Rules and Regulations of the State of Georgia
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Rule 111-8-68-.01 Legal Authority

These rules are adopted and published pursuant to the Official Code of Georgia Annotated § 31-7-1et seq.

Rule 111-8-68-.02 Title and Purposes

These rules shall be known as the Rules and Regulations for Residential Mental Health Facilities for Children and Youth. The purposes of these rules are to emphasize the programmatic requirements necessary to meet the needs of patients in a safe, therapeutic environment, and to set forth the minimum requirements that Residential Mental Health Facilities for Children and Youth shall meet.

Rule 111-8-68-.03 Definitions

(1) "Abuse" means any unjustifiable intentional or grossly negligent act, exploitation or series of acts, or omission of acts which causes injury to a person, including but not limited to verbal abuse, assault or battery, failure to provide treatment or care, or sexual harassment.
(2) "Administrator" means the person, by whatever title used, whom the governing body has delegated the responsibility for the management and operation of the facility including the implementation of the rules and policies adopted by the governing body.
(3) "Behavior management" means those principles and techniques used by a facility to assist a patient in facilitating self-control, addressing inappropriate behavior, and achieving positive outcomes in a constructive and safe manner. Behavior management principles and techniques shall be used in accordance with the patient's treatment plan, written policies and procedures governing service expectations, treatment goals, safety, security, and these rules and regulations.
(4) "Board" means the Board of the Department of Community Health.
(5) "Board certified child psychiatrist" means a child psychiatrist who has successfully met the training and experience requirements and passed the examination in child psychiatry by the American Board of Psychiatry and Neurology.
(6) "Board eligible child psychiatrist" means a child psychiatrist who has successfully met the training and experience requirements sufficient to be eligible for the examinations of the board.
(7) "Child care staff" means those staff members who provide direct care to patients twenty-four (24) hours a day under professional supervision.
(8) "Child psychiatrist" means a physician who successfully completed an accredited training program in child psychiatry consisting of two (2) years general psychiatry and two (2) years child psychiatry.
(9) "Department" means the Department of Community Health of the State of Georgia.
(10) "Emergency safety interventions" means those behavioral intervention techniques that are authorized under an emergency safety intervention plan and are utilized by properly trained staff in an urgent situation to prevent a patient from doing immediate harm to self or others.
(11) "Emergency safety intervention plan" means the plan developed by the facility utilizing a nationally recognized, evidence-based, training program for emergency safety intervention. The plan shall clearly identify the emergency safety interventions staff may utilize and those that may never be used.
(12) "Exploitation" means the illegal or improper use of a person or that person's resources through undue influence, coercion, harassment, duress, deception, false representation, false pretense, or other similar means for another person's profit or advantage.
(13) "Governing body" means the treatment facility authority created by the Georgia Hospital Act, O.C.G.A. § 31-7-72, the board of trustees, the partnership, the corporation, the association, the person or the group of persons who maintain and control the facility. The governing body may or may not be the owner of the properties in which the facility services are provided.
(14) "Hospital" means any institution designed, equipped and staffed to receive two (2) or more persons for diagnosis, treatment and other health services under the supervision of a practitioner for periods continuing twenty-four (24) hours or longer, and in which professional policies are adopted by the governing body after consultation with the active professional staff.
(15) "Manual hold" means the application of physical force, without the use of any device, for the purpose of restricting the free movement of a patient's body and is considered a form of restraint. A manual hold does not include briefly holding the patient without undue force to calm or comfort the patient, holding the patient by the hand or by the shoulders or back to walk the patient safely from one area to another where the patient is not forcefully resisting the assistance, or assisting the patient in voluntarily participating in activities of daily living or other functional activities.
(16) "Mechanical restraint" means a device attached or adjacent to the patient's body that is not a prescribed and approved medical protection device, and that he or she cannot easily remove, that restricts freedom of movement or normal access to his or her body. A mechanical restraint does not include devices used to assist patients with appropriate positioning or posture secondary to physical impairments or disabilities.
(17) "Multidisciplinary staff" means staff of various disciplinary backgrounds who can address the physical, social, mental, educational, recreational and other needs of the patient.
(18) "Neglect" means the absence or omission of essential services to the degree that it harms or threatens with harm the physical or emotional health of a person.
(19) "Patient" means any person residing in a treatment facility for the express purpose of receiving diagnostic, treatment or other health services for physical or mental conditions.
(20) "Patient safety interventions" means the safety observations, supervision, and methods developed and implemented by the facility to ensure the safety of patients.
(21) "Patient safety plan" means the plan developed by the facility that outlines the requirements for patient monitoring to ensure the continuous provision of sufficient regular, special, and emergency observation and supervision of all patients twenty-four (24) hours a day.
(22) "Permit" means authorization granted by the department to the governing body to operate a treatment facility and signifies substantial compliance with these rules and regulations.
(23) "Plan of correction" means a written plan submitted by the governing body and acceptable to the Department. The plan shall identify the existing noncompliance of the treatment facility, the proposed procedures, methods, means and period of time to correct the noncompliance.
(24) "Practitioner" means physician, dentist or osteopathic physician authorized to provide care in Georgia.
(25) "Provisional permit" means authorization granted by the department to the governing body to operate a treatment facility on a conditional basis to allow a newly established treatment facility a reasonable but limited period of time to demonstrate operational procedures in substantial compliance with these rules and regulations; or to allow an existing treatment facility a reasonable length of time to comply with these rules and regulations, provided said treatment facility shall first present a plan of improvement acceptable to the department.
(26) "Pharmacist" means any person who is licensed to practice in this State under the provisions of the Georgia Pharmacy Practice Act, O.C.G.A. § 26-4-5.
(27) "Physician" means any person who is authorized to practice medicine in this State under the provisions of the Composite State Board of Medical Examiners, O.C.G.A. § 43-34-20et seq.
(28) "Psychiatrist" means a physician who has successfully completed an accredited training program in psychiatry.
(29) "Qualified psychiatric nurse" means a nurse who holds a masters degree in psychiatric nursing from an accredited school of nursing.
(30) "Qualified psychologist" means any person who is licensed to practice in this State under the provisions of the Georgia Board of Examiners of Psychologists, O.C.G.A. § 43-39-1 and who has training and experience in child and adolescent psychology.
(31) "Qualified social worker" means a social worker who has a masters degree in social work from an accredited school of social work.
(32) "Registered Nurse" (R.N.) means any person who holds a current license as a registered nurse issued by the State of Georgia.
(33) "Record(s)" means the individual files established and maintained by a facility which include data concerning a patient.
(34) "Residential mental health facility for children and youth" or "facility" is a sub-classification of a "Specialized Hospital" and is defined as a facility providing twenty-four (24) hour care and having the primary functions of diagnosing and treating patients to age twenty-one (21) with psychiatric disorders to restore them to an optimal level of functioning.
(35) "Seclusion" means the involuntary confinement of a patient away from other patients, due to imminent risk of harm to self or others, in a room or an area from which the patient is physically prevented from leaving.
(36) "Shall" means a mandatory requirement.
(37) "Specialized hospital" means any hospital which limits its admissions to persons whose physical or mental disability is of a specific class or type. The department shall use a sub classification which adequately describes the proposed service. This service shall be under the supervision of physicians.
(38) "Supervision" means the continued responsibility of the facility to take reasonable action to provide for the health, safety, and well-being of a patient while under the supervision of the facility or the agent or employee of the facility, including protection from physical, emotional, social, moral, financial harm, and personal exploitation while in care. The facility is responsible for providing the degree of supervision indicated by the patient's age, developmental level, physical, emotional, and social needs.
(39) "Time out" means a behavior management technique that restricts a patient for a brief period of time to a designated area from which the patient is not physically prevented from leaving, for the purpose of permitting the patient to de-escalate and for providing an opportunity for the patient to regain self-control.

Rule 111-8-68-.04 General Policies

(1) Application. An application to operate a licensed facility must comply with the following:
(a) The governing body of the facility shall submit to the department an application for a permit. Such application shall be signed by the executive officer of the governing body.
(b) The application for a permit shall be prepared in duplicate on forms provided by the department. The original copy shall be forwarded to the department and the copy retained by the governing body.
(c) The application for an original permit shall be accompanied by a program narrative of the service or services provided, a copy of the bylaws of the governing body and a copy of the policies and procedures adopted by the professional staff and approved by the governing body.
(d) The application for an original permit shall be submitted to the department not later than thirty (30) days prior to the anticipated date of the opening and commencement of operation of the facility.
(e) Application for change in status of a facility shall be submitted to the department not later than thirty (30) days prior to the effective date proposed.
(f) Proof of ownership and a notarized personal identification form shall accompany the application.
1. Corporations shall submit a copy of their charter and the name and address of all owners with ten (10) percent or more of the stock and shall identify each corporate officer;
2. Non-profit associations and facility authorities shall submit legal proof of the organization, the name and address of each trustee and the office held, if any; and
3. All other types of facilities shall submit the name and address of each person with ownership interests in the facility.
(2) Permits. The following requirements pertain to the permit to operate the licensed facility:
(a) The facility must be in substantial compliance with these rules and regulations and the provisions of law which apply to the location, construction and maintenance of treatment facilities and the safety of the patients therein. A permit shall remain in force and effect unless suspended or revoked or otherwise removed as hereinafter provided.
(b) Prior to the issuance of a permit and at the request of the department, the governing body shall furnish the department evidence of compliance with any laws or regulations thereunder applicable to facilities but the enforcement of which is the responsibility of a department or agency of government other than the department.
(c) The permit shall show the classification of the facility, and shall specify the number of beds designated for such treatment facility.
(d) The permit shall be framed and publicly displayed at all times.
(e) Permits are not transferable from one governing body to another, nor valid when the facility is moved from one location to another.
(f) The permit shall be returned to the department when the facility ceases to operate, or is moved to another location, or the ownership changes, or the governing body is significantly changed, or the permit is suspended or revoked.
(g) A permit shall be required for each facility. At the request of the governing body of multi-building facilities, a single permit may be issued to include all buildings provided that each building is in substantial compliance with these rules and regulations.
(3) Provisional Permits. The following requirements pertain to the issuance of a provisional permit to operate the licensed facility:
(a) Provisional permits may be granted to the governing body of a new or established facility to demonstrate operational procedures in substantial compliance with these rules and regulations.
(b) A provisional permit may be granted to the governing body of an existing facility to give reasonable time to comply with regulations and standards, which relate to the structural or physical condition of the treatment facility.
(c) Provisional permits granted to allow reasonable time to demonstrate satisfactory compliance with operational procedures shall be limited to periods of not more than six(6) months.
(d) Provisional permits granted to allow reasonable time to correct noncompliances relating to the structural or physical condition of the facility shall be limited to a period of not more than twelve (12) months; provided, however, that the department may extend such period for a period not to exceed another twelve (12) months.
(e) No provisional permits shall be granted to the governing body of a newly established facility which is not in substantial compliance with these rules and regulations, and standards relating to the structural or physical condition of the facility.
(f) A provisional permit shall not be issued when there is noncompliance of any type which present an immediate hazard to the life, health or safety of patients.
(g) No provisional permit shall be granted unless the governing body first presents to the department a plan of correction which shall list each noncompliance to be corrected, the time required to correct noncompliance which relates to the structural or physical condition of the facility and the means, methods and procedures to be used in the correction of the noncompliance.
(h) The governing body shall make periodic reports to the department regarding the progress being made in correcting noncompliance as agreed to by the terms of the plan of correction.
(i) The governing body of a facility operating under a provisional permit may petition the department for an extension of time, if needed, to correct noncompliance where the failure to make such corrections within the time allotted is due to an extenuating circumstance beyond the control of the governing body. Such petition shall be submitted to the department as agreed to by the terms of the plan of correction.
(4) Patient Capacity. The number of patients receiving care within the facility shall not exceed the number of residential mental health beds shown on the permit.

Rule 111-8-68-.05 Organization and Administration

(1) Incorporation. All facilities shall be incorporated unless operated by a local or state governmental authority. The purpose or function of the facility shall be stated in the charter of incorporation.
(2) Governing Body. The governing body must ensure that the following requirements are met:
(a) Every facility shall have a governing body which has responsibility for the overall operation of the facility. Each governing body shall establish and be operated by a set of bylaws and guidelines.
(b) Bylaws or rules and regulations shall be in accordance with legal requirements and shall assure the quality of patient care. They shall also include:
1. a definition of powers and duties of the governing body, its officers and committees;
2. a statement of the qualifications of members, method of selection, numbers and terms of appointments, or election of officers and committees;
3. a determination of frequency of meetings, which shall be at least quarterly, attendance requirements and quorums at meetings;
4. provision for the appointment of a full-time administrator with a description of the qualifications, authority and responsibilities of such a person;
5. provision for the appointment of a clinical director with a description of the qualifications, authority and responsibilities of such a person;
6. a mechanism by which the administrative and clinical staff consult with and report to the governing body;
7. an effective, formal means by which the administrative and clinical staff may participate in the development of the facility's policies relative to both facility management and patient care; and
8. provision to establish rules and regulations that are not limited to, but shall include:
(i) a statement of the regulations by which the clinical staff and administrative staff shall function;
(ii) a requirement that controls are established for insuring that each professional member of the staff will observe all the ethical principles and standards of his profession, and will assume and carry out clinical and/or administrative functions consistent with local, state and federal laws and regulations; and
(iii) a requirement that the evaluation and authentication of psychiatric and medical histories, the performance and recording of physical examinations, and the prescribing of medication be carried out by physicians with appropriate qualifications, licenses and clinical privileges within his/her sphere of authorization.
9. For a facility whose governing body does not solely function in support of the residential mental health facility, then an advisory board shall also be appointed to advise and advocate for the residential mental health program for children and youth. This board's members shall be selected with a broad community representation with specific expertise and/or interest in the mental health of children and youth. The advisory board shall meet at regular intervals, not less often than quarterly.
(3) Finances. The facility shall be operated in a fiscally responsible manner and addresses the following:
(a) Each facility shall have a sound plan for financing, which assures sufficient funds to enable it to carry out its defined purposes.
(b) A new facility shall have sufficient funding assured to carry it through its first year of operation.
(c) An accounting system shall be maintained that produces information reflecting fiscal experience and the current financial position of the facility.
(d) The facility shall employ a system of accounting that clearly indicates the cost elements for assessment and therapeutic services for each program.
(e) All accounts shall be audited at least annually by a certified public accountant and the report made a part of the facility's records. A copy of this report shall be made available to the department upon request if the facility is subsidized by state or federal funds.
(4) Goals, Policies and Procedures. The facility shall develop and update as necessary, goals, policies and procedures which address the following:
(a) Each facility shall have a clear written statement of its purpose and objectives, with a formal, long-range plan adapted to guide and schedule steps leading to attainment of its projected objectives. This plan shall include a specifically delineated description of the services the facility offers. The plan shall also include:
1. the population to be served, age groups and other limitations;
2. an organizational chart with a description of each unit or department and its services, its relationship to other services and departments and how these are to contribute to the priorities and goals of the facility; and
3. plans for cooperation with other public and private agencies to assure that each patient will receive comprehensive treatment. Ongoing working arrangement contracts with agencies, such as schools and/or welfare agencies, shall be included as indicated, as well as regularly planned interagency conferences, which shall be documented.
(b) The facility shall develop and implement effectively policies and procedures for operations, including but not limited to:
1. the initial screening process;
2. the intake or admission process;
3. the development of treatment plans, including the involvement of the patient, parent(s), and/or legal guardian;
4. the appropriate use of behavior management techniques and emergency safety interventions;
5. the appropriate use of patient safety methods to ensure the continuous provision of sufficient regular, special, and emergency observation and supervision of all patients;
6. the provision of any community education consultation programs; and
7. the provision or arrangement for services required by the patient:
(i) other medical, dental, special assessment and therapeutic services, which shall become a part of the clinical services plan;
(ii) medical emergency services;
(iii) educational services for all patients; and
(iv) discharge and follow-up care and evaluation.
(5) Personnel. The facility shall meet the following personnel requirements:
(a) Composition. The composition of the staff shall be determined by the needs of the patients being served and the goals of the facility, and shall have available a sufficient number of mental health professionals, child care workers and administrative personnel to meet these goals.
1. The administrator of the facility shall have a master's degree in administration or a professional discipline related to child and adolescent mental health, and have at least three (3) years administrative experience. A person with a baccalaureate degree may also qualify for administrator with seven (7) years experience in child and adolescent mental health care with no less than three (3) year's administrative experience.
2. The clinical director shall be at least board eligible in psychiatry with experience in child and adolescent mental health.
3. If the clinical director is not full-time, then there shall also be a full-time service coordinator who is a professional person experienced in child and adolescent mental health and is responsible for the coordination of treatment aspects of the program.
4. Mental health professionals shall include, but are not limited to, child psychiatrists, qualified psychologists, qualified social workers and qualified psychiatric nurses. These persons, if not on a full-time basis, must be on a continuing consulting basis. The authority and participation of such mental health professionals shall be such that they are able to assume professional responsibility for supervising and reviewing the needs of the patients and the services being provided. Such individuals shall participate in certain specific functions, e.g., assessment, treatment planning, treatment plan and individual case reviews, and program planning and policy and procedure development and review.
5. Other professional and paraprofessional staff shall include, but not be limited to, physicians, registered nurses, educators and twenty-four (24) hour child care staff. Also included on a regular basis, or as consultants on a continuing basis shall be activity therapists and vocational counselors.
6. Consultation shall be available as needed from dietitians, speech, hearing and language specialists, and other therapeutic professionals.
(b) Organization. The facility shall have an organizational plan which clearly explains the responsibilities of the staff. This plan shall also include:
1. lines of authority, accountability and communication;
2. committee structure and reporting or dissemination of material; and
3. established requirements regarding the frequency of attendance at general and departmental/service and/or team/unit meetings.
(c) Policies and Records. Personnel policies and practices shall be designed, established and maintained to promote the objectives of the facility and to ensure that there are sufficient qualified personnel to provide for the needs, care, safety, and supervision of patients.
1. Each facility shall have written personnel policies covering at least the following areas: job classifications; personnel selection; procedures and requirements for health evaluations; staff orientation and training programs; the maintenance and content of personnel records and, for all persons employed after effective date of these rules, the use of employment and criminal background checks to ensure that the employee has no history of violent or abusive behavior. Each new employee shall be given a copy of personnel practices when hired, including the policy to conduct employment and criminal background checks.
2. All prospective personnel must be checked against state sex offender registries where the applicant has lived since becoming an adult or have satisfactory criminal records check information on file prior to employment by the facility. The facility shall not hire or retain staff who have a history of violent or abusive behavior.
3. There shall be clear job descriptions for all personnel. Each description shall contain the position title, immediate supervisor, responsibilities and authority. These shall also be used as a basis for periodic evaluations by the supervisor.
4. Accurate and complete personnel records shall be maintained for each employee and include at least the following:
(i) current background information, including the application, employment references, the results of employment and criminal background checks, and any accompanying documentation sufficient to justify the initial and continued employment of the individual and the position for which he was employed. Applicants for positions requiring a license shall be employed only after the facility has obtained verification of the license. Where certification is a requirement, this shall also be verified. Evidence of renewal of a license or certification shall be maintained in the employee's personnel record;
(ii) current information relative to work performance evaluations, including any records of employee discipline arising from the inappropriate use of behavior management techniques and/or emergency safety interventions;
(iii) records of initial, regular, and targeted health screenings, sufficient in scope to ensure that all facility personnel who are employed or under contract with the facility who may have patient contact or are providing patient care services do not have conditions that may place patients or other personnel at risk for infection, injury, or improper care; and
(iv) records of orientation training and any continuing education or staff development programs completed.
(d) Staff Development. The facility shall provide and document completion of orientation programs and other staff training.
1. There shall be appropriate orientation and training programs provided for all new employees. Prior to working with patients, all employees, including administrative staff who work with the patients shall complete an orientation program which includes at a minimum instruction in:
(i) the employee's assigned duties and responsibilities;
(ii) facility policies and procedures for receiving and handling family and patient grievances and complaints;
(iii) policies and procedures related to child abuse, neglect and exploitation including reporting requirements.
(iv) policies and procedures regarding appropriate behavior management and emergency safety interventions; and
(v) policies and procedures to protect the confidentiality of patient records.
2. The staff development program shall be facility-based with a designated person or committee who is responsible, on a continuing basis, for planning and insuring that training programs are implemented. The facility shall also make use of educational programs outside the facility.
(6) Volunteer Program. When volunteers are utilized in a program, a qualified staff member of the facility shall be designated to plan, supervise and coordinate the volunteer's functions as well as an appropriate training program.
(7) Research and Human Rights Review. Research practices involving human subjects shall comply with the State of Georgia agency policy on "Protection of Human Subjects."
(8) Reporting. Written summary reports shall be made to the department in a form acceptable to the department within twenty-four (24) hours (with a detailed investigative report to follow in five working days if not provided initially) regarding the following serious occurrences involving patients in care:
(a) Serious injury which causes any significant impairment of the physical condition of the resident as determined by qualified medical personnel. This includes, but is not limited to burns, lacerations, bone fractures, substantial hematoma, and injuries to internal organs, whether self-inflicted or inflicted by someone else;
(b) deaths;
(c) suicide attempts;
(d) emergency safety interventions resulting in any injury of a patient requiring medical treatment beyond first aid;
(e) elopements when the patient cannot be located within twenty-four (24) hours or where there are circumstances that place the health, safety, or welfare of the patient or others at risk; or
(f) any incident which results in any federal, state, or private legal action by or against the facility which affects any patient or the conduct of the facility. However, legal action involving the juvenile justice system is not required to be reported.
(9) Child Abuse Reports. Whenever the facility has reason to believe that a patient in care has been subjected to abuse, neglect or exploitation, the facility shall make a report of such abuse to the child welfare agency providing protective services as designated by the Department of Human Services (Division of Family and Children Services) or in the absence of such an agency to an appropriate police authority or district attorney in accordance with the requirements of O.C.G.A. § 19-7-5. A copy of the report shall also be filed with the Division of Healthcare Facility Regulation, Department of Community Health.

Rule 111-8-68-.06 Facilities

(1) General Requirements. The facility shall provide an environment that is therapeutic to and supportive of all the patients, their healthy development and their changing needs. The therapeutic environment shall take into consideration the architecture of the facility, indoor and outdoor activity areas, furnishings, equipment, decorations and all other factors that involve the physical environment.
(a) Facilities shall be designed to meet the needs of the age group of the patients and the objectives of the program.
(b) Facilities shall be maintained in a safe and clean manner and must meet fire, safety, health and sanitation regulations.
(c) There shall be adequate and appropriate space and equipment for all facility programs and their various functions within the facility.
(d) Facilities shall provide sufficient space and equipment to ensure housekeeping and maintenance programs sufficient to keep the building and equipment clean, tidy and in a state of good repair.
(2) Disaster Preparedness. The facility shall prepare for potential emergency situations that may affect patient care by having an effective disaster preparedness plan that identifies emergency situations and outlines an appropriate course of action. The plan must be reviewed and revised at least annually, as appropriate, including any related written agreements.
(a) The disaster preparedness plan shall include at a minimum plans for the following emergency situations:
1. local and widespread weather emergencies or natural disasters, such as tornadoes, hurricanes, earthquakes, ice or snow storms, or floods;
2. man-made disasters such as acts of terrorism and hazardous materials spills;
3. unanticipated interruption of service of utilities, including water, gas, or electricity, either within the facility or within a local or widespread area;
4. loss of heat or air conditioning;
5. fire, explosion, or other physical damage to the facility; and
6. pandemics or other situations where the community's need for services exceeds the availability of beds and services regularly offered by the facility.
(b) There shall be plans to ensure sufficient staffing and supplies to maintain safe patient care during the emergency situation.
(c) There shall be plans for the emergency transport or relocation of all or a portion of the facility patients, should it be necessary, in vehicles appropriate to the patient's condition(s) when possible, including written agreements with any facilities which have agreed to receive patients in these situations.
(d) The facility shall document participation of all areas of the facility in quarterly fire drills.
(e) In addition to fire drills, the facility shall have its staff rehearse portions of the disaster preparedness plan, with a minimum of two (2) rehearsals each calendar year either in response to an emergency or through planned drills, with coordination of the drills with the local Emergency Management Agency (EMA) whenever possible.
(f) The facility shall provide a copy of the internal disaster preparedness plan to the local Emergency Management Agency (EMA) and shall include the local EMA in development of the facility's plan for the management of external disasters.
(g) The facility's disaster preparedness plan shall be made available to the department for inspection upon request. In addition, when provided with sixty (60) days notice in writing, the department may direct the facility to submit and periodically update the disaster preparedness plan electronically in a format acceptable to the department.
(h) The department may suspend any requirements of these rules and the enforcement of any rules where the Governor of the State of Georgia has declared a state of emergency.
(3) Construction. The plan, design and construction of the facility must meet the following requirements:
(a) All plans and specifications for the construction of new facilities shall be approved by the department prior to commencing work on the building. Such construction includes new buildings, additions, alterations, or renovations to existing buildings.
(b) A program narrative shall be submitted prior to or along with the submission of schematic plans for proposed new construction, additions or conversions. The program narrative shall contain information regarding:
1. sponsorship;
2. community needs;
3. program of service;
4. type of construction; and
5. financing for the construction and operation of the facility.
(c) Any individual or group planning construction of a facility shall submit schematic and/or preliminary plans to the department for review and counsel in the interpretation of these rules and regulations. Completed or final plans and specifications shall besubmitted for final review and approval; including site, driveways and parking areas, type of construction, mechanical and electrical systems, the type and location of major equipment, the intended use of each room, the proposed system of garbage and refuse disposal.
(d) Plans for additions and/or alterations to an existing building shall be submitted in sufficient detail to include type of construction and layout of the existing building to show overall relationship.
(e) Approved final plans shall not be materially changed without prior approval of such changes by the department.
(4) Location and Site.
(a) The site shall be approved by the department; and
(b) The site shall have proper drainage, sewage disposal, water, electrical, telephone and other necessary facilities available to the site.

Rule 111-8-68-.07 Services

(1) Intake and Admission. Services shall be designed to meet the needs of the patient and must conform to the stated purposes and objectives of the facility.
(a) Acceptance of a child or adolescent for inpatient treatment shall be based on the initial assessment, arrived at by a multidisciplinary team of clinical staff, and clearly explained to the patient, parent(s), and/or legal guardian.
1. Whether the family voluntarily requests services or the patient is referred by the court, the facility shall involve the family's participation to the fullest extent possible.
2. Acceptance of the child or adolescent for treatment shall be based on the determination that the child or adolescent requires treatment of a comprehensive and intensive nature and is likely to benefit by the programs that the residential mental health facility has to offer.
3. Admission shall be in keeping with stated policies of the facility and shall be limited to those patients for whom the facility has qualified staff, program and equipment available to give adequate care.
4. Staff members who will be working with the patient, but who did not participate in the initial assessment, shall be oriented regarding the patient and the patient's anticipated admission prior to meeting the patient. When the patient is to be assigned to a group, the other patients in the group shall be prepared for the arrival of the new member. There shall be a specific staff member assigned to the new patient to observe the patient and help with the orientation period.
5. The admission procedure shall include communication with parent(s) and/or legal guardian, and documentation of such communication, concerning:
(i) responsibility for financial support including medical and dental care;
(ii) consent for medical and surgical care and treatment;
(iii) arrangements for appropriate family participation in the program, phone calls and visits when indicated;
(iv) arrangements for clothing, allowances and gifts;
(v) arrangements regarding the patient leaving the facility with or without medical consent;
(vi) description of the facility's services and the daily routines of patients;
(vii) the facility's policies and procedures for discipline and grievances;
(viii) patient rights; and
(ix) the facility's policy and procedures for the use of emergency safety interventions with written acknowledgment that the patient, parent(s), and/or legal guardian has been informed of these procedures and has been provided a copy of the procedures along with contact information for the Georgia protection and advocacy agency, currently designated as the Georgia Advocacy Office.
6. Decisions for admission shall be based on the initial assessment of the patient made by the appropriate multidisciplinary team of clinical staff. This assessment shall be in writing and recorded on admission. The initial assessment shall clearly indicate the patient's needs as related to the services offered by the facility.
7. The admission order must be written by a physician.
(2) Assessment and Treatment Planning Including Discharge. The facility shall provide to families at the time of initial assessment a description of the treatment services it provides, including content, methods, equipment and personnel involved. Each patient's treatment program must be individualized, and must describe which of the offered services are needed and are to be provided.
(a) Assessment. The facility is responsible for a complete assessment of the patient, some of which may be completed prior to admission, by reliable professionals acceptable to the facility's staff. The complete assessment shall include but is not limited to:
1. Physical examination, which includes at least a general physical examination and neurological assessment, performed within twenty-four (24) hours after admission by a licensed physician or a nurse practitioner or physician's assistant working under the direction of a licensed physician who is on staff at the facility. However, in lieu of performing the required physical examination; the staff physician, nurse practitioner or physician's assistant working under direction of the physician may examine and update the patient's physical condition within twenty-four (24) hours after admission where an appropriate physical examination completed by any licensed physician or a nurse practitioner or physician's assistant working under the direction of the licensed physician was performed within forty-eight (48) hours prior to admission.
2. Assessment of motor development and functioning;
3. Dental assessment;
4. Speech, hearing and language assessment;
5. Vision assessment;
6. Review of immunization status and completion according to the U.S. Public Health Service Advisory Committee on Immunization Practices and the Committee on Control of Infectious Diseases of the American Academy of Pediatrics;
7. Laboratory workup including routine blood work and urinalysis;
8. Chest x-ray and/or tuberculin test;
9. Serology;
10. Follow-up testing and/or treatment by appropriately qualified and/or trained clinicians where any of the physical health assessments indicate the need for further testing or definitive treatment with any plans for treatments coordinated with the patient's overall treatment plan;
11. Psychiatric/psychological examination, including but not limited to:
(i) Direct psychiatric evaluation and behavioral appraisal, evaluation of sensory, motor functioning, a mental status examination appropriate to the age of the patient and a psychodynamic appraisal. A psychiatric history, including history of any previous treatment for mental, emotional or behavioral disturbances shall be obtained, including the nature, duration and results of the treatment, and the reason for termination. An initial and ongoing assessment of the patient's potential risks of harm to self and others is also required;
(ii) Appropriate psychological testing;
(iii) An initial and ongoing assessment of the need for safety supervision and monitoring.
(iv) Developmental/social assessment, including but not limited to:
(I) The developmental history of the patient including the prenatal period and from birth until present, the rate of progress, developmental milestones, developmental problems, and past experiences that may have affected the development. The assessment shall include an evaluation of the patient's strengths as well as problems. Consideration shall be given to the healthy developmental aspects of the patient, as well as to the pathological aspects, and the effects that each has on the other shall be assessed. There shall be an assessment of the patient's current age, appropriate developmental needs, which shall include a detailed appraisal of his peer and group relationships and activities.
(II) A social assessment including evaluation of the patient's relationships within the structure of the family and with the community at large, an evaluation of the characteristics of the social, peer group, and institutional settings from which the patient comes. Consideration shall be given to the patient's family circumstances, including the constellation of the family group, their current living situation, and all social, religious, ethnic, cultural, financial, emotional and health factors. Other factors that shall be considered are past events and current problems that have affected the patient and family; potentialities of the family's members meeting the patient's needs; and their accessibility to help in the treatment and rehabilitation of the patient. The expectations of the family regarding the patient's treatment, the degree to which they expect to be involved, and their expectations as to the length of time and type of treatment required shall also be assessed.
12. Nursing. The nursing assessment includes, but is not limited to the evaluation of:
(i) Self-care capabilities including bathing, sleeping, eating;
(ii) Hygienic practices such as routine dental and physical care and establishment of healthy toilet habits;
(iii) Dietary habits including a balanced diet and appropriate fluid and caloric intake;
(iv) Responses to physical diseases such as acceptance by the patient of a chronic illness as manifested by his compliance with prescribed treatment;
(v) Responses to physical handicaps such as the use of prostheses or coping patterns used by the visually handicapped; and
(vi) Responses to medications such as allergies or dependence.
13. Educational/Vocational. The patient's current educational/vocational needs in functioning, including deficits and strengths, shall be assessed. Potential educational impairment and current and future educational/vocational potential shall be evaluated using, as indicated, specific educational testing and special educators or others.
14. Recreational. The patient's work and play experiences, activities, interests and skills shall be evaluated in relation to planning appropriate recreational activities.
(b) Treatment Planning. An initial treatment plan shall be formulated, written, and interpreted to the staff and patient within forty-eight (48) hours of admission. The comprehensive treatment plan shall be formulated for each patient by a multidisciplinary staff, written, implemented, and placed in the patient's records within fourteen (14) days of admission. This plan must be reviewed at least monthly, or more frequently to meet the needs of the patients or if the objectives of the program indicate. Review shall be noted in the record. A psychiatrist as well as multidisciplinary professional staff must participate in the preparation of the plan and any major revisions.
1. The initial treatment plan shall be based on screening and initial assessments and shall reflect the reasons for admission, significant problems, and preliminary treatment and medication modalities to be used pending completion of the comprehensive treatment plan.
2. The comprehensive treatment plan shall outline an active treatment program and be based on the assessment of the physical; developmental; psychological; chronological and developmental age; family; educational; vocational; social; and recreational needs of the patient. The reason for admission should be specified as should specific treatment goals, stated in measurable terms, including a projected timeframe; treatment modalities to be used; staff who are responsible for coordinating and carrying out the treatment; and expected length of stay and designation of the person or agency to whom the patient will be discharged. The comprehensive treatment plan shall be reviewed and revised at least monthly or more frequently to meet the needs of the patients.
3. The degree of the patient's family's involvement (parent or parent surrogates) shall be defined in the treatment plan.
4. Collaboration with resources and significant others shall be included in treatment planning, when appropriate.
(c) Discharge. Discharge planning begins at the time of admission. A discharge date shall be projected in the treatment plan. Discharge planning shall include a period of time for transition into the community, e.g., home visits gradually lengthened, schools, etc. for those patients who have been in the facility for an extended period of time. The facility shall provide clinical or other patient information as required for the receiving organization to provide appropriate follow-up care.
(3) Staff Coverage. There shall be a master clinical staffing plan which provides for the continuous provision of sufficient regular, special, and emergency supervision and observation of all patients twenty-four (24) hours a day to meet their physical, mental, social, and safety needs.
(a) There shall be a registered nurse on duty at all times. Services of a registered nurse shall be available for all patients at all times. An exception may be permitted in facilities having less than a daily average of twenty (20) patients or less than twenty-five (25) beds, in that a registered nurse will not be required to be on duty at all times. In such cases, a licensed practical nurse shall be on duty and shall be assigned responsibility for the care of the patient, and a physician or registered nurse shall be on call and available for emergencies.
(b) A physician shall be on call twenty-four (24) hours a day and accessible to the facility within sixty (60) minutes. The physician's name and contact information shall be clearly posted in accessible places for all staff.
(c) Assessments of staffing needs shall be made on an ongoing basis but minimally every twenty-four (24) hours. Staffing patterns shall be adjusted to meet the assessed needs of patients. Special attention shall be given to times which probably indicate the need for increased direct care, e.g., weekends, evenings, during meals, transition between activities, awaking hours, numbers of patients requiring special observations, etc.
(d) Staff interaction shall ensure that there is adequate communication of information regarding patients, e.g., between working shifts or change of personnel, with consulting professional staff at routine planning and patient review meetings, etc. These shall be documented in writing.
(4) Program Activities. Program goals of the facility shall include those activities designed to promote the "normal" growth and development of the patients, regardless of pathology or age level. There should be positive relationships with general community resources, and the facility staff shall enlist the support of these resources to provide opportunities for patients to participate in normal community activities as they are able.

All labeling of vehicles used for transportation of patients shall be such that it does not call unnecessary attention to the patients.

(a) Group Size. The size and composition of each living group shall be therapeutically planned and depend on the age, developmental level, sex and clinical conditions. It shall allow for appropriate staff-patient interaction, security, close observation and support.
(b) Daily Routine. A basic routine shall be delineated in a written plan which shall be available to all personnel. The daily program shall be planned to provide a consistent well structured yet flexible framework for daily living and shall be periodically reviewed and revised as the needs of individual patients or the living group change. A basic daily routine shall be coordinated with special requirements of the patient's treatment plan.
(c) Social and Recreation Activities. Programs of recreational, physical, and social activities shall be provided for all patients for daytime, evenings, and weekends, to meet the needs of the patients and goals of the program. Programs should be designed to assist patients to develop a sense of confidence, individuality, self-esteem, and establish appropriate skills for living within the community. There shall be documentation of these activities as well as schedules maintained of any planned activities.
(d) Religious Activities. Opportunity shall be provided for all patients to participate in religious services and other religious activities within the framework of their individual and family interests and clinical status. The option to celebrate holidays in the patient's traditional manner shall be provided and encouraged.
(e) Education. The facility shall arrange for or provide an educational program for all patients receiving services in that facility. The particular educational needs of each patient shall be considered in both placement and programming.
(f) Vocational Programs. The facility shall arrange for or provide some degree of vocational and/or prevocational training for patients in the facility for whom it is indicated.
1. If there are plans for work experience developed as part of the patient's overall treatment plan the work shall be in the patient's interest with payment where appropriate, and never solely in the interest of the facility's goals or needs.
2. Patients shall not be responsible for any major phase of the facility's operation or maintenance, such as cooking, laundering, housekeeping, farming and repairing. Patients shall not be considered as substitutes for employed staff.
3. Adequate attention shall be paid to federal wage and hour laws.
(5) Nutrition. Food services must comply with the Rules and Regulations for Food Service, Chapter 290-5-14. There must be a provision for planning and preparation of special diets as needed. Menus shall be evaluated by a consultant dietitian relative to nutritional adequacy at least monthly, with observation of food intake and changes seen in the patient.
(6) Physical Care. The facility shall have available, either within its own organizational structure or by written arrangements with outside clinicians or facilities, a full range of services for the treatment of illnesses and the maintenance of general health. The facility's written plan for clinical services shall delineate the ways the facility obtains or provides all general and specialized medical, surgical, nursing and dental services. Definite arrangements shall be made for a licensed physician to provide medical care for the patients. This shall include arrangements for necessary visits to the facility as well as office visits. Each patient shall have a primary physician who maintains familiarity with the patient's physical health status.
(a) Patients who are physically ill shall be cared for in surroundings that are familiar to them as long as this is medically feasible. If medical isolation is necessary, there shall be sufficient and qualified staff available to give appropriate care and attention.
(b) Arrangements shall be made in writing for patients from the facility to receive care from outside clinicians and at appropriate hospital facilities in the event a patient requires services that the facility cannot properly handle.
(c) Every patient shall have a complete physical examination annually and more frequently if indicated. This examination shall be as inclusive as the initial examination. Efforts shall be made by the facility to have physical defects of the patients corrected through proper medical care. Immunizations shall be kept current (DPT, polio, measles, rubella), appropriate to the patient's age.
(d) Each member of the staff shall be able to recognize common symptoms of the illnesses of patients, and to note any marked defects of patients. Staff shall be able to provide nursing care under the supervision of a registered nurse.
(e) Staff shall have knowledge of basic health needs and health problems of patients, such as mental health, physical health and nutritional health. Staff shall teach attitudes and habits conducive to good health through daily routines, examples and discussion, and shall help the patients to understand the principles of health.
(f) Each facility shall have a definitely planned program of dental care and dental health which shall be consistently followed. Each patient shall receive a dental examination by a qualified dentist and prophylaxis at least twice a year. Reports of all examinations and treatment should be included in the patient's clinical record.
(7) Emergency Services. All clinical staff shall have training in matters related to handling emergency situations.
(a) Policies and procedures shall be written regarding handling and reporting of emergencies and these shall be reviewed at least quarterly by all staff.
(b) All patient care staff must have an up-to-date first-aid certificate and certification in basic cardiopulmonary resuscitation (CPR). The facility must maintain suction equipment and an automatic external defibrillator (AED). All patient care staff must have training in the use of oral suction and the use of an AED.
(c) There shall be an emergency kit made up under the supervision of a physician and inspected regularly with documentation of inspections. This kit shall include emergency drugs, equipment, etc. This kit shall be stored in a locked area, easily accessible to appropriate staff.
(d) There shall be an adequate number of appropriately equipped first aid kits stored with appropriate safeguards but accessible to staff in appropriate locations such as living units, recreation and special purpose areas, buses, vans, etc.
(8) Pharmaceutical Services. Policies and procedures related to pharmaceutical services shall include but are not limited to:
(a) The facility shall have a pharmacy or drug room onsite that shall be directed by a registered pharmacist.
1. The pharmacy or drug room shall be under competent supervision.
2. The pharmacist shall be responsible to the administration of the facility and for developing, supervising and coordinating all activities of the pharmacy.
(b) If there is a drug room with no pharmacist, prescription medication shall be dispensed by a qualified pharmacist elsewhere and only storage and distribution shall be done at the facility. A designated person shall have responsibility for the day-to-day operation of the drug room. A consulting pharmacist shall assist in developing policies and procedures for the distribution of drugs, and shall visit the facility as needed.
(c) Special locked storage space shall be maintained at the facility to meet the legal requirements for storage of narcotics and other prescribed drugs.
(d) Written arrangements with outside pharmacies, clinicians or facilities shall be made for emergency pharmaceutical service.
(e) Establishment and maintenance of a satisfactory system of records and bookkeeping in accordance with the policies of the facility.
(f) An automatic stop order on all prescribed drugs not specifically prescribed as to time and number of doses. These stop orders shall be in accordance with federal and state laws. Individual drug plans shall be reviewed by a physician weekly or more frequently as needed.
(g) A drug formulary accepted for use in the facility which is developed and amended at regular intervals by medical staff in cooperation with the pharmacist.
(h) Drugs may be administered only by a licensed nurse, in accordance with the Nurse Practice Act, O.C.G.A. § 43-26-12et seq. relating to the practice of nursing in Georgia.
(i) Intravenous medications and fluids shall be administered in accordance with Georgia law. If administered by licensed nurses, they shall be administered only by those who have been trained and determined competent to perform this duty.
(j) Each facility shall provide pharmaceutical services in compliance with State and federal laws and regulations.
(9) Medical orders shall be in writing and signed by the physician. Telephone/verbal orders shall be used sparingly and given only to a licensed nurse or otherwise qualified individual as determined by the medical staff in accordance with State law. The individual receiving the telephone/verbal order shall immediately repeat the order and the prescribing physician shall verify that the repeated order is correct. The individual receiving the order shall document, in the patient's clinical record that the order was repeated and verified. Telephone/verbal orders must be signed by the physician within the timeframe designated in the facility's policies and procedures which ensure that it is done as soon as possible. Where telephone/verbal orders are routinely not being signed within the timeframe designated in the policy, the facility will take appropriate corrective action.
(10) Laboratory and Pathology Services. Provision shall be made for those services within the facility or with an outside facility to meet the needs of the patient. These services shall be provided by a CLIA certified facility. Laboratory and pathology tests to be performed require an order from a qualified physician and reports from such tests shall be part of the patient's clinical records. Abnormal laboratory and pathology reports shall be followed up appropriately.
(11) Patients' Rights. Every effort shall be made to safeguard the legal and civil rights of patients and to make certain that they are kept informed of their rights, including the right to legal counsel and all other requirements of due process when necessary.
(a) Treatment. Each patient shall be provided treatment and care in the least restrictive environment as possible; each patient, parent(s), and/or legal guardian shall be encouraged to participate in the development of the patient's individualized treatment plan; and each patient shall be provided treatment and care in a manner that respects the patient's personal privacy and dignity.
(b) Visitors. Policies shall allow visitation of patient's family and significant others unless clinically contraindicated. Appropriate places for visits shall be provided.
(c) Telephone and Mail. Patients shall be allowed to conduct private telephone conversations with family and friends and to send and receive mail. When restrictions are necessary because of therapeutic or practical reasons, such as expense, these reasons shall be documented, explained to the patient and family and re-evaluated at least monthly.
(d) Behavior Management. Behavior management techniques shall be fair and consistent and must be applied based on the individual's needs and treatment plan, and following established and approved behavior management techniques in accordance with the Rule 111-8-68-.08.
(e) Restraint and Seclusion. Each patient has the right to be free from restraint or seclusion, in any form, used as a means of coercion, discipline, convenience, or retaliation.
(f) Clothing. Individual patients shall have their own appropriate amounts and types of clothing for the particular activities, climate, etc. There shall be an appropriate storage place for their clothing.
(g) Grievances. The patients shall have the opportunity to present opinions, recommendations and grievances to appropriate staff members. The facility shall have written policies and carry out appropriate procedures for receiving and responding to such patient communications in a way that will preserve and foster the therapeutic aspects of conflict-resolution and problem solving; e.g., patient-staff government meetings.
(12) Records. The form and detail of the clinical records may vary in accordance with these rules.
(a) Content. All clinical records shall contain all pertinent clinical information and each record shall contain at least:
1. Identification data, consent forms, acknowledgment of patient, parent(s), and/or legal guardian's receipt and explanation of facility's emergency safety intervention procedures and a copy of patients' rights; when these are not obtainable, reason shall be noted;
2. Source of referral;
3. Reason for referral, e.g. chief complaint, presenting problem;
4. Record of the complete assessment;
5. Initial formulation and diagnosis based upon the assessment;
6. Written treatment plan;
7. Medication history and record of all medications prescribed;
8. Record of all medication administered by facility staff, including type of medication, dosages, frequency of administration, and persons who administered each dose;
9. Documentation of course of treatment and all evaluations and examinations, including those from other facilities, example, emergency room or general hospital;
10. Documentation of the use and monitoring of emergency safety interventions;
11. Documentation of the use of patient safety observations/interventions;
12. Periodic progress report;
13. All consultation reports;
14. All other appropriate information contained from outside sources pertaining to the patient;
15. Discharge or termination summary report; and
16. Plans for follow-up and documentation of its implementation.
17. Identification data and consent form shall include the patient's name, address, home telephone number, date of birth, sex, next of kin, school name, grade, date of initial contact and/or admission to the service, legal status and legal document, and other identifying data as indicated.
18. Progress Notes. Progress notes shall include regular notations at least weekly by staff members, consultation reports and signed entries by authorized identified staff. Progress notes by the clinical staff shall:
(a) Document a chronological picture of the patient's clinical course;
(b) Document all treatment rendered to the patient;
(c) Document the implementation of the treatment plan;
(d) Describe each change in each of the patient's conditions;
(e) Describe responses to and outcome of treatment including the use of any emergency safety interventions and medications; and
(f) Describe the responses of the patient and the family or significant others to significant events.
19. Discharge Summary. The discharge summary shall include the initial formulation and diagnosis, clinical resume, final formulation, and final primary and secondary diagnoses, the psychiatric and physical categories. The final formulation shall reflect the general observations and understanding of the patient's condition initially, during appraisal of the fundamental needs of the patients. All relevant discharge diagnoses should be recorded and coded in the standard nomenclature of the current "Diagnostic and Statistical Manual of Mental Disorders," published by the American Psychiatric Association, and the latest edition of the "International Classification of Diseases," regardless of the use of other additional classification systems. Records of discharged patients shall be completed following discharge within a reasonable length of time, and not to exceed fifteen (15) days. In the event of death, a summation statement shall be added to the record either as a final progress note or as a separate resume. This final note shall take the form of a discharge summary and shall include circumstances leading to death. All discharge summaries must be signed by a physician.
20. Recording. Entries in the clinical records shall be made by all staff having pertinent information regarding the patient, consistent with the facility policies, and authors shall fully sign and date each entry. When mental health trainees are involved in, patient care, documented evidence shall be in the clinical records to substantiate the active participation of supervisory clinical staff. Symbols and abbreviations shall be used only when they have been approved by the clinical staff and when there is an explanatory legend. Final diagnosis, both psychiatric and physical, shall be recorded in full, and without the use of either symbols or abbreviations.
(b) Clinical Records Policies and Procedures. The facility shall have written policies and procedures regarding clinical records which are enforced and provide that:
1. Clinical records shall be confidential, current and accurate;
2. The facility shall protect the confidentiality of clinical information and communication between staff members and patients;
3. All staff shall have training, as part of new staff orientation and with periodic updates, regarding the effective maintenance of confidentiality of clinical records. It shall be emphasized that confidentiality also refers to discussions regarding patients inside and outside the facility. Verbal confidentiality shall be discussed as part of all employee training.
4. Clinical records are the property of the facility and shall be maintained for the benefit of the patient, the staff and the facility;
5. The facility is responsible for safeguarding the information in the clinical record against loss, defacement, tampering or use by unauthorized persons;
6. Except as required by law, the written consent of the patient, or if the patient is a minor, the parent(s), and/or legal guardian, is required for the release of clinical record information;
7. Records may be removed from the facility's jurisdiction and safekeeping only according to the policies of the facility or as required by law; and
(c) Maintenance of Records. Each facility shall provide for a master filing system which shall include a comprehensive record of each patient's involvement in every program aspect.
1. Appropriate records shall be kept on the unit where the patient is being treated or be directly and readily accessible to the clinical staff caring for the patient;
2. The facility shall maintain a system of identification and filing to facilitate the prompt location of the patient's clinical records;
3. The facility shall retain patients' records at least until the fifth anniversary of the patients' discharge. If the patient is a minor, the records must be retained for at least five (5) years past the age of majority. Records may be preserved in the facility's format of choice, including but not limited to paper or electronic format, so long as the records are readable, capable of being reproduced in paper format upon request, and stored and disposed of in a manner that protects the confidentiality of the record;
4. The clinical record services required by the facility shall be directed, staffed and equipped to facilitate the accurate processing, checking, indexing, filing, retrieval and review of all clinical records. The clinical records service shall be the responsibility of an individual who has demonstrated competence and training or experience in clinical record administrative work. Other personnel shall be employed as needed, in order to effect the functions assigned to the clinical record services; and
5. There shall be adequate space, equipment and supplies, compatible with the needs of the clinical record service, to enable the personnel to function effectively and to maintain clinical records so that they are readily accessible.
(13) Program and Patient Evaluation. The staff shall work towards enhancing the quality of patient care through specified, documented, implemented and ongoing processes of clinical care evaluation studies and utilization review mechanisms.
(a) Individual Case Review.
1. There shall be regular staff meetings and/or unit meetings to review and monitor the progress of the individual child or adolescent patient. Each patient's case shall be reviewed within a month after admission and at least monthly during residential treatment. Review of the use of emergency safety interventions shall be in accordance with Rule 111-8-68-.08(2)(l). The reviews shall be documented and the meeting may also be used for review and revision of treatment plans.
2. The facility shall provide for a follow-up review on each discharged patient to determine effectiveness of treatment and disposition.
(b) Program Evaluation.
1. Clinical Care Evaluation Studies. There shall be evidence of ongoing studies to define standards of care consistent with the goals of the facility, effectiveness of the program, the facility's progress in reducing the use of emergency safety interventions, and to identify gaps and inefficiencies in service. Evaluation shall include, but is not limited to, follow-up studies. Studies shall consist of the following elements:
(i) Selection of an appropriate design;
(ii) Specification of information to be included;
(iii) Collection of data;
(iv) Analysis of data with conclusions and recommendations;
(v) Transmissions of findings; and
(vi) Follow-up on recommendations.
2. Utilization Review. Each facility shall have a plan for and carry out utilization review. The review shall cover the appropriateness of admission to services, the provision of certain patterns of services, and duration of services. There shall be documentation of utilization review meetings either in minutes or in individual clinical records.

Rule 111-8-68-.08 Behavior Management and Emergency Safety Interventions

(1) Behavior Management.
(a) The facility shall develop and implement policies and procedures on behavior management. Such policies and procedures shall set forth the types of patients served in accordance with its program purpose, the anticipated behavioral problems of the patients, and acceptable methods of managing such problems.
(b) Such behavior management policies and procedures shall incorporate the following minimum requirements:
1. Behavior management principles and techniques shall be used in accordance with the individual treatment plan, written policies and procedures, treatment goals, safety, security, and these rules and regulations.
2. Behavior management shall be limited to the least restrictive appropriate method, as described in the patient's treatment plan, and in accordance with the prohibitions as specified in these rules and regulations.
3. Behavior management principles and techniques shall be administered by facility staff members and shall be appropriate to the severity of the patient's behavior, chronological and developmental age, size, gender, physical, medical, psychiatric condition, and personal history (including any history of physical or sexual abuse).
(c) The following forms of behavior management shall not be used by staff members with patients receiving services from the facility:
1. assignment of excessive or unreasonable work tasks;
2. denial of meals and hydration;
3. denial of sleep;
4. denial of shelter, clothing, or essential personal needs;
5. denial of essential program services;
6. verbal abuse, ridicule, or humiliation;
7. restraint, manual holds, and seclusion used as a means of coercion, discipline, convenience, or retaliation;
8. denial of communication and visits unless restricted in accordance with Rule 111-8-68-.06(i)(2); and
9. corporal punishment.
(d) Patients shall not be permitted to participate in the behavior management of other patients or to discipline other patients, except as part of an organized therapeutic self-governing program in accordance with accepted standards of clinical practice that is conducted in accordance with written policy and is supervised directly by designated staff.
(2) Emergency Safety Interventions.
(a) Emergency safety interventions shall only be used when a patient exhibits a dangerous behavior reasonably expected to lead to immediate physical harm to the patient or others and less restrictive means of dealing with the injurious behavior have not proven successful or may subject the patient or others to greater risk of injury.
(b) Any emergency safety intervention involving use of mechanical restraints, manual holds, or seclusion must be ordered by a physician or other licensed professional trained in emergency safety interventions and authorized by State law to order such use.
1. The order may not be a standing order or on an as-needed basis.
2. If the order is a verbal order, it must be received by a licensed nurse or otherwise qualified staff as determined by the medical staff in accordance with State law, prior to initiation of the emergency safety intervention, while the intervention is being initiated by staff, or immediately thereafter. The individual issuing the order must verify the verbal order in a signed written form in the patient's record within the timeframe designated by facility policy and procedure which ensures that it is done as soon as possible. The individual ordering the use of the intervention must be available to staff for consultation, at least by a two-way communication device, throughout the course of the emergency safety intervention.
3. Each order for use of restraint or seclusion must be limited to no longer than the duration of the emergency safety situation.
4. Each order for the use of mechanical restraint, manual hold, or seclusion, must include the name of the physician or other licensed professional, the date and time the order was obtained, the type of intervention ordered, and the length of time for which the use of the intervention was authorized. Restraint and seclusion orders shall not exceed:
(i) four (4) hours for patients ages 18 to 21;
(ii) two (2) hours for patients ages 9 to 17;
(iii) one (1) hour for patients under age 9; and
(iv) fifteen (15) minutes for manual holds with one order renewal for an additional fifteen(15) minutes for a total of thirty (30) minutes.
5. If the emergency safety situation continues beyond the time limit authorized in the order, a registered nurse or other licensed professional must immediately contact the ordering physician or the ordering licensed professional to receive further instructions.
(c) Emergency safety interventions shall not include the use of any restraint or manual hold that would potentially impair the patient's ability to breathe or has been determined to be inappropriate for use on a particular patient due to a documented medical or psychological condition.
(d) The facility shall have written policies and procedures for the use of emergency safety interventions, a copy of which shall be provided to and discussed with each patient (as appropriate taking into account the patient's age and intellectual development) and the patient's parents and/or legal guardians prior to or at the time of admission. Emergency safety interventions policies and procedures shall include:
1. requirements for the documentation of an assessment at admission and at each annual exam by the patient's physician, a physician's assistant, or a registered nurse with advanced training working under the direction of a physician, which reflects that there are no medical issues that would be incompatible with the appropriate use of emergency safety interventions on that patient. Such assessment and documentation must be reevaluated following any significant change in the patient's medical condition;
2. requirements for prohibiting the use of mechanical restraints, manual holds, or seclusion use by any employee not trained in prevention and use of emergency safety interventions, as required by these rules; and
3. requirements that all actions taken that involve utilizing an emergency safety intervention shall be recorded in the patient's record, including at a minimum the following:
(i) date and description of the precipitating incident;
(ii) the order for use of any mechanical restraints, manual hold, or seclusion;
(iii) description of the de-escalation techniques used prior to the emergency safety intervention, if applicable;
(iv) environmental considerations;
(v) names of staff participating in the emergency safety intervention;
(vi) any witnesses to the precipitating incident and subsequent intervention;
(vii) exact emergency safety intervention used;
(viii) evidence of the continuous visual monitoring of a patient in mechanical restraint, manual hold, or seclusion, documented minimally at fifteen (15) minute intervals;
(ix) the provision of fluids every hour, food at regular intervals, and bathroom breaks every two (2) hours;
(x) beginning and ending time of the intervention;
(xi) outcome of the intervention;
(xii) detailed description of any injury arising from the incident or intervention; and
(xiii) summary of any medical care provided.
(e) Emergency safety interventions may be used to prevent runaways only when the patient presents an imminent threat of physical harm to self or others, or as specified in the individual treatment plan.
(f) Facility staff shall be aware of each patient's known or apparent medical and psychological conditions (e.g. obvious health issues, list of medications, history of physical abuse, etc.), as evidenced by written acknowledgement of such awareness, to ensure that the emergency safety intervention that is utilized does not pose any undue danger to the physical or mental health of the patient.
(g) Patients shall not be allowed to participate in the emergency safety intervention of another patient.
(h) Within one (1) hour of the initiation of an emergency safety intervention and immediately following the conclusion of the emergency safety intervention, a physician or other licensed independent practitioner; or a registered nurse or physician assistant; trained in the use of emergency safety interventions and permitted by the state and the facility to assess the physical and psychological well-being of patients must conduct a face-to-face assessment of the patient. The assessment at a minimum must include:
1. the patient's physical and psychological status;
2. the patient's behavior;
3. the appropriateness of the intervention measures; and
4. any complications and treatments resulting from the intervention.
(i) Manual Holds.
1. Emergency safety interventions utilizing manual holds require at least one (1) trained staff member to carry out the hold. Emergency safety interventions utilizing prone restraints require at least two trained staff members to carry out the hold.
2. When a manual hold is used upon any patient whose primary mode of communication is sign language, the patient shall be permitted to have his or her hands free from restraint for brief periods during the intervention, except when such freedom may result in physical harm to the patient or others.
3. A manual hold requires physician authorization at fifteen (15) minute intervals and may not be used for more than thirty (30) minutes at any one time without the consultation of the ordering physician or other licensed professional authorized to order the use of manual holds. The ordering physician or other licensed professional authorized to order the use of the hold shall be contacted by a two-way communications device or in person to determine that the continuation of the manual hold is appropriate under the circumstances.
4. If the use of a manual hold on a patient reaches a total of one hour within a twenty-four (24) hour period, the staff shall reconsider alternative treatment strategies, and document same.
5. The patient's breathing, verbal responsiveness, and motor control shall be continuously monitored during any manual hold. Documentation of the monitoring by a trained staff member shall be recorded every fifteen (15) minutes during the duration of the restraint.
(j) Seclusion.
1. A room used for the purposes of seclusion must meet the following criteria:
(i) The room shall be constructed and used in such ways that the risk of harm to the patient is minimized;
(ii) The room shall be equipped with a viewing window so that staff can monitor the patient;
(iii) The room shall be lighted and well-ventilated;
(iv) The room shall be a minimum fifty (50) square feet in area; and
(v) The room must be free of any item that may be used by the patient to cause physical harm to himself/herself or others.
2. No more than one (1) patient shall be placed in the seclusion room at a time.
3. A seclusion room monitoring log shall be maintained and used to record the following information:
(i) name of the secluded patient;
(ii) reason for the patient's seclusion;
(iii) time of patient's placement in the seclusion room;
(iv) name and signature of the staff member that conducted visual monitoring;
(v) signed observation notes; and
(vi) time of the patient's removal from the seclusion room.
(k) Training, Evaluation, and Reporting.
1. All facility staff members who may be involved in the use of emergency safety interventions, shall have evidence of having satisfactorily completed a nationally recognized training program for emergency safety interventions to protect patients and others from injury, which has been taught by an appropriately certified trainer in such program. Emergency safety interventions may only be used by those staff members who have received such training and successfully demonstrated the techniques learned for managing emergency safety situations.
2. At a minimum, the emergency safety intervention program that is utilized shall include the following:
(i) techniques for de-escalating problem behavior including patient and staff debriefings;
(ii) appropriate use of emergency safety interventions;
(iii) recognizing aggressive behavior that may be related to a medical condition;
(iv) awareness of physiological impact of a restraint on the patient;
(v) recognizing signs and symptoms of positional and compression asphyxia and restraint associated cardiac arrest;
(vi) instructions as to how to monitor the breathing, verbal responsiveness, and motor control of a patient who is the subject of an emergency safety intervention;
(vii) appropriate self-protection techniques;
(viii) policies and procedures relating to using manual holds, including the prohibition of any technique that would potentially impair a patient's ability to breathe;
(ix) facility policies and reporting requirements;
(x) alternatives to restraint;
(xi) avoiding power struggles;
(xii) escape and evasion techniques;
(xiii) time limits for the use of restraint and seclusion;
(xiv) process for obtaining approval for continual restraints and seclusion;
(xv) procedures to address problematic restraints;
(xvi) documentation;
(xvii) investigation of injuries and complaints;
(xviii) monitoring physical signs of distress and obtaining medical assistance; and
(xix) legal issues.
3. Emergency safety intervention training shall be in addition to the training required in Rule 111-8-68-.05(5)(d) and shall be documented in the staff member's personnel record.
4. The facility shall take and document appropriate corrective action when it becomes aware of or observes the inappropriate use of an emergency safety intervention technique as outlined in these rules and regulations and shall notify each patient's parents and/or legal guardians. Documentation of the incident and the corrective action taken by the facility shall be maintained.
(l) At least monthly, the facility, utilizing a master restraint/seclusion log and the patients' records, shall review the use of all emergency safety interventions for each patient and staff member, including the type of intervention used and the length of time of each use, to determine whether there was a clinical basis for the intervention, whether the use of the emergency safety intervention was warranted, whether any alternatives were considered or employed, the effectiveness of the intervention or alternative, and the need for additional training. Written documentation of all such reviews shall be maintained. Where the facility identifies opportunities for improvement as a result of such reviews or otherwise, the facility shall implement these changes through an effective quality improvement plan designed to reduce the use of emergency safety devices.
(m) Facilities shall submit to the department electronically or by facsimile a report, within twenty-four (24) hours, whenever the facility becomes aware of an incident which results in any injury of a patient requiring medical treatment beyond first aid that is received by a patient as a result of or in connection with any emergency safety intervention. In addition facilities must report the following:
1. For any thirty (30) day period, where three (3) or more incidents for the same patient occur where the facility has used mechanical restraint or seclusion lasting four (4) or more hours for patients ages 18-21; two (2) or more hours for patients ages 9 to 17; or one (1) or more hours for patients under nine (9) years of age and/or when three (3) or more incidents for the same patient occur where the facility has used manual holds lasting thirty (30) or more minutes. The reports shall include the type of emergency safety intervention, total amount of time in the intervention, and any actions taken to prevent further use of emergency safety interventions.
2. On a monthly basis, the total number of emergency safety interventions shall be reported by patient unit, including the total amount of time each intervention was used, and the monthly average daily census for each unit. The report shall include a summary of the facility's monthly evaluation of their use of emergency safety interventions, including actions taken.

Rule 111-8-68-.09 Waivers and Variances

(1) The department may, in its discretion, grant waivers and variances of specific rules upon application or petition being filed by a facility. The department may establish conditions which must be met by the facility in order to operate under the waiver or variance granted. Waivers and variances may be granted in accordance with the following considerations:
(a) Variance. A variance may be granted by the department upon a showing by the applicant or petitioner that the particular rule or regulation that is the subject of the variance request should not be applied as written because strict application of the rule would cause undue hardship. The applicant or petitioner must also show that adequate standards affording protection for the health, safety and care of the patients exist and will be met in lieu of the exact requirements of the rule or regulations in question.
(b) Waiver. The department may dispense entirely with the enforcement of a rule or regulation upon a showing by the applicant or petitioner that the purpose of the rule or regulation is met through equivalent standards affording equivalent protection for the health, safety and care of patients.
(c) Experimental Variance or Waiver. The department may grant waivers and variances to allow experimentation and demonstration of new and innovative approaches to delivery of services upon a showing by the applicant or petitioner that the intended protections afforded by the rule or regulation which is the subject of the request are met and that the innovative approach has the potential to improve service delivery.

Rule 111-8-68-.10 Enforcement and Penalties

(1) Enforcement of these rules and regulations shall be done in accordance with the Rules and Regulations for Enforcement of Licensing Requirements, Chapter 111-8-25.
(2) The facility shall notify each patient's parents and/or legal guardians of the department's actions to revoke the license or seek an emergency suspension of the facility's license to operate.
(3) The official notice of the revocation or emergency suspension action and any final resolution, together with the department's complaint intake phone number and website address, shall be provided by the facility to each current and prospective patient's parents and/or legal guardians.
(4) The facility shall ensure the posting of the official notice at the facility in an area that is visible to each patient's parents and/or legal guardians.
(5) The facility shall ensure that the official notice continues to be visible to each patient's parents and/or legal guardians throughout the pendency of the revocation and emergency suspension actions, including any appeals.
(6) The facility shall have posted in an area that is readily visible to each patient's parents and/or legal guardians any inspection reports that are prepared by the Department during the pendency of any revocation or emergency suspension action.
(7) It shall be a violation of these rules for the facility to permit the removal or obliteration of any posted notices of revocation, emergency suspension action, resolution, or inspection survey during the pendency of any revocation or emergency suspension action.
(8) The department may post an official notice of the revocation or emergency suspension action on its website or share the notice of the revocation or emergency suspension action and any information pertaining thereto with any other agencies that may have an interest in the welfare of the patients in care at the facility.
(9) The department may suspend any requirements of these rules and the enforcement of any rules where the Governor of the State of Georgia has declared a state of emergency.
(10) Inspections. The facility shall be available at reasonable hours for observation and examination by properly identified representatives of the department.
(a) At least annually, a report providing statistical data and brief program narrative shall be provided to the department, as requested.
(b) The governing body shall notify the department of the anticipated opening date of a newly constructed facility in order that a pre-opening licensure inspection of the treatment facility may be conducted to determine compliance with these rules and regulations.
(c) The administrator or his representative shall accompany the department representative on tours of inspection and shall sign the completed check-list.
(11) Plans of Correction. If violations of these licensing rules are identified, the facility will be given a written report of the violation that identifies the rules violated. The facility shall submit to the department a written plan of correction in response to the report of violation, which states what the facility will do, and when, to correct each of the violations identified. The facility may offer an explanation or dispute the findings or violations in the written plan of correction, so long as an acceptable plan of correction is submitted within ten (10) days of the facility's receipt of the written report of inspection. If the initial plan of correction is unacceptable to the department, the facility will be provided with at least one (1) opportunity to revise the unacceptable plan of correction. Failure to submit an acceptable plan of correction may result in the department commencing enforcement procedures. The facility shall comply with its plan of correction.

Rule 111-8-68-.11 Severability

In the event that any rule, sentence, clause, or phrase of any of these rules and regulations may be construed by any court of competent jurisdiction to be invalid, illegal, unconstitutional, or otherwise unenforceable, such determination or adjudication shall in no manner affect the remaining rules or portion thereof. The remaining rules or portions of rules shall remain in full force and effect, as if such rule or portions thereof so determined, declared, or adjudged invalid or unconstitutional were not originally a part of these rules.