Administrative Standards

Download Report

Transcript Administrative Standards

New Licensing Standards - 2960
DOC to license/certify:







ALL
Group Residential
Detention
Secure
Restrictive Techniques
Corrections
Shelter
DHS to license/certify:







ALL
Group Residential
Chemical Dependency
Mental Health
Shelter
Transitional
Restrictive Techniques
ALL
Administrative Standards
2960.0010
Purpose And Applicability
Governs the licensing of
providers of residential
care for children in out-ofhome placement.
2960.0010 - Providers








Unit of government
Individual
Corporation
Limited liability corporation
Partnership
Voluntary association
Other organization or entity
Controlling individual
2960.0010
Scope of the Rule





residential care {on a 24-hour basis
treatment
detention
foster
rehabilitation service
Juvenile sex offender treatment programs also
governed by MN Rule
Definitions

Time out

Disciplinary room time
License

Not transferable to another

individual/entity

location
2960.0030 - Application

Form provided






applicant's name and address
name and location of the program
geographic area to be served
license or certification being requested
requested license capacity
age limits
Application

Organizational
chart depicting
organizational
authority
2960.0030 Subpart 2B-4
Application
The applicant must provide:

description of the services
program's philosophy
target population

program outcomes


2960.0030 Subpart 2B-5
Approvals





Health: Department of Health or
local health inspector
Local building code inspector
Local zoning authority
Fire: State Fire Marshal or
approved local code inspector
or Document waiver
2060.0030 Subpart 2B-6
Community Analysis

Description of the neighborhood
demographic characteristics
•
•
•
•
•
race
socioeconomic characteristics
crime statistics
vehicle traffic
proximity of the proposed facility to
schools, day care providers
Neighborhood Demographics
• public transportation
• public and private recreation
facilities
• neighborhood religious and
spiritual organizations
Neighborhood Demographics
• Information about local business
groups, community groups, block
clubs, and service organizations.
2960.0030 Subpart 2B-7
County Role in Screening
• The license holder must discuss with
the county social services agency of
the county in which the facility is
located, the facility's policy
regarding the county's role in
screening facility residents.
County Role in Screening
• The facility must
document the
contact with the
county and any
agreement
between the
county and the
facility regarding
the county's role
in screening
facility residents.
2960.0030 Subpart 2D
Fee
• An applicant for Department of
Human Services licensure or
certification must pay a licensing fee
which is calculated according to
parts 9545.2000 to 9545.2040.
2960.0030 Subpart 3
DOC Criteria
A. Primarily serve delinquent children who are
at least ten years old, but younger than 21
years old, in a residential setting;
B. Operate a detention or group residential
facility for children alleged to be delinquent;
C. Be certified to provide residential program
services for residents who need correctional
programming.
2960.0030 Subpart 4
DHS Criteria
A. Serve children through the age of 19
B. Operate a group residential program with
possible certifications in the areas of:




chemical dependency treatment
treatment for severe emotional
disturbance
shelter services
transitional services
2960.0030 Subpart 5
Multiple Program Certifications
The Department of Human Services and
the Department of Corrections shall
determine which commissioner will
license or certify the applicant.
2060.0030 Subpart 6
Variance Request
A.
B.
C.
D.
The part or parts of the standard
Reason for the variance
Period of time of the variance
Written approval from the fire
marshal, building inspector, or health
authority as applicable
E. Alternative equivalent measures
2960.0030 Subpart 6E
Variance Authority
Department
of Human Services –
M. S. 245A.04, subdivision 9.
Department
of Corrections –
M. S. 241.021.
The decision of the commissioner of human
services or corrections to grant or deny a
variance request is final and not subject to
appeal under Minnesota Statutes, Chapter 14.
Denial of Application




compliance with laws or rules
health or safety deficiencies
hazardous condition
fire, building, zoning, health approval
Denial of Application
Failure to comply may be indicated by:

Department of Education: lack of
approval of on-site school

Disqualification of the applicant/
controlling individual

Failure to submit a completed
application

DHS Denial = DOC Denial
2960.0030 Subpart 9
Drug and Alcohol Use Prohibited



Includes prescription drugs
Policy required
Training in the drug policy
2960.0030 Subpart 11
Policy and Procedure Review

The license holder
must submit the
facility's program
policies and
procedures to the
commissioner of
human services or
corrections for
review.
2960.0030 Subpart 11
License/Certification Terms







name of the license holder
address of the program
effective date and expiration dates
type of license
maximum number and ages of residents
any special conditions of licensure
certification(s) granted
Subpart 12
Licensing Actions

Department of Human Services:
Minnesota Statutes, Chapter 245A.

Department of Corrections:
Minnesota Statutes, Section 241.021.
2060.0040
Statement of Intended Use
Target population served:





cultural background
gender
license holders expertise and
qualifications to provide the services
age
medically fragile condition
Statement of Intended Use



legal status: chips, delinquency,
voluntary placement, self-referral
primary needs of residents met in the
licensed facility
resident services provided by
programs outside the setting
Statement of Intended Use



Specific extent and limitations of the
program
Restrictive procedures-extent and
limitations
Involvement of the resident's cultural
or ethnic community to ensure
culturally appropriate care
2960.0500 - Basic Rights




reasonable observance of cultural and
ethnic practice and religion
reasonable degree of privacy
participate in development of the
resident's treatment and case plan
positive and proactive adult guidance,
support, and supervision
2960.0500 - Basic Rights





free from abuse, neglect, inhumane
treatment, and sexual exploitation
adequate medical care
nutritious and sufficient meals and
sufficient clothing and housing
clean, safe surroundings
public education
2960.0500 - Basic Rights

Reasonable communication and
visitation, which may include:





Parent
Extended
family
members
Siblings
Legal guardian
Caseworker





Attorney
Therapist
Physician
ReligiousSpiritual
advisor
Case manager
2960.0500 - Basic Rights




access to protection and advocacy
services
state-appointed ombudsman
personal property
courteous and respectful treatment

Minnesota Statutes, Sections
144.651 Patients Bill of Rights
253B.03 Rights of Patients
2960.0500 - Basic Rights

grievance procedure

free from restraint or seclusion used for a
purpose other than to protect the resident
from imminent danger to self or others; except
for the use of disciplinary room time as it is
allowed in the correctional facility's discipline
plan

free from bias and harassment regarding race,
gender, age, disability, spirituality, and sexual
orientation
2960.0500 - Basic Rights

nutritious and sufficient meals and
sufficient clothing and housing

clean, safe surroundings

public education
2960.0500
License Holder Duties



provide basic services
develop operational policies and
procedures which correspond to the
basic rights
give the resident a written copy of
the resident's basic rights
2960.0500
Basic Rights Information



explain to the resident in a language
that the resident can understand
rights related to the resident's care
explained within 24 hours of
admission
procedures which correspond to the
basic rights
2960.0500
Basic Rights Information


tell the resident's parent, guardian, or
custodian within a reasonable time that the
information regarding rules is available
Post resident rights in the:



Residents and staff area
Staff station
how to contact the appropriate stateappointed ombudsman: name, address,
and telephone number
2960.0060
Statement of Program Outcomes

written policies that identify program
outcomes and promote the resident's
development as a physically and
mentally healthy person

the program services offered by the
license holder must be consistent
with the resident's case plan
2960.0060
Outcome Measures



the measurement must document the degree to
which the license holder's services provided to
the resident, or the resident's family, have been
successful in achieving the intended outcome of
the services offered to the resident and the
resident's family
measure the success in achieving statement
outcomes
specific factors as required by DHS/DOC
2960.0060
Outcome Measures

specific factors as required by
DHS/DOC

the program services offered by the
license holder must be consistent
with the resident's case plan
2960.0060
Program Evaluation

annually evaluate strengths and
weaknesses of the program using at least
the following performance indicators:
 accidents
 use of restrictive procedures
 grievances
 adverse maltreatment findings and
legal actions against the license holder
2960.0060
Program Evaluation


satisfaction survey results
critical incidents

Must be kept for two licensing periods

Must use the program evaluation
findings to make program
improvement
Independent Program Audit





comply and cooperate with independent
program audits DHS/DOC
comply with the findings
document with operational policies and
procedures
retain demographic information on a
resident
document the extent of the resident's
program completion on designated form
Community Involvement

Board of directors or advisory
committee that represents the
interests, concerns, and needs of the
residents and community served and
comply with the findings

The Board or advisory committee
must meet at least annually
Community Involvement

The license holder meet at least
annually with community regarding:





the nature of the program
types of residents served
results of the services the program
provided to residents
number of residents served in the past
12 months
the number of residents likely to be
served in the next 12 months.
2960.0070
Admission Process

The license holder must have written
specific identifiable admission criteria
consistent with the statement of
intended use.

The License holder must:

Have resources and qualified staff
to respond to residents with
disabilities
Admission Process
The license holder must:
Admission Process


Consider placing a female
resident when there are few
other female residents in the
facility
Whether the facility could offer
gender-specific services for
female residents
Admission Process



Consider placing a male resident
when there are few other male
residents in the facility
Whether the facility could offer
gender-specific services for male
residents
Seek approval of the commissioner
of corrections to serve those over
age 19
2960.0070 Subpart 3
Admission Documentation

Within 5 working days after admission





legal authority for resident placement
date and time of admission
name and nicknames
last known address and permanent
address
name, address, and telephone number
of parents, guardian, and advocate
Admission Documentation




date and place of birth
race or cultural heritage
languages the resident speaks and
writes
tribal affiliation
Admission Documentation





description of presenting problem
medical problems
circumstances leading to admission
mental health concerns
safety concerns: assaultive
behavior, victimization concerns
Admission Documentation




resident assets and strengths and
related information from the resident,
family, and concerned persons
name, address, and telephone number
for the last educational program
contact person
spiritual or religious affiliation
placing agency's case plan goals for
the resident
2960.0070 Subpart 4
Resident Property


inventory the resident's personal
property (including clothing)
resident and the license holder sign the
inventory upon admission


(resident refusal: two staff sign)
ensure resident use and availability of
personal funds/property unless
restrictions justified in treatment plan
2960.0070 Subpart 4
Resident Funds

Whenever the license holder assists with
residents funds they must:


Keep separate facility and resident funds
When safekeeping funds/property



Document receipt and disbursement
Must have signatures of resident/
conservator/payee
Return to the resident funds/property
within 3 working days request.
Funds-Must Nots






borrow money from a resident
purchase personal items from a resident
sell merchandise, except canteen-type
service
sell personal services to a resident
require a resident to buy items for which
the facility is reimbursed
use of funds that would violate part
9505.0425, subpart 3.
2960.0070 - Screenings Required






health screening
history of abuse
vulnerability to abuse
potential for self-injury
current medications
most recent physician's/clinic's



name
address
number
Screenings Required



mental health screening
education screening Minnesota Statutes,
section 125A.52
chemical abuse or chemical dependency
screening

(The license holder will provide or
contact the resident's case manager, if
applicable, to arrange a screening to
determine if the resident is chemically
dependent)
Screenings Required

screening for sexually abusive behavior;






written risk management plans (resident,
other residents, staff, community)
vulnerability assessment
culture
gender-specific needs screening
psychosocial needs of the resident
needs regarding the gender of the staff
2960.0070 Subpart 5C
Screening Time Lines



other screenings: begin - 3 working days,
completed - 6 working days
health screening - within 24 hours of
admission
May substitute screening or assessment
completed within the last 6 months


if on file
no reason to believe condition has changed
Screening Time Lines


If a resident is transferred from another
facility - Request of sending facility records
needs to be immediate*
Screenings must include documented
inquiries regarding the degree to which the
family desires to be involved during the
residents stay
*(N/A to residents on detention status for less
than 6 working days)
2960.0080 - Basic Services




Must provide services that fulfill the
basic rights of the resident
Must have stated objectives and
measurable outcomes
Must coordinate and ensure off-campus
program services if applicable
Must meet the basic needs of the
residents served by the facility.
2960.0080 Subpart 3
Cooperation

Cooperate with case manager/other
appropriate parties in creating and
delivering basic services





resident
parent
legal representative
case manager
treatment team
2960.0080 Subpart 3A
Implementation of Case Plan


coordinate facility plan with placing
agency's case plan
work with the placing agency to identify:



projected length of stay
conditions for family reunification or
permanency plan
license holder actions to help carry out
the plan
B - Identify and Share Information
(Per case plan)
 about the resident's treatment

about major treatment outcome plans


including attaining developmentally
necessary/appropriate life skills
communicate as necessary with previous
school and current school
D - Identify and Share Information


report the resident's behaviors and
other important information to the
placing agency
recommend case plan changes to the
placing agency;
F - Identify and Share Information

Share information (as allowed by
law)
 resident's therapist
 physician
 professional treating the resident
 agencies providing discharge
services
Identify and Share Information


Provide records to parent/guardian
Respond to court orders and
authorized information release
requests in 3 business days
2960.0080 Subpart 4
Facility Rules/Due Process



communicate verbally to the resident
and in writing facility's rules and due
process system
acceptable and unacceptable behaviors
and the reasons why
consequences applied in recognizing and
rewarding acceptable behavior and
modifying unacceptable behavior
2960.0080
Facility Rules/Due Process



circumstances, if any, that will result
in time-out or restrictive procedure
use
due process system for disciplinary
consequences
relationship of IEP discipline
recommendations to the facilities
2960.0080 Subpart 5
Discipline Policy/Procedures

Policies and procedure must consider:
 Abuse history
 Developmental needs
 Culture needs
 Disability needs
 Gender needs
2960.0080 Subpart 5
Prohibition of Corporal Punishment
•
•
•
•
•
•
Rough handling
Shoving
Ear or hair pulling
Shaking
Slapping
Kicking
•
•
•
•
•
•
Kicking
Biting
Pinching
Hitting
Throwing Objects
Spanking
2960.0080
Prohibition of Verbal Abuse
•
•
name calling
derogatory statements about the resident/
family
•
•
•
•
•
•
race
gender
disability
sexual orientation
religion
culture
2960.0080
Prohibition of Verbal Abuse
•
statements intended to
• shame
• threaten
• humiliate
•
frighten
2960.0080
Discipline Prohibited


punishment for lapses in toilet habits,
bed wetting and soiling
withholding of:





drinking water
clothing
hygiene facilities
normal sleeping conditions
nutritious diet
2960.0080 Subpart 5A-4
Discipline Prohibited

Withholding of:









proper lighting
educational services
exercise activities
ventilation and proper temperature
mail
family visits
positive reinforcement
medical care
nurturing
2960.0080
Discipline

However, a resident who destroys
bedding or clothing or uses these or
other items to harm self or others,
may be deprived according to the
residents case plan
2960.0080
Discipline Prohibited


assigning work that is dangerous or
not consistent with the residents case
plan
disciplining one resident for the
unrelated behavior or action of
another, except recognized treatment
program peer group restrictions
2960.0080
Discipline Prohibited

Inappropriate use of restrictive
techniques or procedures




as punishment
for the convenience of staff
as compensation for in adequate
staffing
as a substitute for program services
2960.0080 Subpart 5A-9
Discipline Prohibited


communication restrictions beyond
treatment/case plan
prohibited punishments such as:
• extended time in uncomfortable or fixed
positions
• march
• stand
• kneel

delegation of authority to punish another
resident
2960.0080
Discipline

License holder must comply with
9525.2700, subpart 2, item G,
regarding the use of aversive or
deprivation procedures with a
resident who has mental retardation
or a related condition
2960.0080 Subpart 5D
Time-out Requirements

time-out must be used as a nonemergency behavior management
technique which is used to intervene
in a resident's undesirable behavior
and to allow the resident to reflect
and become calm before returning to
ongoing activities at the facility
2960.0080
Time-out Requirements

Must be used under the direction of:






mental health professional
facility director
program manager
Must be consistent with treatment plan
A staff must escort a resident to safe unlocked
room or other separate living space
Staff must assess at least every 30 minutes
2960.0080
Training Requirement Time-Out
Staff must be trained in the following:






the needs and behaviors of residents
building relationships with residents
alternatives to time-out
de-escalation methods
avoiding power struggles with residents
documentation standards for the use of
time-out
2960.0080
Time-out Requirements


Treatment team review of time-out use for
each resident during the treatment plan
review
Document use of time-out in record
•
•
•
•
•
cause factors
circumstances
resident's response
resident's ability to de-escalate
acceptable behavior after time-out
2960.0080 Subpart 5E
Certification Required

Staff must have restrictive
procedures certification (2960.0710)
prior to the use of restrictive
procedures with a resident
2960.0080 Subpart 6
Daily Resident Activities



written schedule of daily activities
know the whereabouts of each
resident
immediately notify the referring or
placing agency of runaway / missing
resident
2960.0080 Subpart 7
Culturally Appropriate Care



document culturally appropriate care
provided
opportunities to associate with culturally
and racially similar adults, peers, and
role models
opportunities to participate in positive
experiences related to the resident's
cultural and racial group
2960.0080
Culturally Appropriate Care


culturally appropriate program services
that address the needs of all residents in
care
cultural sensitivity, including the provision
of interpreters and English language skill
development*
* ( Laws 1995, Chapter 226, article 3, section
60, subdivision 2, paragraph (2), clause (v).)
2960.0080 Subpart 8
Spirituality





Opportunity for voluntary participation in
spirituality services, activities, and counseling
A resident must not be required to attend the
services or activities
Service/activities must be held in a location which
allows choice
Attendance or lack of attendance cannot affect
rights/privilege
Must arrange spiritual counseling if requested by
a resident.
2960.0080 Subpart 8
Spirituality
Accommodate a resident or a resident's
family's request regarding spiritual needs,
If unable: document the reason.
 Within reasonable safety and security rules
 Allow private interviews or counseling
regarding spiritual, personal, or family
problems
 Opportunity to meet with a spiritual or
religious person of their choice.

2960.0080 Subpart 9
Educational Services


Facilitate the resident's admission to an
accredited public school or other lawful
school
Facility- on grounds school
 Year-round basis, if required by law
 Approval of the education services
from the Department of Education
 Cooperate with the school district.
Educational Services




Facilitate the resident's school
attendance and homework activities
Inquire at least every 90 days
Report educational problems to the
case manager or placing agency
Chemical health education to the
resident with inappropriate chemical
use problem
2960.0080 Subpart 11
Health and Hygiene Services

Timely access to:







qualified persons that meet the resident's
needs
basic
emergency
specialized medical
mental health
dental care
treatment services
Health and Hygiene Services:
Pregnant Resident


Ongoing and appropriate prenatal
care from a medically licensed
person
Prenatal, postnatal, and parenting
information
Health and Hygiene Services


Ensure provision of appropriate
medical and dental services
Compliance with medical or dental
insurance
2960.0080 Subpart 11
Health Provider Gender



Consideration of resident's request for a
male or female health care provider
If a female resident requests a female
health care provider, and one is not
available, the license holder must request
permission from the health care provider
that an adult female be allowed to be
present during the health care procedure
Likewise for male residents
2960.0080 Subpart 11B
Health Records

Illness reported by the resident

Action taken by the license holder

Date of the resident's medical,
psychological, or dental care
2960.0080 Subpart 11
Medication Plan


Maintaining stock supplies of
prescription drugs at the facility is
prohibited.
Medication plan (developed with
medically licensed person) for the
safe storage and delivery of
medicine.
2960.0080 Subpart 11D-1
Medication Plan

Contact a newly admitted residents
prescribing medically licensed person to
verify:



instructions about how to administer
the medication
symptoms that the medication will
alleviate
the symptoms that would warrant
consultation with the physician
2960.0080 Subpart 11D-2
Medication Plan

Documentation of attempts to contact
the child's parent or guardian to seek
permission for the facility to administer
the medication.

If permission is denied and the parent
has the legal right to deny permission,
then the medication will be discontinued
under the supervision of a physician
unless a court order to administer the
medication is obtained.
Medication Plan


List of the side effects of medication
Document and follow the prescribing
physician's directions for monitoring
medications used by the resident
2960.0080 Subpart 11-5
Medication Training


Medication assistance training (non
medically licensed person)
Medication aide program completion
 Postsecondary institution
 Formalized training program
• Offered by the license holder
• Taught by a registered nurse
 Documented in staff personnel records
Medication Review


Monthly medication administration
review by medically licensed person
Resident prescription drug record





quantity initially received from the
pharmacy
amount of medication given
dosage
time taken
refusal to take prescription medication
Medication


Prescription medicine belonging to a
resident must be given to the resident's
parent or legal guardian upon the
resident's release or must be disposed
of according to a pharmacy-approved
plan.
The license holder must note the
disposition of the resident's medicine in
the resident's file.
Medication

Upon release, the license holder
must give a resident who is 18 years
of age or older the prescription
medication prescribed for the
resident.
2960.0080 Subpart 12
Food and Nutrition

Balanced diet consisting of foods and
beverages:



palatable
adequate quantity and variety
prepared and served at appropriate
temperatures
• prevent food-borne illness
• conserve nutritional value
Food and Nutrition


Provide a medically prescribed diet,
if ordered
Offer a diet that does not conflict
with the resident's religious or
cultural dietary regimen.
2960.0080 Subpart 13
Clothing, Bedding, and Laundry




adequate amount of clean clothing
appropriate for the season
appropriate sized, clean, fireretardant mattress*
two sheets or one sheet and clean
mattress cover
sufficient clean blankets to provide
appropriate warmth for the season
Clothing, Bedding, and Laundry





One pillow and one pillowcase that is
antiallergenic
Adequate bath towels and washcloths
Bedding and linens furnished upon
admission
Bedding and linens cleaned once a week or
more
No worn out/unfit bedding and linens
2960.0080 Subpart 14
Emergency Plan

Develop a written emergency plan:






fire
natural disaster
serious illness
severe weather
disappearance of a resident
law enforcement/emergency
response situation.
2960.0080 Subpart 14
Emergency Plan



Developed with the advice of local fire
and emergency response authorities.
Including emergency care/Special
assistance if needed by a resident.
Staff and residents plan review every six
months.
Compliance documentation of the plan
and the review.
Subpart 15
Communication and Visitation





Written communications and visiting
policy
Use of the telephone
Mail
Adaptive communications devices
Other means of communication,
compatible with needs/case plan
Subpart 16
Communication and Visitation


No restriction of the parents visiting
rights beyond case plan/court order
limitations(M.S.260C.201)
Accommodation of parent's schedule
Subpart 17
Critical Incident/Maltreatment Reports



Report critical incidents to licensing
within 10 days on approved forms
Maintain records of all critical
incidents on file in the facility
Comply with mandatory maltreatment
reporting*
* (Minnesota Statutes, sections 626.556 and
626.557)
Maltreatment Policy



Policies and procedures to follow if
maltreatment is suspected
Annual review of maltreatment
policies
Policy revision:



comply with changes in law
meet identified needs
review of incident & quality assurance
reports indicate a change is warranted
2060.0080 Subpart 18
Resident & Family Grievance Procedures

Develop & follow written grievance policy
 Allow others in residents life to make a
formal complaint or suggestion or
express concern about any aspect of
the residents care
 Staff may not influence a residents
statement about the facility in a
grievance
Resident & Family Grievance Procedures

The written grievance procedure must
require:
 Must give resident forms and
assistance to file the grievance
 Identify the person authorized to
resolve the complaint & appeal
information
 Upon request, the grievance must be
carried to the highest administration or
placing agency
Subpart 19
Family Involvement

If family involvement is a goal in a
resident's case plan, the license holder
must:
 list procedures and program plans
which are in accordance with a
resident's case plan,
 facilitate the involvement of the
resident's family or other concerned
adult, in the resident's treatment or
program activities.
2960.0090 Subpart 2
No Eject Policy




Written no eject policy
Confer with other interested persons to
review the issues
Review process must not exceed five
working days
Any additional strategies to resolve the
issues and prevent discharge
No Eject Policy



If discharge is warranted the reasons for it
and the alternatives considered or
attempted must be documented
A resident may be temporarily removed
from the facility during the five-day review
period
This subpart does not apply to a resident
removed by the placing authority or a
parent or guardian
Subpart 3
Property Return



The license holder must return all of the
resident's personal property to the resident
Signed receipt upon discharge, unless
prohibited to do so by law or case plan
Discrepancies between the resident's
inventoried property turned over to the facility
at admission and the property returned to the
resident at discharge, and the resolution of
the discrepancy, must be documented by
facility staff
2960.0100
Staffing Plan



Approved by the Commissioner of
Human Services or Corrections
Identifies the assignments of facility
staff
Meets the cultural and ethnic needs
of the facility residents to the extent
permitted by law
2960.0100 Subpart 2
Recruitment of Culturally
Balanced Staff


To the extent permitted by law, it is the
license holder's responsibility to actively
recruit, hire, and retain full-time staff who are
responsive to the diversity of the population
served
If the facility staffing plan does not meet the
cultural and racial needs of facility residents
the license holder must document the reasons
Recruitment of Culturally
Balanced Staff


Work with cultural or racial communities to
meet the needs of residents.
In addition, the license holder must contact a
cultural or racial community group related to
the resident's cultural or racial minority
background and seek information about how
to provide opportunities for the resident to
associate with adult and peer role models with
similar cultural and racial backgrounds on a
regular basis.
2960.0100 Subpart 3
Orientation


The license holder must provide
training for staff that is modified
annually to meet the current needs of
individual staff persons.
The training must be directly related to
serving the program's target population
and to achieving the program's
outcomes.
Orientation

The license holder must ensure that
staff who will have direct contact with
residents attend and successfully
complete orientation training before
having unsupervised contact with
residents.
Orientation Training
Emergency Procedures

evacuation routes

emergency telephone numbers


severe storm and tornado
procedures
location of facility alarms and
equipment
Orientation Training
Statutes, Rules



Relevant statutes and administrative
rules and legal issues
Reporting requirements for abuse and
neglect specified in Minnesota Statutes,
sections 626.556 and 626.557
Other reporting requirements based on
the ages of the residents
Orientation Training Diversity




Cultural diversity
Gender sensitivity
Culturally specific services
Information about discrimination
and racial bias issues to ensure that
caregivers have cultural sensitivity
and will be culturally competent to
care for residents
Orientation Training Diversity


General and special needs, including
disability needs, of residents and
families served
Operational policies and procedures
of the license holder
Orientation


Data practices regulations and
issues.
The license holder must ensure that
staff who have direct contact with
residents receive ongoing training.
Training must help staff meet the
needs of residents and must include
skills development.
2960.0100 Subpart 3B
Ongoing Training


The license holder must ensure that
staff who have direct contact with
residents receive ongoing training.
Training must help staff meet the
needs of residents and must
include skills development.
Subpart 4
Specialized Training


If needed, license holders and staff
must have specialized training to
develop skills to care for residents
Specialized training must be
directly related to serving the
program's target population and to
meeting the program's certification
requirements
2960.0100 Subpart 5
Personnel Policies

Documentation of training. The
license holder must document the
date and number of hours of
orientation and in-service training
completed by each staff person in
each topic area and the name of the
entity that provided the training.
Subpart 6
Qualifications

The license holder and staff must
have the education and
experience required to meet the
functions and program activities
that the license holder declared in
the facility statement of intended
use according to part 2960.0040.
Staff Qualifications




Responsible, mature, healthy adult who
is able to carry out the license holder's
duties.
Able to accomplish the license holder's
duties to the resident's case plan and
treatment plan and meet the resident's
needs.
Trained in gender-based needs and
issues.
At least 21 years old.
Subpart 7
Background Study

A license holder and individuals
identified in Minnesota Statutes,


DHS: Minnesota Statutes, section
245A.04, subdivision 3.
DOC: Minnesota Statutes, section
241.021, subdivision 6.
must submit to a background study.
2960.0110
PHYSICAL ENVIRONMENT / EQUIPMENT


The facility must be equipped and
maintained in a manner that
conforms to its statement of
intended use.
The physical environment must
provide for the comfort, privacy,
and dignity of residents.
2960.0110 Subpart 3
Facilities


The license holder must ensure that
food services, storage, housekeeping,
laundry, and maintenance are operated
on a consistent, healthy basis.
If food service is contracted to a food
service vendor, the food service vendor
must meet health code requirements.
Facilities


If the license holder provides educational
services on site, the classrooms must
provide an atmosphere that is conducive
to learning and meets the resident's
special physical, sensory, and emotional
needs.
The license holder must provide adaptive
equipment and furnishings to meet the
resident's special needs.
Subpart 4
First Aid Kits

A facility must have first aid kits
readily available for use by residents
and staff. The kits must be sufficient
to meet the needs of residents and
staff.
2960.0120
Physical Plant Standards



Fire, health, zoning, and building code
Sleeping rooms for 4 or less
Multi-bed bedrooms: ambulatory residents



60 square feet per resident of useable
flood space
three feet between beds placed side by
side
one foot between beds placed end to end
Subpart 2
Code Compliance

Multi-bed bedrooms: non-ambulatory
residents
 80 square feet per resident of useable
floor space
 adequate space for clothing and
personal possessions
 appropriate furnishings to
accommodate these items.
Code Compliance





Outdoor recreational space
One shower or bathtub/sink/toilet per 8
residents
Hot and cold water
Heating plant providing comfortable
temperature in all resident areas
Lighting appropriate to function of area
Code Compliance

Sufficient indoor space
 For quiet group program
activities
 On site education: Facility must
meet the DOE provisions of
educational services
 Private intake admission area