable, but must be capitalized and amortized over a period of no less than 35 consecutive months beginning with the month in which the first resident is admitted for care. Examples of these costs are wages paid for services rendered prior to the opening of the facility. Costs related directly to the purchase, construction, or renovation of the building must be depreciated over the life of the building.

7.1.7 Facility Rental Costs - Facility rental costs under sale and lease-back agreements, lease with option to buy arrangements, or agreements with related organizations will be allowable for the lesser of the actual cost or the cost that would have been allowed if the provider owned the facility.

7.1.8 Indirect Costs - Indirect costs which are distributed from other facility cost centers, or, in the case of state owned facilities, from other state agencies and other cost centers of the facility itself, are allowable costs when the basis for such distribution have a statistical basis and have been approved as part of the budgetary process.

7.1.9 Return on Capital Investment - A reasonable rate of return on capital investment will be considered as an allowable cost for proprietary providers. In addition to the budgetary constraints, return on capital will be further limited to a maximum rate per annum as determined by the Administering Agency and applied to that portion of the owner's equity which is used to serve medical assistance residents.

Section 7.2 Non-allowable Costs

Non-allowable costs may be identified in three areas: cost for services not chargeable to the medical assistance program cost for expenses not related to patient care or costs not actually incurred, and costs that are judged unreasonable by the Administering Agency.

7.2.1 Services Not Chargeable to ICF/MR Medical Assistance Program - Services not chargeable to the ICF/MR Medical Assistance Program include, but are not limited to, the following list (if in establishing a new service, the facility is unable to find the requirement for such service, the Administering Agency should be contacted for an opinion):

a. Education services.

b. Vocational services.

c. Medical services billable under other provisions of the Medical Assistance Program.

d. Services that are specifically funded directly through other sources at least to the extent to which they are funded.

7.2.2 Cost for Expenses not Related to Patient Care - Cost for expenses not related to patient care or costs not actually incurred include but are not limited to, the following:

a. Depreciation for noted assets.

b. Amortization on intangible assets.

c. Bad debts arising from uncollectable resident accounts.

d. Fund raising.

e. Charitable contributions.

f. Entertainment.

7.2.3 Disallowance - The Administering Agency shall have the right to disallow any costs that relate to management inefficiency and/or unnecessary care of facilities. The cost effect of transactions that are conceived for the purpose of circumventing the regulations contained in this publication will be disallowed under the principle that the substance of the transaction shall prevail over form.

Section 7.3 Rate Limitations

- Notwithstanding any other provisions of these regulations, the actual cost rate for residential services will not exceed the provider's normal rate charged private residents of comparable residential services.

Section 7.4 Acceptance of Medical Assistance Rate

- The provider must accept the actual cost rates as full and final payment for ICF/MR services delivered to the Medical Assistance client.

Section 7.5 Rate Determination

7.5.1 Budgetary Process

a. Each provider will submit, at least two days prior to the first day of its fiscal year, a budget for the ensuing fiscal year, in the format prescribed by the Administering Agency. This budget will contain line items of expense based on prior year's expenses and allowances for known cost changes as described in Paragraph e. of this section. Each line item must be justified by a concise narrative. For personnel costs, position titles and job descriptions must be used. All projected costs included in the budget which do not meet the criteria of allowable costs as defined in the Allowable Costs section of these regulations, must be deducted in the calculation of net cost.

b. This budget will be reviewed by the Administering Agency, adjusted if necessary, and when approved, will serve as a basis for the service payment rate and the calculation of the actual cost rate. Providers will be required to adhere to their approved budget. Expenditures which are in excess of allowable budgetary limits will be reimbursable. Allowable budgetary limits are defined as the approved line item amount plus 10% or $ 500.00, whichever is greater. Under no circumstances, however, will the total of allowable costs exceed the approved total net cost. If a provider foresees costs exceeding allowable budgetary limits, he may apply to the Administering Agency for a budget amendment. Such request must state justification for the change. Costs, in excess of the allowable budgetary limits, incurred prior to approval by the Administering Agency will not be reimbursable.

c. The service payment rate will be determined by dividing the net cost by the estimated patient days. The provider must indicate the number of certified beds and must estimate patient days based on past experience and known changes, but in no case may estimated patient days indicate an occupancy of less than 85%.

7.5.2 Exceptions to the Budgetary Process

a. State Agencies - State agencies which operate ICF/MR facilities and submit biennial budgets for legislative approval shall be exempt from the budgetary process. For these providers, the service payment rate will be calculated in accordance with the budget as approved by the Legislature. The actual cost rate will be determined in accordance with Paragraph c. of the above section of these regulations, except that budgetary constraints will not be imposed.

b. New Facilities - New facilities will be subject to Paragraph c., above, with the exception that budgets will be derived only from projections of operations for the ensuing fiscal year. New facilities will have the option of having the service payment rate adjusted quarterly if they can substantiate that the service payment rate is not within 10% of the actual cost rate. New facilities are defined as those which have not completed one full fiscal year of operation.

c. Loss or Abandonment - Loss on the sale or abandonment of fixed assets may be submitted for consideration after incurrence, but such submission must be within ten days of determination of loss.

7.5.3 Allowance for Known Cost Changes - Future cost increases or decreases, known as of the budget filing date, must be taken into consideration in the budget preparation process. Cost increases will be considered only when they meet the criteria for allowability as defined in the Allowable Costs section of these regulations, and the following requirements:

a. Salary and wage changes must be based on changes in effect at the end of the current period and/or future changes substantiated by labor contracts, board resolutions, written policies, or minimum wage laws.

b. Changes in facility costs will be based on changes in effect at the end of the current period and/or future changes substantiated in the budget narrative.

c. The cost effects based on the need to change program services must be accompanied by justification of, and need for, such change.

d. Cost changes may be justified by references to pertinent Federal, State, or local laws and regulations.

e. Cost changes in all line items not specifically outlined above must be justified by referring to cost changes during the last completed fiscal quarter prior to the budget submission date plus consideration of reasonable increases expected to occur during the budget period.

7.5.4 Written Notification - The Administering Agency will provide written notification of the proposed service payment rate or the actual cost rate within ten days of its determination of such rate. Notification will include the method used in determining such rates and the method of submitting comments from the public to the Administering Agency. The posted, or an adjusted rate, shall become final on the tenth day following the date posted in the notification for receipt of comment.

Section 7.6 Payment Mechanisms

Payments are made to providers from the Department of Mental Health. Providers must submit a properly completed form to:

Department of Social Welfare

Medical Services Division

Waterbury Office Complex

Waterbury, VT 05676

A copy of this form and instructions for completion are attached. Provide should expect payment for verified services within four weeks of mailing completed forms. Providers will receive a form listing any adjustments made to the billings. Information regarding the processing of any claims may be obtained from the Department of Mental Health at 241-2600. The provider will be reimbursed on a monthly basis during its fiscal year at the service payment rate, but no payment will be initiated prior to receipt of required reports. Reimbursement adjustments based on the actual cost rate will be determined within thirty days of receipt of an acceptable audit. If the determination requires a payment to the provider payment shall be initiated within thirty days after the date of final determination. If the determination requires a repayment from the provider, the provider must make such repayment within ninety days of the final determination.

Section 7.7 Service Payment Rate

The service payment rate will be based upon the total net costs of the approved budget divided by the estimated resident days. The Administering Agency reserves the right to revise this rate at any time if the rate seems substantially inconsistent with the actual allowable costs.

Section 7.8 Actual Cost Rate

The actual cost rate will be calculated by dividing the allowable costs for the fiscal year, in accordance with the budgetary provisions of the Rate Determination section of these regulations, actual resident days, except if actual resident days are 85% or less of maximum occupancy, 85% occupancy will be used to calculate the actual cost rate. Furthermore, the Administering Agency will require an annual audit (by a qualified person or firm, not connected with the provider), to determine the fairness of the actual cost rate. The Administering Agency may, at its option, provide said audit.

Section 7.9 Record Keeping

7.9.1 All providers receiving Medical Assistance payments for ICF/MR's must meet the following financial accountability requirements:

a. All records must be maintained on a full accrual basis, excepting State agencies shall use a modified cash system approved by the Commissioner of Finance.

b. All non-allowable costs under the services provision in the Non-allowable Costs section of these regulations must be physically segregated (i.e., a separate set of financial records) from allowable costs, or if intermixed with allowable costs, must be readily identifiable for audit purposes. Costs eligible under the provisions of Part H of the Allowable Costs section of these regulations, that readily identify the basis for distribution, meet this condition.

c. All financial records must be maintained in accordance with generally accepted accounting principles and must provide a clear audit trail.

d. All reports required in the Reports section of these regulations will be subjected to a desk audit and may be subjected to a field examination of supporting records and compliance with regulations. If such audits reveal inadequacies in provider record keeping and accounting practices, the Administering Agency may require that the provider engage competent professional assistance to properly prepare the required reports.

e. Clinical records must be maintained in the manner prescribed in the ICF/MR Operating Regulations, and must provide a means of readily identifying the number of resident days. All records and reports pertaining to financial transactions must be maintained by the provider for not less than three years from the date of the submission of an approved audit for the period to which the material pertains.

Section 7.10 Reports

7.10.1 Required Reports - In order to receive reimbursement at the service payment rate, the provider must submit a monthly report, in the format prescribed by the Administering Agency. The report must include cumulative revenue and expenditures according to budgetary line items, an invoice for the units of service rendered, and/or any other data relevant to justification or support of the Medical Assistance rate as deemed necessary by the Administering Agency.

7.10.2 Report Deadlines - All provider reports shall be submitted no late than the 30th of the month following the month being reported. Reports received after this date, and reports received in unacceptable condition, will be subject to at least a thirty day payment delay.

7.10.3 Report Certification - Reports must be certified, in the place indicated, by signature of the operating executive.

7.10.4 False Reports - False information knowingly supplied by the provider on a required report will result in termination of the provider's contractual agreement and/or prosecution under the applicable Federal and State statutes.

7.10.5 Amended Reports - Providers must file amended reports immediately upon discovery of any errors in the number of units of service billed. If an error is discovered in the financial reporting, appropriate adjustments must be made the succeeding month.

7.10.6 Audits - An audit will be conducted annually in accordance with provisions of the Actual Cost Rate section of these regulations. Reports will be submitted to the Administering Agency not more than five months after completion of the fiscal year.

Section 7.11 Absence From Facility

Notwithstanding any other provision of these regulations, nothing herein shall be interpreted as an impediment to having ICF/MR residents:

a) visit with family, friends, or other significant persons; or,

b) be away from the facility for social, recreational, or related purposes, provided that all visitations and/or absences for which Title XIX reimbursement is sought are consistent with, and part of, the resident's current habilitation plan.

There shall be no limit to the number of such visitation/absent days per year. However, in the event that a resident's habilitation plan provides for visitations/absences in excess of fifteen (15) days per quarter or sixty (60) days per annum, approval for such excess days shall be obtaine in advance from the Commissioner of Mental Health.

The Department shall not withhold such approval unless:

a. The resident's habilitation plan does not specifically provide for the amount of visitation/absence requested.

b. The extent of visitation/absence suggests that continued ICF/MR placement is inappropriate.

c. The resident's habilitation plan is not current or has not been reviewed in accordance with facility policy.

Section 7.12 Appeal Procedures

7.12.1 Scope of Appeal Procedure - These procedures describe the manner by which unresolved individual provider disputes concerning application of these regulations shall be settled. Unresolved disputes are defined as those disagreements that cannot be resolved between the provider and the Administering Agency. Such disputes may be appealed by the provider.

7.12.2 Appeal Procedure - An appeal shall be submitted in writing to the Vermont Human Services Board and shall include facts, arguments, and other pertinent data. Appeals shall be heard by the Appeals Examiner who shall be an impartial party designated by the Board.

7.12.3 Time Limit - The provider has thirty days from the date of the Administering Agency's final determination of the matter disputed to initiate formal appeal.

7.12.4 Settlement Mechanism - If the appeal is related to a change in the provider's rate, the amount in dispute will not be adjusted until final determination according to the appeal procedure is made. If the appeal determination requires a payment to the provider, payment shall be initiated within thirty days after the date of final determination. If the appeal determination requires repayment from the provider, the provider must make such repayment within ninety days of the final determination.

7.12.5 Findings and Conclusions - Any findings, conclusions, or opinion of the Appeals Examiner about any appeal will be made available the provider and to the Administering Agency.

Notes

13-007 Code Vt. R. 13-150-007-X

Effective Date: April 1, 1981 (Secretary of State Rule Log # 81-19)