212-RICR — Department of Behavioral Healthcare, Developmental Disabilities and Hospitals

A. These regulations are promulgated pursuant to the authority conferred under R.I. Gen. Laws §§ 23-17.8-9, 40.1-1-13, 40.1-2-2, 40.1-5-3, 40.1-5.4-11, 40.1-8.5-7, 40.1-21-12, 40.1-22-4, 40.1-24-9, 40.1-24.5-2, 40.1-26-11, and 40.1-27-3; as well as R.I. Gen. Laws Chapter 42-35, and are established for the purpose of adopting prevailing standards for the licensure and operation of facilities and programs providing rehabilitation, support, and guidance for individuals with developmental disabilities or cognitive disabilities.

B. It the expectation of the Department that each individual’s array of supports and services be customized to meet the individual needs and desires in the least restrictive environment.

C. These Rules and Regulations apply to any licensed organization under Subchapter 05 Part 1 of this Chapter (Rules and Regulations for Developmental Disability Organizations), and Subchapter 10 Part 1 of this Chapter (Rules and Regulations for Behavioral Healthcare Organizations).

D. These Rules and Regulations do not apply to the following:

1. Health care facilities licensed by the Rhode Island Department of Health pursuant to R.I. Gen. Laws Chapter 23-17;

2. Assisted living residences licensed by the Rhode Island Department of Health pursuant to R.I. Gen. Laws Chapter 23-17.4;

3. Facilities and programs licensed by the Rhode Island Department of Children, Youth and Families pursuant to R.I. Gen. Laws Chapter 42-72.1;

4. Facilities, programs, or organizations already licensed or certified by any other appropriate state agency, pursuant to R.I. Gen. Laws.

The statutes cited in § 1.1 of this Part delineate the general scope of authority for this Chapter, as do the Part’s specific provisions.

A. Wherever used in this Part, the following terms shall be construed to mean:

1. “Abuse” means the treatment or act toward any person with developmental disabilities, as defined in R.I. Gen. Laws § 40.1-27-1 on the part of anyone, including an employee, intern, volunteer, consultant, contractor, visitor, family member, caregiver, neighbor, citizen or other person with a disability, whether or not the person is or appears to be injured or harmed. The failure to exercise one’s responsibility to intercede on behalf of a person receiving services also constitutes abuse. Abuse includes:

a. "Physical abuse" may include, but is not limited to: physical assault, battery and/or actions such as: hitting, kicking, biting, pinching, burning, strangling, shoving, shaking, dragging, yanking, punching, slapping, pulling hair, grabbing or pushing, or using more force than is necessary for the safety of the person.

(1) For incidents involving a caregiver, abuse is defined as the willful subjection of an adult with developmental disabilities to willful infliction of physical pain, willful deprivation of services necessary to maintain physical or mental health, or to unreasonable confinement.

(2) For incidents of physical abuse involving two people with disabilities, only an attack resulting in injury in which one person needs medical care beyond routine first aid or a series of deliberate acts (i.e. hitting, kicking, slapping, pulling hair, etc.) displayed by one person with a disability towards another person with a disability should be reported to the Office of Quality Assurance. Other incidents should be documented and handled by the agency’s internal Incident Management Committee.

b. "Sexual abuse" means any sexual contact, consensual or otherwise, between a person receiving services and a paid employee, consultant or contractor of the Organization. Any sexual contact between a person receiving services and an immediate blood relative is incest and is sexual abuse. Any non-consensual sexual contact between a person with a disability and another person with a disability is also sexual abuse. This includes but is not limited to oral/genital contact, sexual penetration or fondling and any other assault as defined in R.I. Gen. Laws § 11-37.1-1 et seq.

c. "Sexual contact" means the touching, fondling or intrusion of the genitals or other intimate parts of the person or offender directly or through clothing for the purpose of sexual arousal or gratification.

d. "First degree sexual assault" means any forced or coerced intrusion, however slight, of the vagina, anus, or mouth, by part of another person’s body or by an object, including cunnilingus or fellatio.

e. "Second degree sexual assault" means any forced or coerced or intentional touching or sexual contact (not penetration) clothed or unclothed, with a person’s genital area, anal area, groin, buttocks, or the breasts of a female for the purpose of sexual arousal, gratification or assault.

f. "Third degree sexual assault" means penetration where one person is 18 years of age or older and the other is over the age of 14 years, but under the age of consent (age 16 years).

g. "Sexual exploitation" may include, but is not limited to, causing a person to expose or touch themselves or anyone else for the purpose of demeaning the person, for the sexual arousal or personal gratification, taking sexually explicit photographs, forcing or encouraging a person to view pornographic materials encouraging a person to use sexually explicit language which he/she may not fully understand, the use of harmful genital practices such as creams, enemas, etc. to meet the idiosyncratic needs of an offender, etc.

h. "Psychological/verbal abuse" means intentionally engaging in a pattern of harassing conduct which causes or is likely to cause emotional harm. This includes the use of verbal or non-verbal expression that subjects a person to ridicule, humiliation, contempt, manipulation, or is otherwise threatening, socially stigmatizing and fails to respect the dignity of the individual, including name-calling or swearing at a person, intimidating or condescending actions, behaviors, or demeaning tone of voice or any other pattern of harassing conduct.

i. “Mistreatment” means the inappropriate use of medications, isolation, or use of physical or chemical restraints as punishment, for staff convenience, as a substitute for treatment or care, in conflict with a physician's order, or in quantities, which inhibit effective care or treatment, which harms or is likely to harm the individual.

j. “Neglect” means the failure of a person to provide treatment, care, goods and services necessary to maintain the health and safety of the individual, as defined in R.I. Gen. Laws § 40.1-27-1, and other laws. For the purposes of this Part, “Neglect” shall also include the failure to report or act on health problems of the person or changes in his or her health conditions as indicated within a plan approved by the Department. Neglect also includes lack of attention to the physical needs of the person including personal care, cleanliness and personal hygiene, meals and/or failure to provide appropriate nutrition or a safe and sanitary environment; failure to carry out a plan of treatment or care prescribed by a physician and/or other health care professional; failure to provide services/supports as indicated within an ISP approved by the Department; and failure to provide proper supervision to the persons as required within an ISP or by a court.

k. "Financial exploitation” means the use of funds, personal property or resources of a person receiving services by an individual for their own monetary or personal benefit, profit or gain with or without the informed consent of the person, including but not limited to the coercion or manipulation of a person to spend their own personal funds for something they may or may not have use for or soliciting of gifts, funds or favors. This includes any suspected theft of or missing property or funds of a person. For incidents involving a caregiver, financial exploitation is defined as an act or process of taking pecuniary advantage of a person with a developmental disability by use of undue influence, harassment, duress, deception, false misrepresentation, false pretenses, or misappropriation of funds.

2. “Administer” means the direct application of a medication, whether by injection, inhalation, ingestion, or any other means, to the body of an individual by

a. a licensed and authorized agent and under his or her direction; or

b. the individual at the direction and in the presence of the licensed and authorized agent.

3. “Admission” means acceptance into a program or service, after an initial biopsychosocial assessment has been conducted and includes opening a treatment record for the person, orienting him or her to the organization, and assigning his or her treatment to an appropriate staff person or team. Individuals shall be admitted to the organization no later than their third consecutive face-to-face clinical service.

4. “Advocate” means a:

a. legal guardian or

b. an individual acting in support of or on behalf of a person in a manner consistent with the interests of the person.

5. “Assessment” means the process of testing, gathering biopsychosocial information, and making a diagnostic judgment to determine an individual's behavioral health status and need for services, conducted by a qualified staff person.

6. “Assistive technology” means specialized medical equipment and supplies to include devices, controls, or appliances, specified in the individualized service plan, that enable individuals to increase their ability to perform activities of daily living; devices, controls, or appliances that enable the individual to perceive, control, or communicate with others in the environment in which they live; including such other durable and non-durable medical equipment not available under the state plan that is necessary to address individual functional limitations. Items reimbursed with waiver funds are in addition to any medical equipment and supplies furnished under the state plan and exclude those items that are not of direct medical or remedial benefit to the individual. All items shall meet applicable standards of manufacture, design and installation and are subject to prior approval on an individual basis by the Department.

7. “Authorization” means the service approved by BHDDH for everyone based upon the ISP or treatment plan.

8. “Behavioral healthcare” means the umbrella term that encompasses all mental health and substance use related assessment, treatment, prevention, and support services.

9. “Behavioral healthcare organization” or “BHO” means a public or private establishment primarily constituted, staffed, and equipped to deliver mental health and/or substance use services to the public.

10. “Board” means the Board of Directors of the organization and/or the Advisory Board of a local Organization that is:

a. a for profit entity or

b. a not for profit entity providing services in Rhode Island.

11. "Caregiver" means a person who provides care for a person with disabilities without payment, natural support.

12. “Certification” shall have the meaning as defined under § 05-1.2(A)(15) of this Chapter and Subchapter 10 Part 1 of this Chapter depending on the program being utilized.

13. “Change in operator” means a transfer of the authority of the Board of Directors, by the Board of an organization, to any other person or group of persons (excluding delegations of authority to the medical or administrative staff of the Organization).

14. “Change in owner” means:

a. When an Organization is a partnership: the removal, addition, or substitution of a partner that results in the new partner acquiring a controlling interest in the Organization.

b. When an Organization is an unincorporated sole proprietorship: the transfer of the title and property to another person.

c. When an Organization is a corporation:

(1) A sale, lease, exchange, or other disposition of all, or substantially all the property and assets of the corporation.

(2) A merger of the corporation into another corporation.

(3) The consolidation of two (2) or more corporations resulting in the creation of a new corporation.

d. When an Organization is a for profit corporation: any transfer of corporate stock that results in a new person acquiring a controlling interest in such corporation.

e. When an Organization is a non-profit corporation: any change in membership that results in a person acquiring a controlling vote in such corporation.

15. “CMHC” or “CMHO” means a private, non-profit community mental health center organization designated by the Director of the Department and licensed as such to ensure services are available through program delivery, local planning, service coordination, and monitoring outcomes within a specified geographical area according to R.I. Gen. Laws Chapter 40.1-8.5 for the Department's priority targeted populations within eight (8) areas according to R.I. Gen. Laws § 40.1-5.4-7(3).

16. “Cognitive disability organization” or “CDO” means an organization licensed by BHDDH to provide services to adults with cognitive disorders. As used herein, CDOs shall have the same meaning as “providers” or “Organizations" and shall meet the licensing requirements of DDOs.

17. “Community residence” means a facility that operates twenty-four (24) hours a day to provide room, board, supervision and supportive services to three (3) or more people who have developmental, mental and/or substance related disabilities.

18. "Complaint" means a formal, written request for further review of an unresolved concern or an allegation against a licensed organization or provider regarding an alleged violation of ethical standards, regulations, or law.

19. “Concern” means an issue that is perceived as interfering with a person receiving adequate treatment.

20. "Controlled medications" or "controlled substances" means substances pursuant to R.I. Gen. Laws Chapter 21-28 that have a high potential for abuse which may lead to severe psychological or physical dependence.

21. “Co-occurring disorder” is the coexistence of two or more behavioral health conditions, existing simultaneously and often independently of each other.

22. “Day program service” means a service offered at a center-based day program or a community-based day program by a licensed developmental disability organization. The service includes the provision of education, training and opportunity to acquire the skills and experience needed to participate in the community. This may include activities to support individuals with building problem solving skills, social skills, adaptive skills, daily living skills, and leisure skills. Other services include assistance in establishing friendships, using public transportation, participating in community events, or otherwise undertaking activities to promote community integration.

23. "Department” means the Rhode Island Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH).

24. “Developmental disability organizations” or “DDOs” means an organization licensed by BHDDH to provide services to adults with disabilities, as provided herein. As used herein, DDOs shall have the same meaning as “providers” or “Organizations."

25. “Director” means the Director of the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH).

26. “Evidence-based practice” is an intervention or service for which there is strong research demonstrating effectiveness in assisting persons to achieve desired outcomes.

27. “Facility” means the physical plant where programs and services are provided and/or overseen, or could be provided, and as defined in R.I. Gen. Laws § 40.1-24-1(6) and other laws as applicable.

28. "Human rights committee” or “HRC" means any duly constituted group of people with developmental disabilities, advocates, volunteers, and professionals who have training or experience in the area of behavioral treatment, and other citizens who have been appointed to a provider’s human rights committee for the purposes of

a. promoting human rights;

b. reviewing, approving and monitoring individuals’ plans designed to modify behavior which utilize restrictive interventions techniques or impair the individual’s liberty, or other plans and procedures that involve risks to the person’s protection and rights; and,

c. participating in the provider’s individual grievance procedures.

29. “Incident” means a situation in which a person who receives services from the Department and/or an Organization licensed by the Department is harmed, or is involved in an event, which causes concern for the person’s health, safety and/or welfare. It also refers to any adult, whether or not the person is receiving services from the Department, with developmental disabilities who is harmed or is involved in an event, which causes concern for the person’s health, safety and/or welfare.

30. "Independent contractor" means a person who is not an employee of the Organization and provides and/or contributes to the direct service to and/or has responsibility for an individual.

31. “Individual” or “individual served” means a person who receives services or is assessed to need services based on the results of an initial assessment. The term "person served" shall be synonymous herein with the term "individual" or “individual served.”

32. "Individual service plan" or “ISP” means the annual document derived from a person-centered plan which details the services for an individual supported.

33. "Integration" means:

a. The use by individuals with developmental disabilities of the same community resources that are used by and available to other persons in the community;

b. Participation in the same community activities in which persons without a developmental disability participate, together with regular contact with persons without a developmental disability; and

c. Individuals with developmental disabilities who live in homes that are in proximity to community resources and foster contact with persons in their community.

34. “Investigation” means a systematic review and search for facts. It is objective in nature and is intended to identify facts, sequence and chronology of events, active failure(s), latent failure(s) and assessment of risk as pertinent to a specific adverse event. An investigation may be undertaken because of a complaint, an adverse event or incident report, or other information that comes to the attention of the Department or the organization.

35. “Non-congregant residential support services” means services provided in residential settings other than a host family that are not Community Residences as defined herein. The service includes residential support services and may include specialized residential support services. Non-congregant residential support services do not include payments for room and board. Payments for non-congregant residential support services are based on residential resource levels.

36. “Office of Licensure and Standards” means the unit within BHDDH that is responsible for licensing provider organizations and programs.

37. “Office of Quality Assurance” or “OQA” shall have the same meaning as the office described in R.I. Gen. Laws § 40.1-26-10.

38. “Orientation” means a process to provide initial information about the BHO and DDO and its services to persons served and to staff of the organization. For staff, orientation includes an assessment of their competence relative to their job responsibilities and the organization's mission, vision, and values.

39. “Outcome” means the result(s) of the performance or the non-performance of a function or process.

40. “Participant” means an adult who has a developmental disability as defined herein. As used in this Part, “individual” shall have the same meaning, in addition to its meaning in § 1.3(A)(31) of this Part.

41. "Person" means any individual, governmental unit, corporation, company, association, or joint stock association and the legal successor thereof.

42. "Person-centered" shall have the meaning as defined in the BHO or DDO regulations, depending on the program being utilized.

43. “Premises” means a tract of land and the buildings thereon where direct services are provided.

44. “Program” means a planned structured service delivery system structured to provide specific components that are responsive to the needs of the persons served.

45. “Provider” means a person or organization that manages or delivers clinical and/or support services.

46. "Residential services” shall have the meaning as defined in the BHO and DDO regulations, depending on the program being utilized.

47. “Restraint” means restricting the movement of the whole or a portion of a person's body as a means of controlling a person's physical activity to protect the person or others from injury.

a. “Chemical or pharmacological restraint” means medication that is given for the emergency control of behavior when the medication is not standard treatment for the individual's medical or psychiatric condition.

b. “Mechanical restraint” means the use of an approved mechanical device that restricts the freedom of movement or voluntary functioning of a limb or a portion of a person's body as a means to control his or her physical activities.

c. “Physical restraint” means the use of approved physical interventions or "hands on" holds to prevent an individual from moving his or her body to engage in a behavior that places him, her or others at risk of physical harm.

48. “Services” mean individually planned interventions intended to reduce or ameliorate the symptoms of mental disorders or substance dependence or abuse through treatment, training, rehabilitation, or other supports. Services also refer to person-centered interventions provided to developmentally disabled adults.

49. “Significant others” mean and include individuals who are important to the person served, as identified by the person served.

50. “Staff” means, including but not limited to, any employee, intern, trainee, or volunteer performing a service or activities for the organization and for meeting the needs of individuals served for which competent performance is expected.

51. “Support coordinator” means the individual employed by the Organization who delivers Support Coordination services. The term is synonymous with Case Manager in these regulations and includes, but is not limited to, the external coordination and monitoring of the Shared Living Arrangements.

52. “Treatment” or “Care” means a set of individually planned interventions or supports that help an individual work towards his or her recovery goals and obtain or maintain an optimal level of functioning, reduce the effects of disability or discomfort, or ameliorate symptoms, undesirable changes or conditions specific to physical, mental, behavioral or social functions.

53. “Violation of human rights” means any action or inaction which deprives an individual of any of his or her civil rights, as articulated in federal or state law or in this Part.

1.4.1 Application for Licensure, Renewal, or Change in Licensure Status

A. To apply for a license, renew an existing license, or remove or replace the provisional or conditional status of a license, an applicant or licensee shall contact the Department’s Office of Licensure and Standards. The Office of Licensure and Standards shall provide an applicant or licensee with the appropriate Departmental license forms.

B. Application for a license to conduct, maintain or operate a BHO, DDO, or Cognitive Disability Organization shall be made to the Department upon forms provided by the Department and shall contain such information as the Department requires, including but not limited to evidence of ability to comply with any and all applicable Department rules and regulations.

C. The Department shall either deny an application or renewal, or shall issue or renew a provisional license, conditional license or license.

D. Such license shall be issued to the applicant or licensee for the operation of specific agencies and facilities and shall not be transferable or assignable except with the written approval of the Director.

1.4.2 Licensed Organizations

A. An Organization that wishes to provide services shall apply for a License under the relevant Organizational category:

1. Behavioral Healthcare Organization ("BHO").

2. Developmental Disability Organization ("DDO").

3. Cognitive Disability Organization (“CDO”), which shall also meet all DDO licensing requirements.

B. Authorization to provide services to individuals will require meeting approved certification standards by BHDDH. The Department will grant licenses to agencies providing services and to agency premises in which services are delivered. Services may be delivered in the community in accordance with the needs of individuals.

1.5.1 General Requirements

An application for licensure is required for an initial license; for license renewal; for changes in owner, operator, or lessee; and when there is a new legal affiliation of two (2) or more Organizations.

1.5.2 Licensure

A. All licensed DDOs, BHOs and CDOs that provide services to adults in Rhode Island must meet all the requirements contained in these regulations.

B. An entity seeking to become a licensed DDO, BHO or CDO shall complete initial applications for licensure using the forms and in the format specified by the Department. Upon approval by the Department, an applicant shall be granted a license for a period of two (2) years.

C. Upon approval by the Department, including an on-site review, an applicant for certification shall be granted provider service certifications that shall remain in effect for up to two (2) years. To remain a licensed provider, the provider must maintain active approved certifications.

1.5.3 Components of Licensing

A. The licensing process shall include but is not limited to a review of the prospective Organization’s:

1. Mission.

2. Corporate philosophy.

3. Organizational background and corporate history.

4. Experience providing services to individuals in RI and other states.

5. Corporate experience.

6. Demonstrated commitment to individuals.

7. Provisions for how individuals who are served participate in the operation of the Organization.

8. Strategies for promoting community inclusion and membership. (DDO specific)

9. Approach to the respectful, age-appropriate imagery of people with developmental disabilities, and strategies for increasing valued roles and perceptions of people in the community.

10. Strategies for providing a voice in all aspects of daily life for the individuals the Organization serves.

11. Human Rights Committee.

12. Board of Directors.

13. Staffing.

14. Staff experience.

15. Job descriptions.

16. Staff resumes.

17. Staff recruitment, selection, training and supervision approach.

18. Criminal background checks.

19. Conflicts of interest.

20. Financial disclosure information.

21. Audit (annually audited financial statements for past three (3) years).

22. Fiscal capacity (including business plan if it is a new entity).

23. Tax compliance.

24. References.

25. Written policies and procedures.

26. Certification Standards Application.

B. The Organization shall demonstrate compliance with applicable laws and regulations. The Organization shall submit to readiness reviews and onsite visits to ensure preparedness for service provision.

C. If an applicant fails to provide complete, accurate, and truthful information during the application and licensing process, the Department may cause licensure to be delayed, or may deny or revoke the license.

D. Any applicant or person with a controlling interest in a BHO or DDO will be considered responsible for acts occurring during, and relating to, the operation of licensed services or Organization for purpose of licensing.

E. The Department may consider the background and operating history of the applicant(s) and each person with a controlling ownership interest when determining to issue a license.

F. When an application for initial licensure is made by an applicant(s) who owns or operates other licensed Community Residences or facilities in Rhode Island, the Department may deny the license if the applicant’s existing Community Residences or facility(ies) are not, or have not been, in substantial compliance with the applicable Rhode Island licensing authority regulations and/or health and safety standards.

G. All applicants must fulfill the applicable requirements described in this Part.

1.5.4 Application Process

A. Upon receipt and approval of an application for a license, the Department shall issue a license or renewal thereof for a period of no more than two (2) years, if the applicant meets the requirements of the rules and regulations herein and the other applicable standards and requirements contained in other regulations.

1. A license shall not be transferable, except with the written approval of the Department. The license shall be issued only for the individual owner, program sponsor, operator, or lessee or to the corporate entity responsible for its governance.

B. The procedure for renewing a license is to submit a renewal application on a form provided by the Department sixty (60) days prior to the expiration date of the current license.

C. A license continues in effect after the end of the licensure period if the Organization has submitted a timely and sufficient renewal application and there are no grounds to deny the license under any provision of this Part.

D. The Organization shall notify the Office of Licensure and Standards in writing of any plans to suspend services or end services or to close a program at least ninety (90) days prior to any proposed suspension, cessation or closure.

E. The license shall be returned to the Department immediately upon surrender, suspension or revocation of the license.

F. The procedure for applying for approval for alterations or additions to a current facility may be made by completing an application change form provided by the Department and by attaching plans and specifications prior to commencement of construction pursuant to R.I. Gen. Laws § 40.1-24-11.

1.5.5 License Modification

A. Upon written request of the Organization, on the license change form provided by the Department, the license may be modified during the term of the license with respect to the populations served, the programs and services offered, the locations where programs and services are provided, the maximum number of persons served in residential programs and homes, and any stipulations. Approval of such request shall be at the sole discretion of the Department.

B. Any change which requires a license modification shall not be implemented prior to approval by the Department.

A. The Department, and if required, any federal, state or accrediting authority, shall be notified of any proposed mergers, affiliations or change of ownership, program sponsor, or operator at least ninety (90) days prior to that proposed merger, affiliation or change. Any such change or action will require the application for and issuance of a new license.

B. In cases where the application involves a merger, consolidation or otherwise legal affiliation of two (2) or more Organizations, the application shall include the proposed immediate and long-term plans of such Organizations with respect to the programs to be offered and services to be provided by such Organizations because of the merger, consolidation or otherwise legal affiliation.

1.7.1 Provisional License

A. A Provisional License may be issued to a new Organization that demonstrates compliance with:

1. administrative and policy-related regulations;

2. all health and safety requirements; and

3. has demonstrated the ability to perform services to individuals in accordance to this Part;

B. A Provisional License may be issued to a new Organization that has not demonstrated compliance with all the regulations.

C. A Provisional License:

1. may not exceed six (6) months.

2. may be renewed but the cumulation the original provisional license and all renewals shall not exceed twelve (12) successive months;

3. will be issued only if such issuance will not result in undue hazard to residents or persons served, as determined by the Department, or by the State Fire Marshal, or by the State Fire Marshal’s delegated authority.

D. An Organization holding a Provisional License shall demonstrate ongoing progress toward compliance remaining requirements for full licensure.

1.7.2 Conditional License

A. A Conditional License may be issued to an Organization that has demonstrated:

1. an inability to maintain compliance with regulations;

2. has a serious violation of human rights or applicable regulations;

3. has multiple violations of human rights or licensing regulations;

4. has demonstrated conduct or practice found by the Department to be detrimental to the welfare of the persons served; or

5. has failed to comply with a previous plan of correction.

B. A Conditional License may be issued at any time during either the issuance or renewal process or during the term of a license at the discretion of the Department.

C. The term of a Conditional License may not exceed six (6) months.

D. A Conditional License may be renewed; however, a Conditional License and any renewals shall not exceed twelve (12) successive months for all Conditional Licenses and renewals combined.

E. An Organization holding a Conditional License shall demonstrate progress towards full compliance with the regulations.

F. The Department may issue a Conditional License if the Department determines that denial of a renewal application or Revocation of an existing license would not be in the best interests of the persons served by the licensee or in the best interests of the community served by the licensee. The Department shall state the requirements of and orders with which a licensee must comply to receive a Conditional License in lieu of denial of a renewal application or Revocation.

G. A Conditional License shall be issued only if such issuance shall not result in undue hazard to residents or persons served, as determined by the Department or by the State Fire Marshal or the State Fire Marshal’s delegated authority.

1.7.3 License with Stipulations and Restrictions

A license may bear stipulations. Stipulations may be limitations on the Organization or may impose additional requirements. Stipulations may be added at any time at the discretion of the Department subject to R.I. Gen. Laws Chapter 42-35. Terms of any such stipulations shall be listed on the Organization’s license.

Reports of deficiencies noted in inspections conducted in accordance with these and other applicable Regulations, and results of any Departmental investigation, and plans of correction or compliance orders as described herein, shall be maintained on file in the Department, and shall be considered by the Department in rendering determinations to deny, condition, limit, suspend or revoke the license or to curtail certain specific activities and programs of an Organization.

If the Director finds that public health, safety, or welfare requires emergency action and the Department incorporates such findings in an order, the Director may order summary suspension of the license or curtailment of activities as enumerated above, pending proceedings for revocation; or other action in accordance with R.I. Gen. Laws § 42-35-14(c).

The Department may deny, suspend, annul, withdraw, amend, refuse to issue or renew, or revoke the license of, or the operation of a specific program authorized under the license of, or curtail some or all the activities of, any Organization if the Department has sufficient evidence to establish that the licensee has violated federal or state statute or regulation subject to § 1.9 or § 1.12 of this Part.

A. The Department may take licensing action against the license in whole and/or in part:

1. The Department may curtail, revoke, suspend or place on conditional status certain services, programs and/or facilities or premises without revoking or otherwise taking sanctions against the Organization’s license.

2. The Department shall determine, in part or in whole, which of those applied for services, programs, and/or facilities or premises included by the Organization on the application for licensure or certification issuance or renewal shall be granted.

A licensee has the right to appeal any decision made by the Department. All appeals will be addressed in accordance with the Appeals Process and Procedures for EOHHS Agencies and Programs, 210-RICR-10-05-2.

A. The Department shall make or cause to be made such inspections and investigations that it deems necessary, in accordance with the Department rules and regulations.

1. Authorized persons from the Department shall have free access to the grounds, buildings, and all books and records relating to any Organization.

2. The Department shall be entitled to receive from all persons connected in any way with the Organization, such information and assistance for any examination or inquiry as the Department may require.

3. The Department shall investigate complaints regarding potential violations of licensing regulations. Organizations shall cooperate fully with any complaint investigation.

B. Any non-compliance with the regulations cited herein shall constitute a valid ground for licensure action.

C. If an Organization has received certification from an acceptable national accreditation body, the Department shall substitute relevant accreditation review findings for related licensure requirements.

1. The following documentation will be required from the Organization for consideration:

a. A copy of the certificate awarded by the accrediting body.

b. The written report from the accrediting body regarding the results of its survey.

c. The Organization’s response, if any, to the report of results from the accrediting body.

D. The Department may deem the Organization in compliance with relevant licensure standards, in part or in whole, after consideration of the extent of compliance with the accrediting body’s standards.

E. The Organization shall also be prepared for periodic full quality program reviews.

A. The Department shall notify the Executive Director or other Organization legal authority of violations of any Subchapter of this Chapter through a notice of deficiencies which shall be sent to the Organization, unless the Department determines that immediate action is necessary to protect the health, welfare, or safety of the public (or any member thereof) through the issuance of an immediate Compliance Order.

B. If the Department rejects the plan of correction, or if the Organization does not provide a plan of correction within the stipulated period, or if the Organization whose plan of correction has been approved by the Department fails to execute its plan within a reasonable time, as determined by the Department, the Department may invoke the sanctions enumerated herein.

C. The Organization that receives a notice of deficiencies must submit a plan of correction, which shall include time frames for completion, to the Department within thirty (30) days of the date the Organization receives notice of the deficiencies. The plan of correction may include any requests for variances in accordance with the Variance Procedures requirements. The plan shall include evidence of compliance for each resolution or a plan for how evidence will be presented upon resolution.

1. Upon request from the Department, the provider shall submit a Plan of Correction in a time frame that is less than thirty (30) days.

2. An amended plan of correction shall be submitted if the Department determines that the initial submission is insufficient to address the deficiencies. The amended plan of correction must be submitted to the Department within ten (10) business days of the date of the Organization’s receipt of the request for an amended plan of correction.

a. An immediate Compliance Order shall identify violations of the applicable licensing standards and instruct the Organization to immediately comply with such order. A copy of the compliance order shall be maintained in the agency record file of the Licensing Office.

D. If the Organization is aggrieved by the action of the Department, the Organization may appeal the decision and request a hearing in accordance with R.I. Gen. Laws Chapter 42-35.

1. The notice of the hearing to be given by the Department shall comply in all respects with the provisions of R.I. Gen. Laws Chapter 42-35. The hearing shall in all respects comply with the provisions therein.

E. All actions of this Section are subject to the provision of § 1.12 of this Part.

A. An Organization may apply for a variance.

B. A variance, at the discretion of the Department, may be granted if it is determined that the variance does not adversely impact the health, safety or welfare of individuals receiving services.

C. The Organization shall also demonstrate how meeting the regulation as written will cause undo harm.

D. The request for variance should be sent to the Department’s Office of Licensure and Standards in writing with an explanation of the Organization’s intent to meet the spirit of the regulation being varied and/or its intent over time to meet the stated regulation as written.

E. The regulation may not be varied by the Organization until the Organization has received written approval from the Department.

F. No provision or procedure prescribed by state or federal statute shall be waived.

Operation of an unlicensed agency may be fined in accordance with R.I. Gen. Laws § 40.1-24-14.

1.17.1 Provider Governance

A. Leadership and Organization Planning

1. The Organization shall operate in accordance with all applicable local, state and federal laws, rules, and regulations.

2. Each Organization shall have an organized Board that functions as its governing body and that is ultimately responsible for:

a. Program and fiscal management and operation of the Organization;

b. Assurance of the quality of services;

c. Compliance with all federal, state, and local laws and regulations pertaining to Organizations, and the regulations herein; and

d. Compliance with all applicable components of the Americans with Disabilities Act and other federal and state disability civil rights laws.

3. The Board shall provide appropriate Organizational oversight.

4. The Board shall include persons who represent the greater community, including individual and family participation. At least twenty-five percent (25%) of the Board shall be persons who reflect the population served by the Organization and/or family members of individuals. At a minimum, one (1) Board member shall be an individual served. Evidence of compliance shall be provided to the Department upon request but shall be non-public for purposes of R.I. Gen. Laws Chapter 38-2. Efforts shall be made to recruit members who represent the cultural diversity and population of the local community of the Organization.

5. The Board of Directors shall adopt by-laws, or an acceptable equivalent, that shall:

a. Describe the lines and levels of authority for relationships among itself, the executive director, or equivalent position and the community;

b. Define the ethical standards and the responsibilities for the governance of the operation and performance of the Organization; and

c. Stipulate at least four (4) regular meetings of the Board of Directors each year and shall describe qualifications for membership, quorum requirements and require recording of minutes.

6. There shall be a written statement of the specific responsibilities of the Board of Directors.

7. The Board of Directors shall review and approve major program changes recommended by the executive director, or equivalent position or and equivalent position.

8. The Board of Directors shall adopt an annual budget, approve policies, and receive written reports of income and expenditures by program and receive a copy of the annual audit.

9. The Board of Directors shall be responsible for annually evaluating the performance of the executive director, or equivalent position, or a person serving in an equivalent position, of the Organization.

10. A written plan shall define the mission, vision, and values for the Organization as well as strategic, operational, program-related, and other plans and policies to achieve them.

11. The Organization shall have a written policy and procedure manual that shall be implemented, reviewed, and updated as necessary.

12. The leadership of an Organization shall develop programs to promote staff recruitment, retention, development, and continuing education.

B. Financial Management

1. The Organization shall develop an annual operating budget and long-term capital expenditure plan and strategy to monitor the implementation of the plan, both of which will be approved by the Board of Directors. The plan shall include:

a. An authorized budget with a review of financial performance at least quarterly;

b. Provisions for meeting the needs of individuals and producing the desired outcomes;

c. Attention to long-term financial solvency;

d. Processes to ensure that agency systems are in place to ensure agency appropriate funding streams are available to carry out the purpose for which the provider is licensed;

e. Identification of the sources of funding for the operations of the Organization.

2. The Organization shall contract with an independent certified public accountant to conduct an annual audit of the Organization’s financial statements.

3. The Organization shall provide audited financial statements, audit findings and any recommendations, including corrective action plans, and any supplemental schedules, as may be required by the Department.

4. The Organization shall secure insurance to:

a. Cover damage, injury, or loss of life caused by fire, accident, or any other dangers that might occur during the operation of the Organization;

b. Provide liability coverage for all vehicles owned, leased or operated by the Organization;

c. Carry worker’s compensation insurance in accordance with the laws of the State of Rhode Island.; and,

d. Protect the personal funds of individuals, to cover damage, injury or loss of life caused by fire, accident or any other dangers which might arise in the operation of the Organization.

5. The Organization shall maintain its financial records in accordance with generally accepted accounting and bookkeeping practices

6. The Organization shall have the infrastructure and ability to develop, support, and maintain a billing system that can track services provided and bill accordingly.

7. Organizations shall bill the appropriate entity for services rendered to individuals in accordance with the appropriate program requirements.

C. Organization Ethics

1. Each Organization shall have a written Code of Ethical Conduct.

2. The Organization's written Code of Ethical Conduct shall address ethical issues in the management and provision of services and in the implementation of clinical practices pursuant to §§ 1.17, 1.21, and 1.26 of this Part.

3. All staff, volunteers, independent contractors directly involved in support services and shared living arrangement contractors shall adhere to both the Code of Ethics of their respective disciplines, as applicable, and the Organization's Code of Ethical Conduct that will include:

a. the use of accurate and respectful language in all communications to and about persons served.

b. the prohibition from engaging in or promising to engage in a personal, scientific, professional, financial, or other relationship, that is outside the professional relationship sanctioned by the Organization, with persons currently or formerly served by the Organization.

c. the prohibition of taking advantage of any professional relationship or exploit others for their personal, religious, financial, sexual, political, or business interests.

d. the respect for the confidentiality of each person served.

4. The Organization's policies and procedures shall reflect ethical practices for marketing, admission, transfer and billing.

5. The Organization 's Code of Ethical Conduct shall address the provision of appropriate care without consideration of the individual's personal financial resources.

6. The Organization’s Code of Ethical Conduct shall include a policy regarding gifts, goods, or services given to or received from persons served.

7. The Code of Ethical Conduct shall be made available, in a written or electronic format, in all licensed facilities where services are provided and shall be communicated to all personnel and to all persons served during orientation to the Organization and shall be available upon verbal or written request.

8. Training regarding the Code of Ethical Conduct shall be provided to all staff, volunteers, consultants, and shared living arrangement contractors, as applicable.

a. A record of this training shall be maintained by the Organization.

9. The Organization shall have a written policy and procedure to address any violation of the Code of Ethical Conduct.

10. All staff and volunteers affiliated with the Organization shall sign a copy of the Code of Ethical Conduct to indicate that they understand their responsibility to abide by these standards and maintained in the individual's personnel file.

11. The Organization shall not take retaliatory or punitive action against any employee or person served for his or her report of a possible or perceived violation of any rule, regulation, standard, or statute committed by the Organization or by an employee of the Organization.

A. All Organizations shall have written policies and procedures for assessing individual satisfaction with services and supports received, individual choice regarding services received, and individual involvement in monitoring and directing the provision of services.

B. The Organization shall have an effective, ongoing, Organization-wide quality performance/improvement program to evaluate the provision of services and supports to individuals that addresses the quality requirements of the BHO and DDO regulations.

A. All records, entries and documentation required by these regulations shall be:

1. Prepared at the time, or immediately following, the event being recorded;

2. Accurate and contain no willful falsifications;

3. Legible, dated, and signed by the person making the entry; and

4. Maintained in accordance with EOHHS Records Retention requirements pursuant to R.I. Gen. Laws § 38-3-6(a)(c)(k)(1).

1.20.1 Duty to Report

A. Any Organization shall be responsible to make a telephone report to the Department’s Office of Quality Assurance (OQA) within twenty-four (24) hours after an observation of an overt act, after an observation of physical harm to an individual, after receipt of an individual’s oral, written, or gestured disclosure, any of which make a reasonable person believe that the individual was subjected to a violation of his or her civil rights, including but not limited to financial exploitation, mistreatment, neglect, and/or verbal, mental, sexual, and physical abuse, injury of unknown source, death that may have been caused by abuse or neglect, financial exploitation, and/or misappropriation of client property by anyone,

B. Any Organization that has reasonable cause to believe that an assault or a battery has been committed upon an individual shall make an immediate report to the Department’s OQA, and such report shall include the identity of parties and witnesses, and details of the incident. The Department shall cause the report to be investigated immediately. The Department shall, and the Organization may if the law otherwise allows, notify the Mental Health Advocate and appropriate law enforcement agencies of the Department investigation of such assault or battery.

C. Any health care professional who is licensed in Rhode Island, and any police officer, emergency medical technician, firefighter, or any person (within the scope of their employment at a facility or in their professional capacity) who has knowledge, or reasonable cause to believe, that a patient or resident in a facility has been abused, mistreated, or neglected shall make, within twenty-four (24) hours or by the end of the next business day, a telephone report to the Department’s OQA for those incidents involving community residences for people with developmental disabilities; and a telephone report to the Department of Health of the same such knowledge or reasonable cause to believe if the patient is a on a long-term unit in Eleanor Slater Hospital.

D. Any caregiver or person within the scope of their employment at an Organization or in their professional capacity who has knowledge of or reasonable cause to believe that an individual in a program has been abused, mistreated or neglected shall file within twenty-four (24) hours or by the end of the next business day, a written report.

E. If an individual in a Department-operated community residence dies, the managing officer shall furnish to the Department Director within twenty-four (24) hours after the death the date and cause of death, and other facts as the Department requires. In case of an accident, injury, or death of an individual, the managing officer shall complete a written report, and also telephone the Department’s OQA, within twenty-four (24) hours of the individual’s accident, injury or death. The writer of the report shall include the circumstances of the injury or death as fully as possible, including but not limited to the information listed in § 1.20.1(A) of this Part. Any such record shall be accessible only to the Director of the Department or any such employee designated by the Director as having a need to know such information, unless an applicable law or regulation otherwise permits.

F. For every report required by §§ 1.20.1(A), (B), (C), or (D) of this Part the information in such telephone or written report shall include at least the following:

1. The caregiver or employee’s name, Organization address, Organization telephone number, direct extension if applicable, and occupation,

2. The name and address of the individual who is believed to be the victim of the abuse, mistreatment, or neglect;

3. The details, observations, and beliefs concerning the incident(s);

4. The individual’s oral, written or gestured statements regarding the incident(s), to whom they were made, and at what date and time they were made;

5. The date, time, and place of each incident;

6. The name of all individuals believed to have knowledge of the incident(s); and

7. The name of all individuals believed to have been responsible for the incident(s) or could have been responsible for the incident if unknown cause and unknown perpetrator.

G. Such written report that is filled in by the deadline in this section shall be made available to the Office of Quality Assurance upon request, or within five (5) days of the incident(s), whichever occurs earlier.

H. Any deadline in this section to file a written and/or telephone report of an alleged violation of civil rights, or of an alleged act of abuse, neglect, mistreatment or exploitation against an individual, shall not be extended even if a reporter is allowed to inform a “high managerial officer” of the reporter’s Organization.

I. At the requested/or with the consent of the individual, the Organization shall immediately inform the legal guardians and/or others of any situation involving abuse, neglect, mistreatment, or human rights violations against the individual. If an individual in a Department-operated community residence dies, the managing officer shall furnish to the Department Director within twenty-four (24) hours after the death the date and cause of death, and other facts as the Department requires. In case of an accident, injury, or death of an individual, the managing officer shall complete a written report, and also telephone the Department’s OQA, within twenty-four (24) hours of the individual’s accident, injury or death. The writer of the report shall include the circumstances of the injury or death as fully as possible, including but not limited to the information listed in § 1.20.1(A) of this Part. Any such record shall be accessible only to the Director of the Department or any such employee designated by the Director as having a need to know such information, unless an applicable law or regulation otherwise permits.

J. Such written report that is filled in by the deadline in this section shall be made available to the Office of Quality Assurance upon request, or within five (5) days of the incident(s), whichever occurs earlier.

1.20.2 Internal Investigation Protocol

A. The Organization shall have a written policy specifying designated, authorized individuals who are responsible for conducting investigations in the event of a serious reportable incident and specifying the action or procedures the employee may take.

1. The Organization will establish capacity to implement investigatory protocol established by the department.

2. The Organization’s policy shall specify the intent of an investigation to determine all the facts around a reported incident and to protect any individual with a developmental disability from any further harm.

B. The Organization shall provide information/data on the numbers/types of incidents that are internally reported at the request of the Office of Quality Assurance.

C. Nothing herein shall change the timeframe for report to the Office of Quality Assurance pursuant to R.I. Gen. Laws § 40.1-27-2(a).

D. Based upon the results of its investigation, the Organization shall provide the Department with written recommendations to prevent further abuse, mistreatment or neglect of the individual or other program individuals.

1. The investigative analysis will evaluate if any other risk to the individual or other individuals remain.

2. The Organization shall complete a final investigative analysis report using current standardized forms and protocol provided by the Department and shall submit the report to the Department.

E. The Organization shall take all necessary steps to prevent and protect an individual who has been a victim of abuse, neglect, mistreatment, or other violation of his or her basic human rights from further abuse.

F. When abuse is alleged or death of an individual has occurred and a law enforcement agency, or the Department, or the Department's designee, has determined to initiate an investigation, the Organization shall not endeavor to investigate unless directed by the Department to do so.

G. The Organization shall provide information on the conclusion and recommendations of a completed investigation to the alleged victim or his or her legal guardian, as requested by the individual and/or their legal guardian.

1. The Organization shall develop a safety plan as well as a risk assessment for the alleged victim because of any investigation in which the allegation has been substantiated or inconclusive.

2. The Organization shall develop a quality improvement plan within twenty (20) working days to ensure the health and safety of the individual.

3. The Organization shall complete a status report within three (3) months, responding to the recommendations that were made.

1.20.3 Policies and Training

A. The Organization shall have written policies and procedures for assuring the health, safety and well-being of the population participating in their programs that are consistent with these regulations. The policy shall:

1. Include definitions of abuse, neglect, mistreatment, other human rights violation, and serious incidents; and

2. Explain the types of incidents which need to be reported within the agency; and

3. Explain the process for reporting and documenting the incident in accordance with § 1.25.1 of this Part; and

4. Delineate the responsibilities of employees for conducting and/or participating in investigations that involve a violation of a person’s rights or a serious incident; and

5. Include provisions for administrative action, disciplinary action, and dismissal of employees, contractors, and volunteers involved with abuse, neglect, mistreatment or other human rights violations.

B. Staff Training

1. The Organization shall have established orientation and annual training programs for all new and existing employees as required in their job description. Staff training records shall contain dated documentation of completion, including verification. Orientation and annual training shall include education in the following areas:

a. Minimum training for all employees:

(1) Fire training, which includes training in the program’s emergency evacuation procedures;

(2) Code of ethical conduct;

(3) Rights of individuals, human rights, and the provider’s human rights committee;

(4) Detection and prevention of abuse, neglect, mistreatment, financial exploitation and other human rights violations;

(5) Procedures for reporting allegations of abuse, neglect, mistreatment or other human rights violations to the Office of Quality Assurance, various state agencies or other entities such as police and human rights committee; and

(6) Confidentiality.

b. Job-specific training:

(1) Grievance and appeal procedures;

(2) Service quality;

(3) Overview of person-centered planning in compliance with Medicaid Home and Community Based Services (HCBS) regulations (210-RICR-50-10-1);

(4) Behavioral supports, healthcare and medication administration training; and

(5) Development and implementation of behavioral supports.

2. Organizations that utilized an online learning management system shall have a protocol in place that requires employee registration. The evidence of training may include a completion certificate and/or access to the system for review by staff.

3. Organizations shall determine staff training needs and develop a schedule of ongoing training programs that will be offered to employees. The training opportunities will be individualized based on the needs of the individuals served by the Organization.

A. Basic Personnel Policies and Procedures

1. The Organization shall have and shall implement personnel policies and procedures that:

a. Comply with all applicable state and federal statutes, rules, and regulations regarding non-discrimination in employment practices.

b. Include language for conducting reference, employment, and background checks from the BCI and NCIC within the Office of the Attorney General.

c. Exclude the employment and/or volunteering of any person who has been convicted of child abuse or of a felony for sexual or physical assault including all consultants and/or contractors.

d. Require employees to report to the Organization any changes in the status of their criminal background checks subsequent to their being hired by the Organization.

e. Provide for any fringe benefits provided to full time and part time employees and any reimbursement procedures (as applicable and appropriate).

f. Address suspension, increased supervision, or other appropriate disciplinary employment procedures.

g. Provide written job descriptions that include minimal qualifications for each position, major duties, responsibilities, reporting supervisors and positions supervised.

h. Include a process for evaluating the job performance of each staff member at the end of his or her initial training period and annually thereafter.

B. “Duty to Report” Personnel Policies and Procedures

1. The Organization shall have policies and procedures that prohibit retaliation against any staff, who reports suspected abuse/neglect/mistreatment or retaliation against the individual with respect to any report. Language must also include:

a. A requirement that all personnel participate and cooperate with all authorized persons conducting investigations/regulatory reviews involving the Organization and/or any person receiving supports/services from the Organization.

b. A process for annual notification of mandatory reporting statutes to all employees, advisors, skill trainers, respite providers, contractors, and volunteers of the Organization.

C. Staff Qualifications and Personnel Files

1. Any employee providing direct assistance to individuals shall meet the following criteria:

a. Be at least eighteen (18) years of age

b. Have clear job responsibilities as described in a current and dated job description;

c. Have a high school diploma or a GED®.

2. The Organization shall maintain the personnel record for all employees and contractors that includes the following information as applicable:

a. Reference and qualification checks;

b. An approved BCI and NCIC;

c. Annual job-related training, as applicable to the position, including current valid certification of cardiopulmonary resuscitation (CPR) and biennial first aid training;

d. Evidence of professional licensure or certification, including renewals, as applicable.

3. The Organization shall maintain a record for each volunteer that includes the following documentation:

a. References and qualifications checks;

b. A completed BCI and NCIC;

c. A detailed list of functions for each position.

D. If a criminal background check contains positive findings, the Organization’s Human Resources, with input and guidance from the Organization’s Senior Management, shall make and document a judgment regarding the employment of the prospective employee. The following offenses shall be determined to be disqualifying for employment by the Organization:

1. Any facility or program licensed or operated by the department shall require all applicants for employment -- if that employment involves routine contact with patients, residents or clients without the presence of other employees -- to apply to the bureau of criminal identification (BCI) of the state police or the local police department for a nationwide criminal records center (NCIC) background check. The check will conform to the applicable federal standards, including the taking of fingerprints of the applicant.

2. Any conviction for an offense listed in paragraph 2(b) (Category One) below creates a rebuttable presumption that an individual is disqualified from serving in a caring capacity in a program or service operated or licensed by BHDDH, or from residing in a household wherein such a program or service is provided or from owning or operating any such program or service or from serving as a BHDDH employee, intern, volunteer or consultant or from functioning in any other capacity that is subject to a statewide or nationwide criminal record background check in accordance with federal and/or state law or BHDDH regulation.

a. If a criminal background check contains conviction(s) for any of the crimes listed below in paragraph 4(a) while the applicant was an adult, the Organization shall provide notice to the applicant that the conviction for such crime is presumed to be disqualifying for employment, but the applicant may appeal to rebut such presumed disqualification through the hearing process pursuant to EOHHS regulations.

b. Category One (1) OFFENSES:

(1) Murder, voluntary manslaughter, involuntary manslaughter

(2) First-degree sexual assault

(3) Second-degree sexual assault

(4) Assault on persons sixty (60) years of age or older

(5) Assault with intent to commit specified felonies (murder, robbery, rape, burglary, or the abominable and detestable crimes against nature)

(6) First-degree arson

(7) Crime under section 1128(a) of the Social Security Act (42 U.S.C. § 1320a-7(a))

(8) Criminal offense related to person's involvement in any program under Medicare, Medicaid, or the Title XX services program.

(9) Felony Domestic Violence committed less than five (5) years ago

(10) 1st Degree Child Molestation

(11) 2nd Degree Child Molestation

(12) Child Pornography

(13) Sale or exhibition to minor of indecent publications, pictures or articles

(14) Child nudity in publication

(15) Kidnapping

(16) Car-jacking

(18) Mayhem

(19) Felony Assault committed less than five (5) years ago

(20) Felony Battery committed less than five (5) years ago

(21) A person convicted of any crime under R.I. Gen. Laws Chapters 40.1-24, 40.1-24.5, or 40.1-26.

c. Category Two (2) OFFENSES: If an individual has been convicted of any of the following offenses that was (were) committed within the previous ten (10) years from the date of the application for the background check, the individual will be presumed to be disqualified to work for an Organization, but such presumption may be determined to be rebutted by the Organization after its Administration and/or Board of Directors considers and documents the factors related to current qualification in the context of conviction for any of the crimes listed in this paragraph.

(1) Transportation for Indecent purposes

(2) Harboring

(3) Felony Assault committed over five (5) years ago that resulted in injury to the victim

(4) Felony Battery committed over five (5) years ago

(5) Felony Drug Offense committed less than five (5) years ago

(6) Robbery

(7) Breaking and Entering

(8) Burglary

(9) Illegal Possession of a Firearm

(10) Misdemeanor Domestic Assault

(11) 3rd Degree Sexual Assault

(12) Child Abuse or Neglect Indicated by DCYF or similar out of state agency.

(13) Circulation of obscene publications and shows

(14) First or Second-Degree Arson

(15) Any substantiated finding by a State agency under 42 U.S.C. 1395i–3(g)(1)(C), 1396r(g)(1)(C)) or a Federal agency that a direct patient access employee has committed an act of patient or resident abuse or neglect or a misappropriation of patient or resident property.

(16) Prior employment history of child or client abuse, neglect or Mistreatment

d. If the BCI check reveals conviction of the applicant as an adult for any crime described in Category One (1) in paragraph 2(b), or if the BCI check reveals conviction of the applicant during the ten (10) years prior to the date of application for the background check for any crime listed in Category Two (2) in paragraph 2(c), the BCI of the state police or the local police department will inform the employer, in writing, without disclosing the nature of the disqualifying information, that an item of disqualifying nature has been discovered. In addition, the BCI of the state police or the local police department will inform the applicant, in writing, of the nature of the disqualifying information. An applicant against whom disqualifying information has been found may request that a copy of the criminal background report be sent to the employer.

e. In considering a request to rebut a disqualifying presumption for a Category One (1) or Category Two (2) conviction, the following factors shall be considered and documented:

(1) the circumstances, severity and duration of the crime;

(2) whether the victim of the crime was a child or was an individual with a developmental or other disability;

(3) circumstances such as illegal use of drugs or alcohol, or addiction to substances, at the time the crime was committed;

(4) length of time that has elapsed since the commission of the crime for which the individual was convicted,

(5) length of time that has elapsed since the completion of any imposed sentence;

(6) length of time with no further convictions of crimes;

(7) the individual’s conduct in seeking and actively engaging in rehabilitation;

(8) the individual’s ability to explain their remorse for the crime and/or efforts to prevent commission of such a crime in the future;

(9) the extent to which the crime bears a direct impact on performing the job for which the individual is applying;

(10) any expert opinions of health care providers and clinicians who have worked with the individual if the individual chooses to share such confidential information; and

(11) any work history, education and job training before and after the commission of the crime.

3. The annual evaluation process shall include the following:

a. An assessment of job performance in relation to the required skills and expectations set forth in the job description;

b. A documented review of the evaluation with the staff person maintained within the personnel record;

c. Documentation that individuals served by the employee had input into this process, to the extent possible.

d. Review status of employee criminal background check and enquire about possible criminal conviction(s) since the occurrence of the previous background check.

A. The Organization shall ensure that all the locations where services are provided are accessible to meet the needs of people receiving services from the Organization and designed to protect the health and safety of all persons. The Organization shall also ensure that all the locations where services are provided are clean, sanitary, in good repair, free from accumulation of combustible debris and waste material, and free from offensive odors and insects.

B Reasonable accommodations shall be made available to all individuals living in residential settings, including but not limited to the following:

1. the provision of specialized safety equipment such as irons, toasters, coffee pots, and other equipment that shut off when unattended;

2. an accessible working telephone;

3. any other such services or equipment deemed necessary to assist individuals; and/or,

4. with maximizing independence and living successfully within the home.

C. Restrooms shall be available and accessible for individuals and staff in all the facilities where licensed services are provided.

D. First-aid kits and first-aid manuals shall be readily available to staff in a designated location in all facilities where licensed services are provided.

E. A documented safety review shall be conducted by the Organization every six (6) months to ensure that each facility where licensed services are provided, including, but not limited to community residences, is free of hazards. The documentation shall include date of inspections, name of the person(s) the inspection is conducted by, identification of areas inspected, any corrective actions taken in response to deficiencies cited, and date completed.

F. All the settings where services are provided shall meet the State Fire Code requirements for such facilities and/or occupancies.

G. It is the responsibility of the Organization to ensure that each licensed site, has received an initial and thereafter routine fire and life safety inspections that meet the approval of the Office of the State Fire Marshal. It is the responsibility of the Organization to communicate with the Office of the State Fire Marshal and comply with the State Fire Code, including, but is not limited to, scheduling re-inspections after a violation(s) is resolved.

H. It is the responsibility of the Organization to ensure that each licensed site shall have on site: fire extinguishers, smoke detectors, and any other fire detection and suppression system(s) required by law.

I. All compliance records will be Maintained in accordance with EOHHS Records Retention requirements pursuant to R.I. Gen. Laws §§ 38-3-6(a), (c), and (k)(1).

J. The Organization shall comply with all applicable federal, state, and local governmental safety and sanitation laws, rules and regulations.

K. All toxic materials including, but not limited to, poisons, chemicals, and pesticides shall be:

1. Properly labeled;

2. Stored in original container separate from all foods, food preparation utensils, linens and medications; and

3. Stored in a locked area.

L. All flammable and combustible materials shall be properly labeled, stored and locked in accordance with the State Fire Safety Code.

M. The temperature within premises shall be maintained within a normal comfort range. During times of extreme summer heat, the provider shall make reasonable efforts to keep individuals comfortable using ventilation, fans, or air conditioning.

N. Equipment and supplies shall be provided for cleaning of all surfaces. Such equipment shall be maintained in a safe, sanitary condition and shall be properly stored.

1. Hazardous cleaning solutions, compounds, and substances shall be labeled, stored in a safe place, and kept in an enclosed section separate from other cleaning materials.

A. The interior and exterior of a community residence shall be kept free of litter, garbage and refuse.

B. The exterior of a community residence shall be maintained and kept neat with regular yard work performed as appropriate to the season, including, but not limited to, mowing the lawn, raking the leaves, and snow removal.

C. All measures necessary shall be taken to prevent the entry of and to eradicate the presence of rodents, flies, mosquitoes and other insects at community residences.

D. All well water sources at a community residence shall be tested every three (3) years.

E. Septic tanks or other private sewage disposal systems at community residences shall be in good working order.

F. The water temperature shall not exceed one hundred and twenty (120) degrees Fahrenheit.

G. All heating and cooling devices in a community residence shall be installed in accordance with current building codes and maintained in good working order.

H. Handrails shall be provided on all stairways in a community residence in accordance with any and all federal and state statutes and regulations.

I. All furniture shall be clean and in good repair.

J. Bedroom furniture shall be provided in a community residence for each individual and shall include:

1. A bed, including a frame unless otherwise documented by a clinical team decision, a clean comfortable mattress, a waterproof mattress cover, if the individual is incontinent, and a pillow;

2. A private dresser or similar storage area for personal belongings that is readily accessible to the individual;

3. A closet or similar storage area for clothing that is readily accessible to the individual;

4. Individuals have the freedom to furnish sleeping or living units within the lease or other agreements;

5. Sufficient supply of personal linens.

K. Providers will take all possible steps to ensure privacy is maintained.

L. Swimming pools, hot tubs, saunas, or spas located on the premises of a community residence shall be equipped with safety barriers and devices designed to prevent injury and unsupervised access and shall be clean, sanitary, and maintained in good working order.

M. Sanitation for household pets and other domestic animals shall be adequate to prevent health hazards. Proof of current vaccinations that are required for the pet by a licensed veterinarian shall be maintained on the premises. Pets not confined in enclosures shall be under control and shall not present a danger or health risk to individuals or their guests.

N. Operative flashlights, at least one (1) per floor, shall be readily available to staff in case of emergency within each community residence.

O. Sleeping or living units must have entrance doors lockable by the resident with only appropriate staff having keys to doors. In the case of BHOs, refer to program specific guidelines in cases when this regulation is not applicable by an overriding federal or state statute or regulation.

A. Foods shall be served in a form consistent with the individuals’ needs and provide opportunities for choice in food selection. The Organization will ensure that there is adequate food available at any time, that it is stored appropriately, that it reflects individual preferences and needs. In the case of DDO, for individuals with physician or health care provider ordered modified or special needs diets, plans shall be annually reviewed and contained in the ISP.

B. Adequate supplies of staple foods for a minimum of one (1) week and perishable foods for a minimum of two (2) days shall be maintained on the premises.

C. Food shall be stored, prepared and served in a sanitary manner.

1.25.1 Transportation

A. Organizations, including employees and volunteers, who own or operate vehicles that transport individuals, shall:

1. Maintain the vehicles in safe operating condition. All vehicles utilized by employees of the Organization to transport individuals shall have a current vehicle inspection sticker from the state where the car is registered.

2. Comply with Division of Motor Vehicles laws, rules and regulations;

3. Maintain or assure insurance coverage including liability, on all vehicles and all authorized drivers;

4. Carry a stocked first aid kit in agency vehicles used to transport individuals:

5. The Organization shall be responsible for ensuring that only properly licensed drivers operate Organization vehicles or use their own personal vehicles to transport individuals.

1.25.2 Individual Summary Information

A. A current summary sheet must be maintained by DDOs and updated as necessary for each individual receiving services from the Organization. The summary sheet shall be reviewed annually at a minimum and shall include:

1. The individual’s name, current address, date of birth, sex, marital status, religious preference, preferred hospital, medical insurance information, and guardianship status where applicable; and

2. The name, address and telephone number of:

a. The individual’s legal guardian, family, advocate or other significant person;

b. The individual’s primary care provider, secondary provider or clinic;

c. The individual’s dentist;

d. The individual’s pharmacy;

e. The individual’s day program, or employer, if applicable;

f. The individual’s Support Coordinator/Case Manager; and

g. Other Organizations providing services to the individual.

1.25.3 Emergency Information

A. Subject to the protection of federal and state healthcare confidentiality statutes and regulations, the DDOs and all BHO residential programs shall maintain emergency information for each individual receiving services from the program in addition to the individual summary sheet identified above in this Part.

B. The emergency information shall be reviewed annually, updated as needed, and shall include:

1. The individuals name, date of birth, and medical insurance information;

2. The Organization's name, address and telephone number;

3. The address and telephone number where the individual lives;

4. The individual’s physical description, which could include a picture and the date it was taken, and identification of:

a. The individual’s race, gender identity, height, weight range, hair and eye color; and

b. Any other identifying characteristics that could assist in identifying the individual should the need arise, such as marks or scars, tattoos, or body piercings.

5. Information on the individual’s abilities and characteristics including:

a. How the individual communicates;

b. The language the individual uses or understands;

c. Any additional information that could assist a person not familiar with the individual to understand what the individual can do for him/herself.

6. The individual’s health support needs including:

a. Diagnosis;

b. Allergies or adverse drug reactions;

c. Health issues that a person would need to know when taking care of the individual;

d. Name(s) and telephone number(s) of the primary care provider, and other relevant health care providers/specialists;

e. Date of last annual physical;

f. Special dietary or nutritional needs, such as requirements around the textures or consistency of foods and fluids;

g. Food or fluid limitations, due to allergies, diagnosis or medications the individual is taking, that may be an aspiration risk or other risk for the individual;

h. Additional special requirements the individual has related to eating or drinking, such as special positional needs or a specific way foods or fluids are given to the individual;

i. Immunization information, including date of last tetanus, including DTap (Diptheria-Tetanus Toxoids & Acellular Pertussis);

j. List of current medications and dosages;

k. Protocol for emergency treatment and advance directives (if applicable);

(1) Guardian and/or next of kin’s name(s) and telephone number(s);

l. Physical limitations that may affect the individual’s ability to communicate, respond to instructions or follow directions; and

m. Assistive technology needed for mobility, positioning, communication, or other health related needs.

7. The individual’s emotional and behavioral support needs including:

a. Mental health or behavioral diagnosis and the behaviors displayed by the individual; and

b. Approaches to use when dealing with the individual to minimize emotional and physical outbursts, including an approved behavioral treatment plan.

8. Any court ordered or guardian authorized contacts or limitations;

9. The individual’s supervision requirements and why; and

10. Any additional pertinent information the Organization has that could assist in the care and support of the individual should an emergency or disaster occur.

1.25.4 Emergency Management Plan

A. Subject to the protection of federal and state healthcare confidentiality statutes and regulations, the Organization shall develop, maintain, update, and implement a written Emergency Management Plan for the protection of all individuals in the event of an emergency or disaster, including 911.

B. The Emergency Management Plan shall:

1. Be practiced annually at a minimum. The Emergency Management Plan practice may consist of a walk-through of the duties or a discussion exercise dealing with a hypothetical event, commonly known as a tabletop exercise;

2. Consider the needs of the individuals being served and address all natural and man-made events identified as a significant risk for the facility where a licensed service is provided, (i.e.- terrorist attack, a pandemic or an earthquake, etc.).

3. Include provisions for evacuation and relocation:

a. A method for tracking and reporting to the Department, the physical location of each individual until a different entity resumes responsibility for the individual.

4. Address the needs of the individuals, including provisions to provide:

a. Immediate and continued access to medical treatment and continued access to life-sustaining pharmaceuticals, medical supplies and equipment during and after an evacuation and relocation;

C. Applicable parts of the emergency management plan shall coordinate with each affected program to address the possibility of an emergency or disaster.

1.25.5 Fire Safety and Fire Drill Requirements

A. The Organization shall assess, within twenty-four (24) hours of entry to the premises, the individual’s ability to evacuate the residential setting in response to an alarm or simulated emergency. At a minimum, each individual’s ability to evacuate shall be reassessed and documented in each individual’s Emergency Management Plan on an annual basis and when there is a substantial change in the individual’s functional capacity (physical and/or mental). Individual Safety Plans shall be maintained in each community residence’s or non-congregant residential setting’s fire book.

B. The Organization shall document in each individual’s Emergency Management Plan the level of assistance needed by each individual to safely evacuate the premises within twenty-four (24) hours of entry to the premises and on an annual basis and when there is a substantial change in the individual’s functional capacity (physical and/or mental). Such documentation shall be maintained both in the premises and the individual’s records. Staffing shall reflect the level of assistance required for evacuation and provide for the health and safety of all the individuals as included in the core residential and day program services requirements.

C. A written emergency evacuation plan shall be in effect and available at each location where licensed services are delivered, including but not limited to, community residences. This plan shall include policies and procedures for the evacuation of all occupants from the building in the event of fire, and for their relocation to a safe area outside the building. This plan shall be reviewed annually and updated as the needs of the building occupants change. Staffing shall reflect the level of assistance required for evacuation and provide for the health and safety of all the individuals as included in the core residential and day program services requirements contained herein.

D. All direct service staff shall have specific fire training, consisting of not less than four (4) documented hours per year, and shall include training in the Organization’s emergency evacuation procedures. Staff working in multiple service locations shall review the emergency evacuation plan for each service delivery location at which they work.

E. All individuals residing in premises and/or participating in a day program shall be trained in and practice the proper actions to take in the event of fire. This training shall include actions to take in the event the primary escape route is blocked.

F. Fire exit drills shall be conducted not less than six (6) times per year on a bimonthly basis for community residences with not less than two (2) drills conducted during the night when individuals are sleeping. Drills shall occur at different times of the day, evening and night shifts with exit routes being varied based on the location of a simulated fire. The complete drill shall involve the actual evacuation of the building to a meeting place outside the home where the individuals know to congregate as specified in the written emergency evacuation plan.

G. Fire exit drills shall be conducted not less than quarterly for non-residential programs. The complete drill shall involve the actual evacuation of the building to a meeting place outside the building where the individuals know to congregate as specified in the written emergency evacuation plan.

H. Written documentation shall be made at the time of the fire drill and shall be kept maintained in accordance with EOHHS Records Retention requirements pursuant to R.I. Gen. Laws §§ 38-3-6(a), (c), and (k)(1).

I. Fire drill documentation shall include:

1. For a community residence:

a. The date and time of the drill and the type of drill (obstructed or unobstructed);

b. The location of the simulated fire and exit route;

c. The names of all individuals and staff present on the premises at the time of the drill;

d. The type of evacuation assistance provided by staff to individuals as specified in each individual's safety plan;

e. The amount of time required by each individual to evacuate;

f. The amount of time taken to evacuate the building;

g. The signature of the staff conducting the drill; and

h. The record of problems identified during the drill and a detailed plan of correction to resolve the problems identified.

2. For a non-residential program:

a. The date and time of the drill;

b. The location of the simulated fire and exit route;

c. The names of all staff present on the premises at the time of the drill;

d. The number of individuals present on the premises and evacuated at the time of the drill;

e. The amount of time taken to evacuate the building;

f. The signature of the staff conducting the drill; and

g. The record of problems identified during the drill and a detailed plan of correction to resolve the problems identified.

A. Organizations shall establish written policies and procedures that promote the highest practicable professional standards related to individual rights. These policies and procedures shall be adhered to always, in all settings, and during all interactions.

B. Each individual will be informed of their rights in a way they understand.

C. Organizations shall follow these procedures throughout the entire process of care, including but not limited to, initial contact, application, eligibility determination, admission, orientation, delivery of services, revision of direct services, transfer of services, and discharge from services.

D. Organizations shall continually afford each person these rights and inform them of these rights, as appropriate, and in a manner consistent with his or her individual learning style.

E. Organizations shall maintain a written statement of rights for individuals receiving services and those requesting services.

F. Individuals requesting services shall have the right to receive an individualized assessment.

G. Each individual, legal guardian, and/or advocate shall be provided with a written statement of the “Rights of individuals” that shall contain, the following:

1. This Part hereby adopts and incorporates by reference R.I. Gen. Laws §§ 40.1-24.5-3, 40.1-24.5-5, 40.1-24.5-6, and 40.1-24.5-7 and 40.1-26-3 as applicable to each individual.

2. Each Organization and its employees and volunteers shall mindfully and carefully follow all federal and state confidentiality laws and regulations to protect the privacy and dignity of each individual as much as possible and necessary:

a. to the extent any exception may apply that allows lawful disclosure, including but not limited to, by court order or in emergencies to legally define persons, such Organization will exercise due diligence to ensure compliance with the letter and spirit of the statutory and/or regulatory exception in the applicable confidentiality law.

3. Each Organization will ensure individual’s rights of privacy, dignity and respect and freedom from coercion and restraint.

4. Individuals will be provided with the right to full access to the community, including the right to engage in community life, to control personal resources, and to receive services in the community to the same degree as those not receiving Medicaid HCBS, in accordance with 42 C.F.R. § 441.301(C)(4)(I-vi).

5. Each individual has privacy in their sleeping or living unit:

a. Units have lockable doors by the individual with only appropriate staff having keys to the doors;

b. Individuals sharing units have a choice of roommates in that setting;

c. Individuals have the freedom to furnish and decorate their sleeping or living units within the lease or other agreement.

d. Individuals have the freedom and support to control their own schedules and activities;

e. Individuals have access to food at any time;

f. Individuals may have visitors of their choosing at any time.

g. The setting is physically accessible to the individual.

A. These regulations are promulgated pursuant to the authority conferred under R.I. Gen. Laws §§ 23-17.8-9(6), 40.1-1-13(a)(12), 40.1-2-2, 40.1-21-12, 40.1-22-4, 40.1-24-9, 40.1-24.5-2(c), 40.1-26-11, and 40.1-27-3(6).and are established for the purpose of adopting prevailing standards for the licensure and operation of facilities and programs providing rehabilitation, support, and guidance for individuals with developmental disabilities or cognitive disabilities.

B. It the expectation of the Department that each person’s array of supports and services be customized to meet the individual needs and desires in the least restrictive environment.

C. These Rules and Regulations apply to any licensed developmental disability organization under Subchapter 10 Part 1 of this Chapter.

D. These Rules and Regulations do not apply to the following:

1. Health care facilities licensed by the Rhode Island Department of Health pursuant to R.I. Gen. Laws Chapter 23-17;

2. Assisted living facilities licensed by the Rhode Island Department of Health pursuant to R.I. Gen. Laws Chapter 23-17.4;

3. Facilities and programs licensed by the Rhode Island Department of Children, Youth and Families pursuant to R.I. Gen. Laws Chapter 42-72.1;

4. Facilities, programs, or organizations already licensed or certified by any other appropriate state agency, pursuant to R.I. Gen. Laws.

A. Wherever used in this Part, the following terms shall be construed to mean:

1. “Abuse” means the treatment or act toward any person with developmental disabilities, as defined in R.I. Gen. Laws § 40.1-27-1 on the part of anyone, including an employee, intern, volunteer, consultant, contractor, visitor, family member, caregiver, neighbor, citizen or other person with a disability, whether or not the person is or appears to be injured or harmed. The failure to exercise one’s responsibility to intercede on behalf of a person receiving services also constitutes abuse. Abuse includes:

a. "Physical abuse" may include, but is not limited to: physical assault, battery and/or actions such as: hitting, kicking, biting, pinching, burning, strangling, shoving, shaking, dragging, yanking, punching, slapping, pulling hair, grabbing or pushing, or using more force than is necessary for the safety of the person.

(1) For incidents involving a caregiver, abuse is defined as the willful subjection of an adult with developmental disabilities to willful infliction of physical pain, willful deprivation of services necessary to maintain physical or mental health, or to unreasonable confinement.

(2) For incidents of physical abuse involving two people with disabilities, only an attack resulting in injury in which one person needs medical care beyond routine first aid or a series of deliberate acts (i.e., hitting, kicking, slapping, pulling hair, etc.) displayed by one person with a disability towards another person with a disability should be reported to the Office of Quality Assurance. Other incidents should be documented and handled by the agency’s internal Incident Management Committee.

b. "Sexual abuse" means any sexual contact, consensual or otherwise, between a person receiving services and a paid employee, consultant or contractor of the DDO. Any sexual contact between a person receiving services and an immediate blood relative is incest and is sexual abuse. Any non-consensual sexual contact between a person with a disability and another person with a disability is also sexual abuse. This includes but is not limited to oral/genital contact, sexual penetration or fondling and any other assault as defined in R.I. Gen. Laws § 11-37-1 et seq.

c. "Sexual contact" means the touching, fondling or intrusion of the genitals or other intimate parts of the person or offender directly or through clothing for the purpose of sexual arousal or gratification.

d. "First degree sexual assault" means any forced or coerced intrusion, however slight, of the vagina, anus, or mouth, by part of another person’s body or by an object including cunnilingus, or fellatio.

e. "Second degree sexual assault" means any forced or coerced or intentional touching or sexual contact (not penetration) clothed or unclothed, with a person’s genital area, anal area, groin, buttocks, or the breasts of a female for the purpose of sexual arousal, gratification or assault.

f. "Third degree sexual assault" means penetration where one person is 18 years of age or older and the other is over the age of 14 years, but under the age of consent (age 16 years).

g. "Sexual exploitation" may also include, but is not limited to, causing a person to expose or touch themselves or anyone else for the purpose of demeaning the person, for the sexual arousal or personal gratification, taking sexually explicit photographs, forcing or encouraging a person to view pornographic materials, encouraging a person to use sexually explicit language which he/she may not fully understand, the use of harmful genital practices such as creams, enemas, etc. to meet the idiosyncratic needs of an offender, etc.

h. "Psychological/verbal abuse" means intentionally engaging in a pattern of harassing conduct which causes or is likely to cause emotional harm. This includes the use of verbal or non-verbal expression that subjects a person to ridicule, humiliation, contempt, manipulation, or is otherwise threatening, socially stigmatizing and fails to respect the dignity of the participant including name-calling or swearing at a person, intimidating or condescending actions, behaviors, or demeaning tone of voice or any other pattern of harassing conduct.

i. "Material abuse" means the illegal or improper use or exploitation of the participant and his/her funds, personal property or other resources.

j. “Mistreatment” means the inappropriate use of medications, isolation, or use of physical or chemical restraints as punishment, for staff convenience, as a substitute for treatment or care, in conflict with a physician's order, or in quantities, which inhibit effective care or treatment, which harms or is likely to harm the participant.

k. “Neglect” means the failure of a person to provide treatment, care, goods and services necessary to maintain the health and safety of the participant, as defined in R.I. Gen. Laws § 40.1-27-1. For the purposes of this Part, “Neglect” shall also include the failure to report or act on health problems of the person or changes in his/her health conditions as indicated within a plan approved by the Department. Neglect also includes lack of attention to the physical needs of the person including personal care, cleanliness and personal hygiene, meals and/or failure to provide appropriate nutrition or a safe and sanitary environment; failure to carry out a plan of treatment or care prescribed by a physician and/or other health care professional; failure to provide services/supports as indicated within an ISP approved by the Department; and failure to provide proper supervision to the persons as required within an ISP or by a court.

l. "Financial exploitation” means the use of funds, personal property or resources of a person receiving services by an individual for their own monetary or personal benefit, profit or gain with or without the informed consent of the person including, but not limited to, the coercion or manipulation of a person to spend their own personal funds for something they may or may not have use for or soliciting of gifts, funds or favors. This also includes any suspected theft of or missing property or funds of a person. For incidents involving a caregiver, financial exploitation is defined as an act or process of taking pecuniary advantage of a person with a developmental disability by use of undue influence, harassment, duress, deception, false misrepresentation, false pretenses, or misappropriation of funds.

2. “Administer” means the direct application of a medication, whether by injection, inhalation, ingestion, or any other means, to the body of an individual by:

a. a licensed and authorized agent and under his or her direction; or

b. the individual at the direction and in the presence of the licensed and authorized agent.

3. “Advocate” means a:

a. legal guardian or

b. an individual acting in support of or on behalf of a person in a manner consistent with the interests of the person.

4. “Assessment” means the process of testing, gathering information, and making a diagnostic judgment to determine an individual's health or behavioral health status, functional capability, and need for services, conducted by a qualified person.

5. “Authorization” means the service approved by BHDDH for each participant based upon the ISP.

6. "Annual accounting summary of participant funds" means documentation required by Social Security for Representative Payees.

7. “Behavioral supports” means services provided to a participant who has a behavioral treatment plan in place which was developed in cooperation with professional staff to address chronic and severe behavioral problems and concerns that severely and persistently interfere with the participant’s and/or others’ health and safety. The implementation of behavioral supports requires behavioral professional staff to provide additional training and supervision to direct support professionals that is more extensive than the training and supervision required in the provision of Residential Support Services or Day Program Services.

8. “Behavioral treatment” means any intervention or treatment to develop and strengthen adaptive, appropriate behaviors through the application of behavioral interventions, and to simultaneously reduce the frequency of maladaptive or inappropriate behaviors. Behavioral interventions encompass behavioral analysis, psychotropic medication, or other similar interventions that refer to purposeful, clinical manipulation of behavior.

9. "Best practice" means a procedure that has been shown by research and experience to produce optimal results and that is established or proposed as a standard suitable for widespread adoption.

10. “Board” means the Board of Directors of the organization and/or the Advisory Board of a local DDO that is:

a. A for-profit entity or

b. A not-for-profit entity providing services in Rhode Island.

11. “Career development plan” means a person-centered plan that identifies the Participant’s employment goals and objectives, the services and supports needed to achieve those goals, the persons, agencies, and providers assigned to assist the person attain those goals, and the obstacles to the Participant working in an individualized job in an integrated community-based employment setting at competitive wages, and seeks to identify the appropriate services and supports necessary to overcome those obstacles.

12. "Caregiver" means a person who provides care for a person with disabilities without payment and is a natural support.

13. “Certified services” means services operated by a DDO which the Department has evaluated and recognized as having met predetermined requirements or standards in order to demonstrate competence in a specialty program or service area.

14. “Communicable disease” means an illness due to a specific infectious agent or its toxic products that arises through transmission of that agent or its products from an infected person, animal or inanimate reservoir to a susceptible host. This includes, but is not limited to, sexually transmitted diseases.

15. "Controlled medications" or "Controlled substances" means substances pursuant to R.I. Gen. Laws Chapter 21-28 that have a high potential for abuse which may lead to severe psychological or physical dependence.

16. “DDO health care manual” means the repository for all agency policies and procedures relating to health care practices. These manuals are developed by the agency with the input of nursing and other clinical staff and are intended to serve as a guide for health care practice within the agency. Each agency shall ensure that the DDO Health Care Manual is reviewed and approved by a Professional Nurse (R.N.) on an annual basis and when any changes are made to it. For the purposes of these regulations, “DDO Health Care Manual” can be used interchangeably with “Agency Health Care Manual.”

17. "Department” means the Rhode Island Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH).

18. “Delegation” means the transferring to a competent individual the authority to perform a selected nursing activity in a selected situation. The nurse retains the accountability for the delegation.

19. “Developmental disability organizations” or “DDOs” means an organization licensed by BHDDH to provide services to adults with disabilities, as provided herein. As used herein, DDOs shall have the same meaning as “providers” or “Organizations."

20. “Director” means the Director of the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH), his/her agents or assigns.

21. “Dispense” means the preparation, administration, or delivery of a medication pursuant to the lawful order of a licensed healthcare prescriber.

22. “Distribute” means to deliver a medication, other than by administering or dispensing.

23. “Evaluation” means the Professional Nurse (R.N.) will evaluate and document the person’s response to interventions outlined in the plan of care; revise the plan as necessary; and, identify the degree to which the expected outcomes have been achieved.

24. "Fiscal intermediary" means a licensed DDO authorized to receive and distribute support funds or participant directed goods or services on behalf of a participant in accordance with the participant’s Individualized Service Plan.

25. “Functional behavioral assessment" means a process to identify the function of a person’s behavior. The information collected during the assessment should be used to develop effective behavior supports and plans.

26. “Household” means and includes any person, whether a family member or not, who sleeps within the home full or part-time.

27. "Human rights committee” or “HRC" means any duly constituted group of people with developmental disabilities, advocates, volunteers, and professionals who have training or experience in the area of behavioral treatment, and other citizens who have been appointed to a provider’s human rights committee for the purposes of:

a. Promoting human rights;

b. Reviewing, approving and monitoring individuals’ plans designed to modify behavior which utilize restrictive interventions or impair the participant’s liberty, or other plans and procedures that involve risks to the person’s protection and rights; and

c. Participating in the provider’s participant grievance procedures.

28. “Incident” means a situation in which a person with a developmental disability is harmed, or is involved in an event, which causes concern for the person’s health, safety and/or welfare. This includes individuals who receive services from the Department and/or a DDO licensed by the Department.

29. "Individual service plan” or “ISP" means the annual document derived from a person-centered plan which details the services for an individual supported.

30. “Informed consent” means the permission given by a person who has the legal capacity to give consent to or to authorize treatment. Such person:

a. Is able to exercise free power of choice without the intervention of any element of force, fraud, deceit, duress, over-reaching, or other form of constraint or coercion; and

b. Has been given sufficient information about the risks and benefits of the proposed treatment or procedure and the elements involved to be able to make a knowledgeable and enlightened decision.

31. "Integration" means:

a. The use by individuals with developmental disabilities of the same community resources that are used by and available to other persons in the community;

b. Participation in the same community activities in which persons without a developmental disability participate, together with regular contact with persons without a developmental disability; and

c. Individuals with developmental disabilities who live in homes that are in proximity to community resources and foster contact with persons in their community.

32. “Investigation” means a systematic review and search for facts. It is objective in nature and is intended to identify facts, sequence and chronology of events, active failure(s), latent failure(s) and assessment of risk as pertinent to a specific adverse event. An investigation may be undertaken as a result of a complaint, an adverse event or incident report, or other information that comes to the attention of the Department or the organization.

33. “Medication error(s)” means incidents involving medications which may or may not cause harm to a person’s health and welfare. By way of example, and not in limitation, medication errors include: omission of a dosage(s) or failure to administer, incorrect dosage(s), incorrect medication(s), medication(s) given by incorrect administration route, medication(s) given by incorrect time, medication(s) given to wrong person, any inappropriate use of medications, failure to follow agency procedures for medication administration, and medication or treatment given without an order from a prescriber.

34. “Nursing diagnosis” means concise statements of conclusions derived from assessment data collected and include the presenting medical diagnoses and the person's unique nursing and health care needs. Nursing diagnoses are recorded in a manner that facilitates the nursing process.

35. “Nursing plan of care” means the Professional Nurse (R.N.) will develop a plan of care based upon the data obtained during the assessment. The elements of the plan of care will reflect data obtained as part of the person's initial health care screen as well as subsequent assessments and shall be congruent with the person's unique health care needs. The plan of care provides guidance for support staff in the provision of health care activities. Nursing plans of care are recorded, communicated to others, and revised as necessary according to the provider's written policy and procedure.

36. “Nursing process” means a process by which nurses deliver care to patients. The nursing process is comprised of the following essential elements: assessment/data collection; nursing diagnosis; nursing planning; intervention; and evaluation.

37. “Office of Quality Assurance” or “OQA” shall have the same meaning as the office described in R.I. Gen. Laws § 40.1-26-10.

38. “Office of Licensure and Standards" means the unit within BHDDH that is responsible for licensing provider organizations and programs.

39. “Outcome” means the result(s) of the performance or the non-performance of a function or process.

40. “Participant” means an adult who has a developmental disability as defined by R.I. Gen. Laws § 40.1-21-4.3(5). As used in this Part, “participant” and “individual” shall have the same meaning.

41. "Person" means any individual, governmental unit, corporation, company, association, or joint stock association and the legal successor thereof.

42. "Person-centered" means the formal process that organizes services and supports around a self-directed, self-determined and goal-directed future, and includes the process by which a participant identifies the direction of his/her future activities, including future vocational and employment related activities, based on his/her skills, interests, strengths, and abilities, regardless of whether the participant has the verbal ability to express such information.

43. “Positive behavioral supports” is a systematic, person-centered approach to understanding the reasons for behavior and applying evidence-based practices for prevention, proactive intervention, teaching and responding to behavior, with the goal of achieving meaningful social outcomes, increasing learning and enhancing the quality of life across the lifespan.

44. “Practical nurse” means Practical Nursing as defined in R.I. Gen. Laws § 5-34-3.

45. “Professional nursing” means Professional Nursing as defined in R.I. Gen. Laws § 5-34-3.

46. “Program” means a planned structured service delivery system structured to provide specific components that are responsive to the needs of the persons served.

47. “Residential settings subject to licensure” means any residential setting with three (3) or more unrelated participants who are eligible for Medicaid waiver or other BHDDH licensed services for adults with developmental disabilities including any category of institutions, foster homes, or group living arrangements in compliance with 42 U.S.C. §1382(e) of the Social Security Act. Such standards shall be appropriate to the needs of such participants and the character of the facilities involved, and shall govern such matters as admission policies, safety, sanitation, and protection of civil rights.

48. “Respite care service” means direct support to participants furnished on a short-term basis because of the absence or need for relief of those persons who normally provide care for the participant. Respite care services may be provided in the participant’s home or private place of residence or at the location of a respite care provider or in the community.

49. “Restraint” means restricting the movement of the whole or a portion of a person's body as a means of controlling a person's physical activity to protect the person or others from injury.

a. “Chemical or pharmacological restraint” means medication that is given for the emergency control of behavior when the medication is not standard treatment for the individual's medical or psychiatric condition.

b. “Mechanical restraint” means the use of an approved mechanical device that restricts the freedom of movement or voluntary functioning of a limb or a portion of a person's body as a means to control his or her physical activities.

c. “Physical restraint” means the use of approved physical interventions or "hands on" holds to prevent an individual from moving his or her body to engage in a behavior that places him, her or others at risk of physical harm.

50. "Restrictive intervention" means a procedure that does one or more of the following:

a. Limits an individual’s movement, activity or function;

b. Interferes with an individual’s ability to acquire positive reinforcement;

c. Results in the loss of objects or activities that an individual values;

d. Requires an individual to engage in a behavior that the individual would not engage in given freedom of choice.

51. “Serious reportable incident” means any situation involving a person with developmental disabilities in which the person has:

a. Had an injury that requires medical care or treatment beyond routine first aid;

b. Been involved in an unexplained absence and whose whereabouts are unknown to anyone;

c. Died;

d. Been personally involved (is the alleged victim or perpetrator) in a serious criminal act;

e. Been involved in an event in which law enforcement has been contacted or in an event in which first responders, including, but not limited to, law enforcement, fire, and/or emergency medical personnel, have participated;

f. Been the subject of a serious or repeated medication error; or

g. Had any of his/her civil or human rights violated.

52. “Shared living arrangement contractor” means the adult who is not a participant’s household member who has contracted with a DDO to provide residential support services in his/her home to a Participant.

53. “Staff” includes but is not limited to any employee, intern, trainee, or volunteer performing a service or activities for the organization and for meeting the needs of individuals served for which competent performance is expected.

54. “Supervision” means the provision of guidance by a Professional Nurse (RN) for the accomplishment of a nursing task or activity with initial direction of the task or activity and periodic inspection and documentation of the actual act of accomplishing the task or activity. Total nursing care of an individual remains the responsibility and accountability of the licensed nurse.

55. “Support coordinator” means the individual employed by the DDO who delivers Support Coordination services. The term is synonymous with “Case Manager” in these regulations and includes, but is not limited to, the external coordination and monitoring of the Shared Living Arrangements.

56. “Violation of human rights” means any action or inaction which deprives a participant of any of his or her civil rights, as articulated in law or in this Part.

1.3.1 Fiduciary Duties for the Management of Participants’ Funds

A. The Organization shall have and implement written policies and procedures for the handling and management of participants' money and benefits. Such policies and procedures shall contain provisions related to the following:

1. Allow the participant to manage and have access to his/her own funds and/or benefits unless the ISP annually documents and justifies limitations to self-management;

2. A participant’s funds and benefits are to be safeguarded;

3. Participants receive and spend their money and benefits at their direction in consideration of their preferences;

4. Participants are to have access to their money and benefits considering choice and development of skills; and

5. Funds shall be managed in compliance with all federal and state statutes, rules, and regulations.

B. If assisting with management of funds, the DDO shall have and implement policies and procedures related to the oversight of the participant's financial resources that include:

1. Procedures that prohibit inappropriately expending a participant's personal funds, theft of a participant's personal funds, using a participant's funds for staff's own benefit, co-mingling participant's personal funds with the DDO or another participant's funds, or the DDO becoming a participant's legal representative; and

2. The DDO's reimbursement to the participant of any funds that are missing due to theft or mismanagement on the part of any staff of the DDO, or of any funds within the custody of the DDO that are missing. Such reimbursement must be made within ten (10) business days of the verification that funds are missing.

C. For those participants not yet capable of managing their own money or benefits, and for whom the agency is the representative payee as annually determined by the ISP and/or legal guardian, the DDO shall prepare and maintain an accurate written record for each participant of all money and benefits received or disbursed on behalf of or by the participant. The record shall include:

1. The date, amount and source of income and/or benefits received;

2. The date, amount and purpose of funds disbursed;

3. Signature of the staff making each entry in the participant’s record; and

4. Annual Accounting Summary of Participant Funds.

1.3.2 Earned Income Reporting

A. If the Organization is managing a participant’s funds on his/her behalf, and the participant earns income from employment, the DDO shall be required to report this earned income to the Medicaid Authority (Executive Office of Health and Human Services) pursuant to federal and state Medicaid requirements on behalf of the participant.

B. If the Organization is not managing a participant’s funds, the Organization shall regularly offer the participant financial support and guidance or as requested by the participant.

A. The human rights committee shall have input on all the Organization’s policies pertaining to human rights consistent with the provisions of R.I. Gen. Laws § 40.1-26-4.

B. Members of the human rights committee shall receive training in the areas of human rights and their role as committee members and the role and responsibilities of the Office of Quality Assurance and other state agencies with respect to monitoring or investigating human rights violations.

C. Organizations shall have written policies addressing procedures for informing the human rights committee of any circumstances involving an alleged or possible violation of human rights of any person receiving support or services from the provider.

D. The human rights committee shall be informed of any investigation and shall receive, upon request, copies of final investigation reports from the Organization and/or the Department, including notification of any administrative action taken by the Organization regarding a human rights violation of a participant receiving support or services from the Organization.

E. The human rights committee shall meet a minimum of six (6) times per calendar year. The human rights committee shall keep minutes for each meeting.

A. Every Organization shall establish an accessible grievance procedure.

B. The grievance procedure shall be presented to every participant in a manner consistent with the participant's or applicant's learning style and be conspicuously posted in each Organization. The notice of grievance procedure shall include the name and contact information for Organizations that provide free legal assistance.

C. The participant or advocate shall be entitled to initiate a grievance. It shall be the duty of each Organization to encourage and assist the participant or applicant in exercising his or her rights without threat of discrimination or recrimination.

D. The participant, or advocate, shall initiate the process by filing for a grievance with the executive director of the Organization, the human rights committee or with the Department. The recipient of the grievance shall forthwith forward a copy of the grievance form to the chair of the human rights committee.

E. The executive director of the Organization, or his or her designee, with the assistance of the chair of the human rights committee or his or her designee, shall investigate the grievance and issue a written decision to the participant, or advocate, within five (5) business days of receipt of the grievance. The written decision shall include a copy of the grievance, a list of persons interviewed in the investigation, the steps taken to resolve the grievance, and the conclusion of the Organization’s executive director or his or her designee.

F. The chair of the human rights committee or his or her designee shall, if necessary, assist the participant in requesting a review.

If the participant is not satisfied with the outcome of the grievance proceedings, the participant may file for an administrative hearing in accordance with the Appeals Process and Procedures for EOHHS Agencies and Programs, 210-RICR-10-05-2.

A. The Organization shall immediately provide the participant, legal guardian, family and/or advocate and the Department with a written thirty (30) day notice subject to approval by the Department that clearly describes the clinical basis for the Organization’s decision to terminate services and all reasonable efforts made by the Organization to work with the participant, legal guardian and/or advocate to maintain such services.

B. If a participant is to be either transferred or discharged, the Organization must have documentation in the participant's record that transfer or discharge is for good cause. The Organization must provide a reasonable time to prepare the client and his or her parents or guardian for the transfer or discharge (except in emergencies).

C. At the time of the discharge, the Organization must develop a final summary of the participant's developmental, behavioral, social, health and nutritional status and, with the consent of the participant, parents or legal guardian, provide a copy to authorized persons and agencies; and provide a post-discharge plan of care that will assist the client to adjust to the new living environment.

D. If a participant leaves the Organization and/or refuses all services from the Organization, the Organization shall document the refusal, conduct outreach efforts to the participant, legal guardian, family and advocate and immediately notify the Department. The Organization shall provide transitional discharge information to the Department and/or subsequent Organizations upon request.

E. The participant may appeal the Organization’s decision to terminate services by filing an appeal in accordance with the Appeals Process and Procedures for EOHHS Agencies and Programs, 210-RICR-10-05-2.

If the participant chooses to receive services from a different Organization, the transferring and receiving Organizations shall cooperate fully. The participant shall be afforded the opportunity to have input regarding the transition plan. The Department shall review and approve the transition plan.

A. DDOs must respect and support each participant’s control over their own ISP and the ISP meeting, including participant choice of plan writer, selection of who to invite to the plan meeting, choice of time and location, decision on how to conduct and who will conduct the ISP meeting, and setting of goals and objectives meaningful to the participant.

B. The DDO’s support coordinator is responsible for ensuring that a plan is person-centered, includes a Career Development Plan, agreed to and signed by the participant, amended as needed or requested, and for the ongoing monitoring of how the DDO is meeting the ISP goals and objectives.

C. All Participants receiving services from DDOs shall have an annual ISP submitted and approved before the individual’s anniversary date. Late submissions will cause authorizations to be suspended until a new plan is accepted. DDOs cannot retroactively bill for time when an authorization is suspended.

D. Any modification of the participants rights pursuant to § 00-1.26(G)(1) through (5) of this Chapter must be supported by a specific assessed need and justified in the ISP including but not limited to:

1. Identification of a specific and individualized assessed need.

2. Documentation of the positive interventions and supports used prior to any modifications of the ISP.

3. Documentation of less intrusive methods of meeting the need that have been tried but did not work.

4. Inclusion of a clear description of the condition that is directly proportionate to this assessed need.

5. Inclusion of regular collection and review of data to measure the ongoing effectiveness of the modification.

6. Inclusion of established time limits for periodic reviews to determine if the modification is still necessary or can be terminated.

7. Inclusion of the informed consent of the participant.

8. Inclusion of an assurance that the interventions and supports will not cause harm to the participant.

A. The DDO ensures that the provision of all certified services is in accordance with the goals of the ISP.

B. The DDO must have adequate staffing as identified for each participant and as documented in the ISP.

C. The DDO ensures all communication is in a format and language accessible to participants and families in a clear, accurate and consistent manner wherein special communication needs are identified and addressed.

1.10.1 Health Education

A. Organizations shall develop human sexuality policies and health education policies that reflect the philosophy that people with developmental disabilities are people with sexual identities, feelings and needs.

B. Organizations shall offer training in human sexuality and/or health education to educate persons with disabilities to protect themselves from sexual abuse, sexual exploitation, pregnancy, sexually transmitted diseases and other areas pertaining to sexuality.

1.10.2 Shared Living Arrangement (SLA)

A. In contracting with a Shared Living Arrangement (SLA) contractor, a DDO shall:

1. Have the ability to respond twenty-four (24) hours a day, every day, to support the provider and participant as problems arise;

2. Have a respite procedure for safely accommodating a participant who requires emergency removal from the SLA home;

3. Have a policy to define its SLA oversight plan that includes face-to-face visitation, commensurate with the needs of the provider and the needs and preferences of the participant.

4. Notifies the Department of any change in the household composition.

5. Establishes policies and procedures for the termination of an SLA contract if the participant chooses to leave or if the shared living contractor of any member of the household has:

a. Been charged with or convicted of a crime as defined under § 00-1.21(D) of this Chapter;

b. Abused, neglected, mistreated or exploited a child or adult;

c. Suffered serious illness, injury or stressful situation that impacts deliver of service to the participant;

d. Failure to comply with any of the requirements of the SLA contractor contained herein; or § 00-1.21 of this Chapter.

e. A current or untreated substance use disorder. The DDO shall notify the Department immediately upon discovery. The DDO may continue with the SLA upon written approval of the Department.

6. Require that the SLA contractor is not named as the beneficiary of any insurance policy held by the participant or testamentary instrument and/or document or gift executed by the participant or named on any bank account or as Representative Payee.

B. The DDO and its agents are not to be the participant's legal guardian or Power of Attorney.

C. The DDO ensures that there is a legally enforceable written agreement that includes, at minimum, the same responsibilities and protections from eviction that tenants have under the landlord/tenant laws of the state, county, city or other designated entity.

1.10.3 Fiscal Intermediary Services

A. The Fiscal Intermediary shall ensure that no person shall be hired by an individual prior to the completion of a Bureau of Criminal Identification (BCI) check; prior to the verification of all needed licenses, including a driver's license, proof of insurance, and proof of vehicle inspection certificate.

B. The Fiscal intermediary shall document that employment and reference checks were completed by the individual for potential employees.

1. Said documentation shall include, but not be limited to: the name of the person called for a reference, the telephone number, the date called, the company name, and the reference provided.

C. The Fiscal Intermediary shall obtain assurances from the individual that any non-related person or agency providing supports is not named as a beneficiary on the life insurance policy(ies) of the individual with developmental disabilities.

D. The Fiscal Intermediary shall maintain a record of any formal connections an employee or potential employee has with any entity(ies) providing services to the individual with developmental disabilities.

1. If there is a formal relationship (i.e., board member or an employee of an agency providing support to the individual with developmental disabilities), then this relationship should be stated in writing by the potential employee at the time of the interview, or when such relationship begins (subsequent to employment).

2. In addition, the Fiscal Intermediary shall obtain, from the individual, notice of any family relationship with any potential employee to be hired by the individual prior to the actual hiring.

E. Develop and implement a timesheet for direct support professionals.

F. Distribute, collect, and process direct support professionals' timesheets based upon an agreed-upon period (i.e., weekly, bi-weekly, semi-monthly, monthly).

G. Ensure that the individual’s direct support professionals are paid hourly rates and overtime pay, when applicable, in accordance with Federal and State Department of Labor FLSA rules and regulations.

H. Compute, withhold, file and deposit federal and state income tax, if requested by the individual's direct support professional and agreed to by individual employers in compliance with IRS rules.

I. Compute, withhold, and deposit FICA and FUTA taxes using the IRS Form 940; Employer's Annual Federal Unemployment (FUTA) Tax Return and IRS Form 941; Employer's Quarterly Federal Tax Return (filing in the aggregate under the Fiscal Intermediaries separate FEIN) in accordance with IRS Notice 95-18. Compute, withhold, and deposit any state taxes and unemployment insurance taxes in accordance with State policies and procedures,

J. Ensure that FICA and FUTA withholdings are done appropriately in accordance with IRS rules and regulations when family members are direct support professionals.

K. Prepare and distribute payroll checks for direct support professionals in accordance with the agreed upon time frame with the individual employer. The payroll checks shall include a pay stub that reports the hours worked, gross wages, withholdings by type, and net salary for the current period and year-to-date. The payroll check will be sent to the individual employer or the direct support professional, as agreed to by the individual and the Fiscal Intermediary. The Fiscal Intermediary shall offer direct support professionals the option of having their paychecks directly deposited in their bank.

L. Inform direct support professionals of the availability of receiving advanced Federal Earned Income Credit (EIC) payments and process advanced payments when applicable (i.e., include IRS Notice 797 in the Employee Start-up Packet).

M. File and distribute IRS Forms W-2 and Forms W-3 on behalf of individuals for each of their direct support professionals who have earned the cash wage thresholds for employment taxes (FICA and possibly FUTA) and/or had federal and state income taxes withheld in the calendar year per the IRS rules/instructions for employer agents. Ensure that these forms are completed in accordance with IRS rules for agents.

N. Establish and implement a process for identifying, computing and issuing refunds to direct support professionals (for the employee contribution) and the individual's budget (for the employer contribution) of any over collection of federal employment taxes (FICA and/or FUTA) for direct support professionals who do not earn the federal cash wage threshold amounts from a single employer during the calendar year.

O. Process all judgments, garnishments, tax levies, or any related holds on an employee's funds, as may be required by state or federal laws. The Fiscal Intermediary shall comply with all federal and state income and employment taxes, statutory benefits, and labor laws related to the employment of their direct support professionals. All tasks and responsibilities shall be performed by the Fiscal Intermediary, in accordance with all applicable federal and state laws, rules and/or regulations.

P. Determine the requirements for workers compensation for household employees in the state and facilitate the purchase of worker's compensation insurance for individuals' direct service professionals and process invoices for premium payments. The Fiscal Intermediary shall verify and document that all individual employers have sufficient workers' compensation coverage for all the direct support professionals that they hire.

Q. Develop and implement a process of documenting any relevant training that the direct support professional has at the time of hire, and any additional training that the direct support professional completes after the date of hire.

R. The Fiscal Intermediary shall monitor the expenses reported by the individual to ensure that funds will be available for the full-time frame of the quarterly authorization. Should the Fiscal Intermediary find that funds are being expended at an accelerated pace, it will notify the individual/responsible person of this finding and work with the individual to stay within his/her budgeted resource allocation.

S. The Fiscal Intermediary shall keep an accounting of all services received by the individual, including the dates and types of service.

T. On a quarterly basis, the Fiscal Intermediary shall prepare a report for the individual as to the individual’s financial status.

U. The Fiscal Intermediary shall submit to the Department annual audited financial statements, audit findings and any recommendations, including corrective action plans, and any supplemental schedules, as may be required by the Department. The Fiscal Intermediary shall disclose all Related Party Transactions in the notes to the annual audited Financial Statements.

V. The Fiscal Intermediary shall be required to report earned income to the Medicaid Authority (Executive Office of Health and Human Services) pursuant to federal and state Medicaid requirements on behalf of a participant who earns income from employment.

W. Should the individual subcontract with an Organization/business that should be licensed by the federal or state government, the Fiscal Intermediary shall verify that the Organization/business has the necessary license.

X. The Fiscal Intermediary shall account for any corrected or previously omitted services/encounters reported and process a recoupment to correct payment(s).

Y. The Department shall have the right to request any and all information pertaining to assets, liabilities, revenue, expenditures, records, contracts and any other financial, program, personnel, or administrative data. The Fiscal Intermediary shall submit the information requested to the Department within the time frame specified.

Z. The Department, EOHHS, DHS, CMS and its designated representatives shall have the authority to review all Fiscal Intermediary records, reports of financial data, at any time. The Department, EOHHS, DHS, CMS, or its designated representatives shall have the right at all times to inspect the work performed or being performed under the DDO’s license.

AA. The Fiscal Intermediary shall not undertake any work that represents a legally cognizable conflict of interest or is otherwise contrary to State and Federal law or regulation. The Fiscal Intermediary shall fully and completely disclose any situation and/or relationship that may present a legally cognizable conflict of interest at the time of applying for licensure and/or as such situations occur.

1.10.4 Respite

A. Respite care services may be provided to participants on a short-term basis in the participant’s home, private place of residence, the private residence of a respite care provider, a licensed residence, or at a licensed day program.

B. Respite care services provides for a participant who requires support and/or supervision in his/her day-to-day life, in the absence of his/her primary care giver.

C. Respite care services maintain the participant’s routine while receiving respite care services to attend school, work, or other community activities/outings. Community outings shall be included in the supports provided and shall include school attendance, other school activities, or other activities the participant would receive if they were not in a center-based respite center.

D. Respite care services includes transportation for community outings (included in reimbursement).

E. A respite care service provider who provides services in a participant’s home, private place of residence, or the private residence of a respite care provider:

1. Shall be at least eighteen (18) years old, have a high school diploma or GED certification;

2. Shall complete training and certification as defined by the state to provide the service, that includes criminal, abuse/neglect registry and professional background checks, and completion of the following trainings:

a. Roles and responsibilities of the respite care provider;

b. Human Rights of Adults with Developmental Disabilities;

c. Mandatory reporting of abuse, neglect and mistreatment of adults with developmental disabilities to the Department and appropriate law enforcement agencies;

d. Code of Ethical Conduct;

e. Current valid certification in cardiopulmonary resuscitation (CPR), annual refresher training in CPR, and annual first aid training;

f. Access to medical and psychiatric supports; and

g. Confidentiality.

h. Should have one year of related experience (preferred);

i. May be members of the participant's family, provided the participant does not live in the family member's residence and the family member meets the same standards described above.

j. The DDO shall ensure that health care services are provided and documented for the participant in accordance with the requirements contained herein.

F. A respite care service provider who is also an employee of the DDO respite agency shall be compensated in accordance with state and federal tax and labor laws.

The DDO ensures that there is a legally enforceable written agreement that includes, at minimum, the same responsibilities and protections from eviction that tenants have under the landlord/tenant laws of the state, county, city or other designated entity.

1.11.1 Health Care Services

A. DDOs shall maintain written health care and nursing policies and procedures in a “DDO Health Care Manual,” that addresses all the areas indicated and outlined in this Part.

1. Each agency shall ensure that the DDO Health Care Manual is reviewed and approved by a Professional Nurse on an annual basis and when any changes are made to it.

2. Each agency shall maintain documentation to support the annual, and as needed, approvals of the DDO Health Care Manual by a Professional Nurse.

B. Influenza, pneumococcal, and other adult vaccination policies and protocols shall be developed and implemented by the DDO in accordance with the most current recommendations of The Advisory Council on Immunization Practices (ACIP) Guidelines for these vaccinations, and as recommended and ordered by the person's physician or other licensed health care provider.

C. The DDO shall have written policies to be followed for health care communication with family members and/or legal guardians regarding significant changes in medication and/or medical status of the person with developmental disabilities.

1.11.2 Medical Care

A. The DDO shall ensure that each participant has the opportunity for an annual physical examination. Components of the physical exam shall include a review of prescribed medication, over-the-counter medication and herbal/homeopathic supplements, completion of accepted primary care screenings. If routine screening is deferred by the participant, or their physician or other licensed health care provider, documentation as to the reason for the deferral must be included in the participant's health care record.

B. Any physician, dietician, or other licensed health care provider's prescribed diet order shall be implemented and a copy of the diet is kept the person's health care record.

C. Dental examinations and cleanings shall be performed as recommended by the American Dental Association, unless otherwise determined by the participant or their licensed health care provider.

D. Vision, Audiology, or Speech consults, orthopedic, physical therapy, occupational therapy examinations, and/or other medical referrals shall be performed if indicated.

E. The DDO shall assist in obtaining adaptive or assistive equipment as needed and is kept in good repair. Regular assessment for proper fit and usage shall also be completed. The individual shall receive support to utilize and maintain assistive equipment.

F. The DDO shall document an individual’s refusal of tests, exams, procedures or other health care recommendations in the individual’s plan. Necessity of said procedures will be periodically reviewed and ongoing efforts shall be made to achieve the desired health care goals. Documentation will be maintained in the individual’s health care record.

1.11.3 Documentation Standards and Maintenance of Health Care Records

A. Health care records shall include all pertinent health care related documents including physician or health care provider assessments and orders.

B. Documentation and corrections in health care information shall be made in accordance with standard nursing practice.

C. All health care information shall be placed in the individual’s record in reverse chronological order.

D. Health care records shall be kept for a minimum of ten (10) years following the cessation of services.

E. The Professional Nurse shall complete and document the findings of a nursing assessment on a minimum of an annual basis.

1. The nursing assessment shall include, but not be limited to, a deliberate and systematic collection of data to determine a person's current health status; including physical assessment, data analyses, problem identification, and development of a plan of care.

2. The Professional Nurse will complete a nursing assessment when nursing services are deemed appropriate and per the individual plan as determined by the Professional Nurse based on the person's health care needs.

3. An assessment shall be completed and documented whenever there is a significant change in the individual’s health status.

4. The professional nurse shall complete nursing progress notes as determined by the nature and scope of the individual’s health care needs, and the DDO’s policy and procedure for documentation.

1.11.4 Medication Administration and Treatment

A. The DDO shall have written policies and procedures for medication administration, including protocols for documentation and contact with the DDO professional nurse and/or licensed health care provider in the event of a medication error and/or medication reaction.

1. The DDO shall have a written policy and procedure describing medication safeguards and support protocols for participants who self-administer their medications.

B. Medications shall only be administered by support staff who have:

1. Received documented training in medication administration by a professional nurse;

2. Displayed appropriate competency to carry out said procedure and has been documented by the professional nurse;

3. Received annual training and competency assessment by the professional nurse with appropriate documentation retained in the personnel file.

C. Medications and treatments shall be stored safely, securely and properly, following manufacturer's recommendations and the DDO’s written policy.

1. The dispensing pharmacy shall dispense medications in containers that meet legal requirements. Medications shall be kept stored in those containers. An exemption from storage in original containers is permitted if using a pre-poured packaging distribution system packaged by a pharmacy or professional nurse.

2. A corrected label shall be provided by the pharmacist or noted to indicate change by the professional nurse, correspond to the medication administration sheet, and shall be completed for any medication change orders.

3. Unless otherwise outlined in the individual’s health care plan, medications:

a. shall be stored in a locked area;

b. shall be stored separately from non-medical items;

c. shall be stored under proper conditions of temperature, light, humidity, and ventilation;

d. requiring refrigeration shall be stored in a locked container within the refrigerator; and

e. internal and external medications shall be stored separately;

f. Potentially harmful substances shall be clearly labeled and stored in an area separate and apart from medications.

D. A licensed health care provider and/or nurse shall review the medication sheets monthly and shall sign and date the medication sheets at the time of the review. The medication record shall have a signature sheet of all staff authorized to administer medications, which includes the staff’s signature and the initials he/she will be using on the medication sheet.

E. Medication sheets shall be maintained by the DDO for all persons who do not self-administer their medications. Medication sheets will include:

1. name of the person to whom the medication is being administered;

2. medication(s) name;

3. dosage;

4. frequency;

5. route of administration;

6. date of administration;

7. time of administration;

8. any known medication allergies or other undesirable reaction;

9. any special consideration in taking the medication;

10. the signature and initials of the person(s) administering the medication.

F. All prescriptions shall be reviewed and renewed annually at the time of the annual physical or as indicated by a physician or other licensed health care provider. All medication changes require a new prescription.

G. “PRN” medications are medications administered on an “as needed” basis and shall be specifically prescribed by a physician or other licensed health care prescriber and include specific parameters and rationale for use.

H. All PRN medications shall be documented on medication administration sheets. The documentation shall include:

1. the name of the person to whom the medication is being administered;

2. the name, dosage, and route of the medication;

3. the date, time(s) and reason for administration;

4. the effect of the medication; and

5. the initials of the person(s) administering the medication.

I. The name and dosages of PRN medications administered for behavioral intervention shall be documented per the written policy and procedures of the DDO and as part of an approved plan in accordance with this Part.

J. Medication checks for anyone taking psychotropic medications shall include contact on a regular basis between the person for whom the medications are prescribed and the physician, psychiatrist, or other licensed health care prescriber. The effectiveness of the medication shall be assessed on a regular basis by the multi-disciplinary clinical team.

1.11.5 Monitoring of Controlled Medications

A. Medications listed in Schedules II, III, IV, and V pursuant to R.I. Gen. Laws Chapter 21-28, shall be appropriately stored, documented, and accurately reconciled.

B. Schedule II medications shall be stored separately from other medications in a double locked drawer or compartment, or in a separate storage location which is locked, has additional security restrictions such as a combination lock, and has been designated solely for that purpose.

C. A controlled medication accountability record shall be completed when receiving a Schedule II, III, IV, or V medication.

1. The following information shall be included:

a. name of the person for whom the medication is prescribed;

b. name, dosage, and route of medication;

c. dispensing pharmacy;

d. date received from pharmacy;

e. quantity received; and

f. name of person receiving delivery of the medication.

2. All controlled medications shall be counted and signed for at the end of each shift, or in accordance with the DDO’s written policy and procedure.

3. The DDO shall maintain signed controlled medication accountability records for all persons to whom medications are administered by DDO personnel.

D. When a controlled medication is administered, the person administering the medication shall immediately verify and/or enter all the following information on the accountability record and/or the medication sheet:

1. name of the person to whom the medication is being administered;

2. name of the medication, dosage, and route of administration;

3. amount used;

4. amount remaining;

5. date and time of administration; and,

6. signature of the person administering the medication.

1.11.6 Disposal of Medications

A. DDOs shall have a written policy and procedure for the disposal of damaged, excess, discontinued and/or expired controlled substances. The policy and procedure shall outline the DDO’s protocol for the inventory and disposal of all such controlled medications in accordance with federal Drug Enforcement Administration (DEA) regulations and all other applicable federal, state, and local regulations.

B. Agencies shall have a written policy and procedure for the disposal of all non-controlled medications.

1.11.7 Transcription of Medication Orders

A. The DDO shall have a written policy and procedure describing the conditions under which the support staff may copy a new written medication order from the pharmacy prescription label onto the appropriate documentation form. At a minimum, the procedure shall require the following:

1. Identification of and training requirements for DDO personnel who shall be permitted to copy the medication order from the pharmacy prescription label onto the appropriate documentation form.

2. Safeguards for ensuring that the information has been accurately copied.

3. Protocols for verification by a Professional Nurse per DDO policy.

1.11.8 Individualized Procedures

A. The DDO, in conjunction with the physician, the professional nurse, the individual and his or her family/advocate, shall develop the plan for supporting the individual if they require an individualized procedure to maintain or improve their health status. This procedure is necessary for the health maintenance of the participant and one that the individual is unable to do for themselves. Appropriate training and documentation of competency in performing an individualized procedure shall be specific to the needs, risks and individual characteristics of the person and shall be completed before a support staff performs said task. The fact that a support staff may have been approved to perform an individualized procedure for one person does not create or imply approval for that support staff to perform similar procedures for another individual. When such a procedure is required the following standard for delegation of nursing activities shall apply.

1. Prior to the implementation of an individualized procedure, the RN shall assess the individual’s condition as to whether or not it is of a stable and predictable nature.

2. All training of support staff on the individualized procedure shall be completed by a professional nurse or licensed health care provider.

3. The professional nurse shall assess support staff for their knowledge and demonstrated competency prior to delegating the task for that person to that support staff and communicate and document approval.

4. The professional nurse shall reassess support staff’s competency on an annual basis at a minimum or as the individualized procedures change.

5. The professional nurse shall provide ongoing monitoring of the individual’s health care needs and of the support staff’s skills.

B. If a professional nurse determines that a task or individualized procedure cannot be safely delegated, she/he shall follow DDO policy for communication and resolution while ensuring the health and safety of the individual.

1.11.9 Support Staff Training

A. DDOs shall have written policies and procedures for ongoing health care training as outlined in the DDO Health Care Manual for all support staff.

1. Specific health care related training shall be conducted or supervised by a licensed nurse or a qualified instructor as specified in the DDO’s policies.

2. Professional nursing staff shall delegate tasks only to support staff that have received training commensurate with the DDO’s protocols and have demonstrated competencies in each area of training.

3. Support staff shall be deemed competent upon documentation of satisfactory completion of training. Satisfactory completion and documentation of training shall include knowledge and demonstration of the delegated task.

4. A competency training checklist shall be completed by a professional nurse prior to the delegation of any health care task, including medication administration. The intent of the competency check is to ensure for the delegating nurse that the staff person has satisfactorily completed all required elements of the training program and has satisfactorily demonstrated skills and competencies in the designated areas.

B. Support staff shall receive annual training and a competency evaluation in health care/health and life education areas. Support staff shall demonstrate a working knowledge of comprehensive health care principles and procedures and shall demonstrate the ability to assist individuals to understand their health care needs more fully. The following Core Curriculum is the standardized guideline of minimum expectations for staff training and shall be followed by DDO specific policies, procedures and protocols.

1. Universal Precautions: The support staff shall demonstrate the ability to apply measures to prevent communicable diseases, to recognize and report the presence or onset of communicable disease, and to carry out the recommended procedures.

a. Communicable Diseases;

b. Infection Control; and

c. Exposure Control Plan (OSHA).

2. Wellness & Prevention of Illness: The support staff shall demonstrate an understanding of a comprehensive, holistic approach to health care and positive, healthy behaviors which will enhance the individuals’ overall physical and mental health.

a. Nutrition/Food Handling;

b. Personal Hygiene;

c. Sexual & Reproductive Health; and

d. Healthy Lifestyle

3. Signs & Symptoms of Illness & Injury: The support staff shall be able to recognize the signs and symptoms of illness and injury and take appropriate action.

4. Emergency Care: The support staff shall demonstrate an understanding of how to identify and respond to emergency situations and when to seek outside help

a. Basic First Aid; and

b. Cardio-Pulmonary Resuscitation. All staff who work with individuals supported shall maintain current CPR Certification and documentation of such shall be maintained in the employee’s personnel file.

5. Communication: The support staff shall understand and demonstrate the importance of clear communication and the compliance with DDO policy regarding health care issues.

6. Medication Administration: The support staff shall safely administer, completely document and communicate appropriately on issues related to medication administration per acceptable standards in accordance with this Part.

7. Agency Specific Policy, Procedures and Protocols: The support staff shall demonstrate a working knowledge of the DDO’s specific policies, procedures and protocols regarding healthcare.

8. Individualized Procedures: The support staff shall demonstrate competency in the provision of any individualized procedure as detailed in this Part prior to implementing the procedure.

1.11.10 Professional Nursing

A. The Professional Nurse shall maintain compliance with the RI Department of Health’s “Rules and Regulations for the Licensing of Nurses and Standards for the Approval of Basic Nursing Education Programs” (216-RICR-40-05-3) regarding delegation to unlicensed assistive personnel, including the criteria for appropriate delegation to support staff.

B. The DDO shall have written policy and procedures regarding nursing support protocols for evening, weekend, and holiday coverage.

A. Behavioral Supports are interventions to develop and strengthen adaptive and appropriate behaviors through the application of behavioral interventions, and to simultaneously reduce the frequency of inappropriate behaviors. Behavioral Supports and interventions encompass behavioral analysis and other similar interventions that refer to purposeful, clinical support of behavior.

1. All behavioral supports and treatment shall conform to and abide by R.I. Gen. Laws Chapter 40.1-26 entitled “Rights for Persons with Developmental Disabilities.”

2. Participants shall give written informed consent prior to the imposition of any plan designed to modify behavior including, but not limited to, those plans which utilize restrictive interventions or impairs the participant’s liberty.

a. A guardian, family member or advocate can provide written informed consent if the participant is not competent to do so.

b. If a participant is competent to provide informed consent, but cannot provide written consent, the agency shall accept an alternate form of consent, such as verbal agreement obtained and witnessed, and document in the participant’s record how such consent was obtained.

B. Behavioral Supports shall be developed and implemented in accordance with Positive Behavioral Intervention and Supports as an evidence-based approach to individual behavior and behavior interventions.

1.12.1 Behavioral Intervention Policy and Procedure Manual

A. In accordance with best practices, each Organization shall develop Behavioral Intervention Policies and Procedures. Such policies, at a minimum, shall include staff training requirements, positive clinical strategies, crisis prevention and intervention procedures to be used to keep participants and others safe. Staffing levels will be addressed in a person-centered manner by identifying needs in the ISP.

B. The Behavioral Intervention Policies and Procedures shall utilize evidence-based positive strategy and intervention to reduce the ongoing use of emergency restraints or restrictions on a participant’s rights. Such policies shall also include clear guidelines for:

1. Determining the need to develop a behavior support plan; and

2. How changes shall be made to the Behavioral Support plan.

1.12.2 Staff Training and Support

A. There shall be documentation available in each Organization for inspection and review by the Department related to the following requirements:

1. A description of the specific training (type, content, number of hours, frequency) required of staff to assure that staff are competent to apply each behavioral intervention used, and to apply the provider emergency behavioral crisis prevention and intervention procedures;

2. Listing of staff trained in prevention and intervention techniques;

3. Staff who teach behavioral intervention procedures and techniques, as well as emergency crisis prevention and intervention, shall do so in accordance with the prevailing evidence-based practice;

4. Method to assess staff competency in behavioral intervention and crisis prevention procedures;

5. Monitoring and ongoing support in evidence-based and positive behavioral support plans;

6. Supervision will occur to ensure that the requirements are implemented and documented.

1.12.3 Development of a Behavioral Support Plan

A. Any intervention to alter a participant's behavior must be based on positive behavioral supports and intervention and practice and must be:

1. Annually approved in writing by the participant, Legal Guardian, family and/or advocate where appropriate; and

2. Shall be made by the appropriate member of the ISP team with the informed consent of the participant and described in detail in the participant's record and ISP.

B. A decision to develop a plan to teach alternative skills or alter a person's behavior shall be made by the appropriate members of the ISP team. Behavioral plans shall be developed by the clinician based on assessed clinical needs and are generally to develop and strengthen adaptive, socially appropriate behaviors, and to facilitate communication, community integration, and social interactions. The plans shall be clinically approved and reviewed at least annually by the ISP team and the HRC, as needed.

1.12.4 Functional Behavioral Assessment Required

A. A functional behavioral assessment, performed by the DDO, shall inform the basis for the behavioral support plan which includes restrictive procedures. The functional behavioral assessment shall include:

1. A clear, measurable description of the behavior which includes (as applicable) frequency, antecedents, duration and intensity of the behavior;

2. A clear description and justification of the need to alter the behavior;

3. An assessment of the meaning of the behavior, which accepts that all behavior is communicable in nature and includes the possibility that the behavior is one (1) or more of the following:

a. The result of medical conditions;

b. The result of psychiatric conditions;

c. The result of environmental causes or other factors;

d. The results of the person's inability to communicate emotions or concerns.

4. A description of the context in which the behavior occurs; and

5. A description of what currently maintains the behavior.

1.12.5 Behavioral Support Plans

A. Behavioral Support Plans shall be approved in accordance with all applicable requirements of these regulations, to ensure that the predictable risks, as weighed against the benefits of the procedure, would not pose an unreasonable degree of intrusion, restriction of movement, physical or psychological harm. No Behavioral Support Plans shall be administered to any person in the absence of a written behavioral support plan.

1. All procedures designed to decrease inappropriate behaviors may be used only in conjunction with positive reinforcement programs.

2. Restrictive behavioral interventions shall be used only to address specifically identified extraordinarily difficult or dangerous behavioral problems that significantly interfere with appropriate behavior and/or the learning of appropriate and useful skills, and/or that have seriously harmed or are likely to seriously harm, the individual or others.

3. Behavioral Support Plans written by the clinicians that serve as intervention guidelines, simple problem-solving strategies, or teaching recommendations do not fall within the scope of Behavioral Support Plans to ameliorate negative behavior.

4. All behavioral intervention plans shall conform to and abide by R.I. Gen. Laws Chapter 40.1-26.

B. Any behavioral intervention procedures that are restrictive should be used only as a last resort, subject to the most extensive safeguards and monitoring contained herein.

C. The Behavioral Support Plan shall include:

1. Strategies that are related to the function(s) of the behavior and are expected to be effective in reducing problem behaviors, as included in the functional behavioral assessment;

2. Specific instructions for staff to implement the strategies of the plan;

3. Positive behavioral supports that include the least intrusive intervention possible;

4. Early warning signals or predictors that may indicate a potential behavioral episode and a clearly defined plan of response and de-escalation;

5. Teaching functional behavioral replacement for the behavior targeted for reduction;

6. A procedure for evaluating the effectiveness of the plan, which includes a method of collecting and reviewing data on frequency, duration and intensity of the behavior. Staffing levels will be addressed in a person-centered manner by identifying the staffing needs via an ISP review to determine that appropriate staff levels are maintained; and

7. Adjusting environments to decrease the probability of occurrence of the undesirable behavior.

D. Behavioral Support Plans shall be formalized and written to include the following:

1. Specified, measurable target behaviors;

2. Specified, measurable baseline information;

3. Specified, measurable goals and objectives;

4. Specified, measurable intervention strategies and tactics;

5. A procedure for evaluating the effectiveness of the plan, which include a method of collecting and reviewing data on frequency, duration and intensity of the behavior and for reviewing and reporting progress;

6. Sufficient, qualified, trained staff to implement the behavior plan;

7. Specified named staff to implement and monitor the plan; and

8. Length of time of each program component or intervention.

1.12.6 Notification of Policies and Procedures

The participant, family, legal guardian/advocate will receive a copy of the Behavioral Support Plan.

1.12.7 Use of Restrictive Intervention

A. Restrictive Intervention may be used in such exceptional circumstances that shall meet the heaviest burden of review among all treatments. The use of such procedures will be allowed for a particular person only after a review and approval by clinicians, families, guardians and the Human Rights Committee. This process shall ensure that before the participant can be subjected to this type of procedure, that clinicians have exhausted other less restrictive interventions, and further, that the likely benefit of the procedure to the participant outweighs its apparent risk of life safety.

B. The application of an approved restrictive intervention shall be strictly monitored by the DDO, clinician and the Human Rights Committee.

C. All behavioral interventions, programs, methodologies and applications which utilize any interventions shall be implemented only under the following conditions:

1. At the time of the initial approval of any restrictive behavioral intervention, and at least annually, signature is required for both initial and annual plans from:

a. The participant with the participant's informed consent;

b. Family or advocate or legal guardian (as appropriate);

c. Medical professional;

d. Executive director, authorized representative;

e. Support coordinator;

f. Supervising clinician; and

g. Chair or designee of the human rights committee.

D. Procedures shall include safeguards to be implemented including but not limited to medical supervision, proposed and expected duration, frequency, and precautions to prevent injury. If the person with developmental disabilities shows symptoms of physical injury or distress during the use of any behavioral treatment procedure, the physical injury or distress shall be alleviated. Staff and the person’s responses shall be documented.

E. A statement of possible risk, possible side effects, benefits, cautions, and precautions shall be documented, and shall be described to and discussed with the participant and/or parents, guardian, or advocate, prior to gaining their authorization signatures.

F. Staff shall also have access to a supervisor to determine whether to continue the intervention.

G. Any person receiving behavioral treatment shall have his/her health monitored by a physician or registered nurse over the course of behavioral treatment, as medically indicated. The physician or registered nurse shall document their monitoring activity.

H. Individual records pertaining to the use of behavioral interventions shall be made available for review by the executive director, or equivalent position of the DDO, representatives of the Department, the human rights committee, the participant and/or parent, advocate, or guardian (as appropriate).

I. Any use of restrictive intervention techniques that result in injury to either the participant or any other individual is reportable to the Department.

1.12.8 Prohibited Restrictive intervention

A. In addition to those prohibited under R.I. Gen. Laws §§ 40.1-26-3, 40.1-26-4.1, and 42-158-4, the following procedures shall be specifically prohibited from use under any circumstances:

1. Utilizing law enforcement in lieu of a clinically approved therapeutic emergency intervention or behavioral treatment program.

2. Utilization of behavioral interventions for the convenience of the staff.

3. Utilization of behavioral interventions for any reason except for emergency protocol.

1.12.9 Crisis Prevention and Intervention

A. Restraints shall not be employed as punishment, for the convenience of the staff, or as a substitute for an individualized plan. Restraints shall impose the least possible restrictions consistent with their purpose and shall be removed when the emergency ends. Restraints shall not cause physical injury to the participant and shall be designed to allow the greatest possible comfort, pursuant to R.I. Gen. Laws § 40.1-26-3(8). Restraints shall be subject to the following conditions:

1. Physical restraint shall be used to protect the participant or others from imminent injury;

2. Chemical or mechanical restraint shall only be used when prescribed by a physician in extreme emergencies in which physical restraint is not possible and the harmful effects of the emergency clearly outweigh the potential harmful effects of the chemical restraints; and

3. Any restraint that is conducted shall be in accordance with state statute and federal statutes 42 U.S.C. § 290ii(b) and 42 U.S.C. § 15009(a)(3)(B).

4. Any restraint that is conducted shall also be in accordance with federal regulations 42 C.F.R. § 483.420(a); 42 C.F.R. § 483.450(d); and 45 C.F.R. § 1326.19, incorporated herein by reference pursuant to R.I. Gen. Laws § 42-35-3.2, as were in effect in June 2018 and not including later amendments thereof.

1.12.10 Physical Intervention Techniques in Emergency Situations

A. In the DDO's Behavioral Intervention Policy and Procedure Manual, methods of dealing with behavioral crisis within the DDO shall be developed and documented. Emergency behavioral crisis prevention and intervention procedures, including any provision for individualized techniques or methods shall be documented.

B. In the event that only one (1) staff person is available during a restraint or a hold, that individual is responsible to act as both the lead person, as well as the observer.

C. Use of physical intervention techniques that are not part of an approved plan of behavior support in emergency situations must:

1. Be reviewed by the DDO’s executive director, or equivalent position (or designee) within one (1) hour of resolution of the emergency;

2. Be used only until the participant is no longer an immediate threat to self or others;

3. Prompt an ISP team meeting if an emergency intervention is used more than three (3) times in a six (6) month period or at the request of the participant, their designee, or guardian; and

4. Immediate verbal notification will be provided to the participant's designee or guardian.

D. Description of the application of all approved physical and/or mechanical restraints and holds, must be detailed in writing in the ISP. The following procedural stipulations must be strictly adhered to and specifically stated:

1. One (1) qualified and trained person must be designated the lead person on site for each hold situation, with primary responsibility for directing any other person(s) who is (are) involved in the restraint.

2. No staff can lay across the back of a participant in a hold.

a. The participant shall not be placed in a prone restraint, as prohibited by R.I. Gen. Laws § 42-158-4.

3. One (1) person should have responsibility for observing the participant involved in the hold to watch for any problems that may be a signal of a life-threatening situation. The lead person should determine who shall have this responsibility.

E. Documentation of all physical/mechanical behavioral interventions, both behavior treatment and crisis, shall include, but shall not be limited to:

1. Signs and symptoms of physical condition during all behavioral interventions; and,

2. Specific outcomes of behavioral interventions.

1.12.11 Restraint Report

A. Any use of physical intervention(s) shall be documented in a restraint report which is received by the treating clinician, the participant, their designee and guardian within seventy-two (72) hours of the incident and shall be made available to the Department upon request, consistent with R.I. Gen. Laws § 40.1-26-4(d). The reports shall be kept on file for ten (10) years. The incident report shall include:

1. The name of the participant to whom the physical or mechanical intervention was applied;

2. The date, type, and length of time the restraint;

3. A description of the antecedent incident precipitating the need for the use of the physical or mechanical intervention;

4. Signs and symptoms of physical condition during all behavior interventions, including those resulting from injury.

5. The name and position of the staff member(s) applying restraint;

6. The name(s) and position(s) of the staff witnessing the restraint; and

7. The name of the lead person providing the initial review of the use of the restraint.

1.12.12 DDO Annual Restraint Report

All physical and mechanical restraints that are used to control acute, episodic behavior of participants shall be reported to the Department on an annual basis. All DDOs shall submit an Agency Annual Restraint Report during an annual timeframe specified by DDO.

A.All organizations licensed by the Department to provide services and programs shall have staff with appropriate training, education, experience, credentials and licenses to deliver the services and programs covered in this Part.

B.Direct Service Staff

1.All staff providing direct services in licensed behavioral health organizations who are not licensed independent practitioners will receive clinical supervision by a supervisor who meets the qualifications in § 1.6(C) of this Part.

2.Hours of supervision will be pro-rated for actual hours worked each month.

3.Licensed staff – all professionally licensed staff, including Licensed Practical Nurses (L.P.N.s), who provide a clinical or medical service, and are not independent practitioners, except nurses in an OTP who have no counseling responsibilities, shall receive supervision on a regular and predictable schedule that occurs at least monthly with preference for a minimum of four (4) hours of clinical supervision per month (pro-rated for part-time clinicians), that shall consist of no less than one (1) hour of individual supervision. Each month the remaining three (3) hours of clinical supervision may be in a group setting.

a.L.P.N.s must be supervised on an ongoing basis by a person licensed in the State of Rhode Island as a Registered Nurse (R.N.), an Advanced Practice Registered Nurse (A.P.R.N.), or a physician. Dates and times of supervision of an L.P.N. by any of the professionals listed in this subparagraph must be documented and maintained by the organization.

b.All L.P.N.s must have the knowledge and skill level commensurate with education and clinical expertise within the scope of work. L.P.N.s must have the required trainings and certifications to perform the work responsibilities at the level of practice for which they are hired or are currently employed.

4.Staff without a license – All direct service staff who do not have a professional license, except those who work the third (3rd) shift in a residential program, shall receive supervision on a regular and predictable schedule that occurs at least monthly with preference for a minimum of four (4) hours of clinical supervision per month (pro-rated for part-time direct service staff) of which at least two (2) hours shall be individual clinical supervision. Each month the remaining two (2) hours of documented clinical supervision may be in a group setting. The supervision must be provided by a supervisor who meets the qualifications in § 1.6(C) of this Part below.

5.Direct service staff who work the third (3rd) shift in a residential program shall receive a minimum of one (1) hour of clinical supervision each month, at least thirty (30) minutes of which shall be individual clinical supervision. The supervision must be provided by a supervisor who meets the qualifications in § 1.6(C) of this Part below.

6.All clinical supervision shall relate to the service the staff person is providing and shall be documented.

C.Clinical Supervisors

1.Staff providing clinical supervision shall have, at a minimum, the following qualifications with education, credentials, license, and experience relevant to the service they are supervising:

a.Licensed Independent Practitioner; or

(1)These licenses include Licensed Marriage and Family Therapist (LMFT), Licensed Independent Clinical Social Worker (LICSW), Medical Doctor (MD) and Licensed Ph.D. psychologist, Licensed Nurse Practitioner (LNP), and Advanced Practice Registered Nurse (APRN) as defined in § 1.3.1(A)(3) of this Part above; or

b.Registered nurse with an American Nurses Credentialing Center (ANCC) certification as a Psychiatric and Mental Health Nurse (PMH-BC) or at least two (2) years full time experience providing relevant behavioral health services; or

c.Licensed Chemical Dependency Clinical Supervisor (LCDCS) with experience providing substance use counseling and delivering clinical supervision focused on the clinical skills and competencies for persons providing counseling; or

d.Licensed Chemical Dependency Professional or Certified Alcohol and Drug Counselor who has completed a Department approved course in clinical supervision; Certified Co-Occurring Disorder Professional-Diplomate, Certified Advanced Alcohol and Drug Counselor, Certified Co-Occurring Disorder Professional or

(1)The Certified Co-Occurring Disorder Professional-Diplomate, Certified Co-Occurring Disorder Professional and Provisional Certified Co-Occurring Disorders Professional credentials issued by the Rhode Island Certification Board have been discontinued. Individuals with the credential may renew or recertify this credential but no new credentials will be issued. The Certified Alcohol and Drug Counselor and Certified Advanced Alcohol and Drug Counselor credentials contain the co-occurring competencies.

e.Clinician with relevant Master’s Degree and license and, at least, two (2) years full time experience providing relevant behavioral health services.

1.6.1Clinical Screening

A.The clinical screening process shall, at a minimum, include:

1.Identifying and addressing the immediate and urgent needs of the person; and

2.Determining the need for assessment or treatment either by the organization or by referral to another provider or organization.

B.The organization has written policies and procedures describing the clinical screening process and collection of demographic information necessary to complete the screening. Information collected and recorded shall include:

1.Demographic information (such as name and contact information);

2.The person's use of alcohol and other drugs; and

3.Risk factors, including suicidal or homicidal ideation or behaviors, to determine the need for emergency or urgent care.

C.The organization shall establish written policies and procedures that describe the criteria for scheduling appointments and for admission, and shall include:

1.Criteria to prioritize the scheduling of appointments;

2.Criteria for admitting persons for services;

3.Criteria for denying services; and

4.Criteria for referring to other providers.

D.When a person is found to be eligible for the organization’s services, but not in need of immediate or crisis-related services, an appointment shall be scheduled with reasonable promptness. If the organization lacks the resources to schedule an appointment within six weeks (6) of the screening date, the organization shall refer to another appropriate provider and document the referral.

E.When the screening results in a person not being offered services by the organization the following procedures, at a minimum, shall be implemented:

1.The person is informed that he or she may speak with the screening supervisor if he or she states his or her situation has not been adequately understood;

2.Recommendations are provided for alternative services and referral sources;

3.The person is informed that concerns or complaints may be directed to the Department; and

4.The organization maintains documentation of these actions.

F.Staff conducting clinical screenings shall have access to current information about referral resources that have been approved by the organization.

G.The organization shall ensure that staff supervising and conducting clinical screenings shall, at a minimum, have the following qualifications:

1.The clinical supervisor shall meet the requirements defined in § 1.6(C)(1) of this Part.

H.The above is considered to be sufficient for the treatment record except as prescribed by a specific program, service or payer.

1.6.2Biopsychosocial Assessment

A.An assessment of the individual's physical and psychological status and social functioning shall be conducted for each person who is evaluated for admission to the organization.

1.The following shall be determined and documented through the assessment process:

a.The treatment needs and expectations identified by the person served;

b.The type and level of treatment to be provided;

c.The need for specialized medical or psychological evaluations;

d.The need for the participation of the family or other support persons;

e.Psychological characteristics and mental status exam;

f.History of and current behaviors associated with risk taking and life-threatening ideation and actions; and

g.History of and current behaviors associated with alcohol and illicit substance use, or other behavioral health disorders.

B.Each biopsychosocial assessment shall include an integrated summary that analyzes and synthesizes the findings of the assessment. Formulation of the integrated summary shall include:

1.A description of the person that includes his or her strengths, aspirations, and concerns related to the proposed treatment;

2.Formulation and prioritization of the issues for treatment and a description of the factors that contribute to each issue;

3.Clinical judgments regarding both positive and negative factors likely to affect the person’s course of treatment and clinical outcomes;

4.Current multiaxial Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses and International Classification of Diseases (ICD) codes, both written and coded; and

5.For persons assessed in need of substance abuse services, the assessment summary shall include recommendations for a level and type of service based on current American Society of Addiction Medicine’s patient placement criteria (ASAM-PPC) criteria.

C.The preliminary treatment plan and integrated summary shall be developed that includes, at a minimum, the following:

1.Individualized goals and service needs with consideration of the individual’s expectations and desires; and

2.Identification of preliminary treatment goals and interventions.

D.The person responsible and the date to be completed shall be documented for each intervention.

E.The preliminary treatment plan shall be formulated as part of the assessment and shall suffice up to thirty (30) days after the assessment unless other requirements are designated for a specific program.

F.At least once every twelve (12) months, a review and update of the assessment information and the integrated summary shall be documented. This review/update must be reviewed and validated with the signature of the clinical supervisor within fourteen (14) days of completion. This validation is not required for documents created by licensed clinical staff.

G.Assessment reviews and updates shall be conducted in face-to face interviews with the individual.

H.The biopsychosocial assessment shall be rewritten in its entirety, at least every sixty (60) months. This reassessment must be reviewed and validated with the signature of the clinical supervisor within fourteen (14) days of completion. This validation is not required for documents created by licensed clinical staff.

I.Unless specified otherwise in this Part, staff conducting initial biopsychosocial assessments shall, at a minimum, have the following qualifications with education and experience relevant to the service they are providing:

1.Licensed Independent Practitioner; or

2.Master’s Degree with license to provide relevant behavioral health service or with one (1) year post Master’s Degree full-time experience providing behavioral health services; or

3.Advanced Practice Registered Nurse (APRN) as defined in § 1.3.1(A)(3) of this Part above; or a Registered nurse with either ANCC certification as a Psychiatric and Mental Health Nurse or with one (1) year post RN license full-time experience providing behavioral health services; or Certified Addictions Registered Nurse (CARN); or

4.Licensed Chemical Dependency Professional, Certified Co-Occurring Disorder Professional-Diplomate or Certified Alcohol and Drug Counselor; or

5.Certified Co-Occurring Disorder Professional with no less than one (1) hour of individual clinical supervision each month; or

6.Provisional Alcohol and Drug Counselor or Provisional Certified Co-Occurring Disorders Professional with no less than two (2) hours of individual clinical supervision each month; or

7.Master’s Degree staff working toward licensure and individuals enrolled in Master’s Degree programs working towards Provisional Alcohol and Drug Counselor, or Provisional Certified Co-Occurring Disorders Professional certification, with no less than one (1) hour of individual clinical supervision per week and additional supervision as required by their respective training or licensing programs.

J.The above is considered to be sufficient for the treatment record except as otherwise prescribed by a specific program, service or payer.

1.6.3Person-Centered Treatment Plan

A.Based on the biopsychosocial assessment, a goal-oriented, recovery-focused individualized treatment plan shall be developed and implemented with each person served.

B.The treatment plan shall contain the following elements:

1.The unique needs, expectations, and characteristics of the person served into an appropriate, personalized, and comprehensive plan;

2.Written and coded multiaxial DSM diagnoses and/or ICD codes demonstrating a clear connection between the diagnoses, the data and integrated summary documented in the assessment, and the goals and interventions identified on the treatment plan;

3.Written statement of each issue that needs to be addressed;

4.Observable and measurable long and short-term goals formulated by the person served;

5.Interventions, services, tasks or supports needed to attain goals:

a.When and with what frequency each intervention will occur;

b.The person(s) who will perform each intervention;

c.Timeframes based on the projected length of time to review progress or to accomplish each specific goal and intervention;

d.A member of the professional staff who has the clinical skills and experience to provide the indicated services must be responsible for the overall development and implementation of the treatment plan. This staff member shall be clearly identified in the plan;

e.The treatment plan shall be dated and include the signature of the person served and primary provider and, unless the primary provider meets the qualifications in § 1.6(C)(1) of this Part, shall be validated with the signature of the clinical supervisor of the specific service or program. Each staff person’s credentials and the date shall be clearly documented with the signature or a statement that the person is unwilling or unable to sign.

6.Validation shall be recorded no later than two (2) weeks after completion of the plan; and

7.The treatment plans of individuals receiving services in a CMHC residential or assertive community treatment program require the signature of a psychiatrist.

C.A new treatment plan shall be developed at least once every twelve (12) months.

D.The above is considered to be sufficient for the treatment record except as otherwise prescribed by a specific program, service or payer.

1.6.4Person-centered Treatment Plan Review

A.Goals and interventions indicated in the treatment plan shall be reassessed, updated and modified every six (6) months as necessary, and at each of the following events:

1.At the time of the individual's admission to a specific service or program;

2.Upon changes in the individual’s condition or level of care;

3.At the time of an internal transfer between programs;

4.When an intervention is completed or a goal attained;

5.When an intervention is not helping the individual attain the desired outcome;

6.Upon the individual's frequent use of crisis intervention services;

7.If an individual refuses services or makes him or herself unavailable for services; and/or

8.At the request of the person served.

B.The results of the review must be specifically referenced in the treatment plan and shall be:

1.Documented on a supplement to the treatment plan that is clearly labeled “Treatment Plan Review,” or

2.Documented in a detailed progress note that is clearly labeled “Treatment Plan Review.”

C.Treatment plan reviews shall be signed and validated according to requirements specified in § 1.6.3 of this Part.

D.The person-centered treatment plan is considered to be sufficient for the treatment record except as otherwise prescribed by a specific program, service or payer.

1.6.5Progress Notes

A.The person’s current status and progress relative to the treatment plan and the treatment process shall be documented as progress notes in the treatment record.

B.Progress notes shall be recorded according to a standard charting format.

C.Progress notes shall provide documentation of relevant events occurring during the individual’s course of treatment.

D.The following shall also be recorded in progress notes:

1.Information about the individual’s progress in the treatment process;

2.Duration of service;

3.Discussions pertinent to the informed decision-making process;

4.Decisions made by the individual served; and

5.Cancelled and missed appointments.

E.The progress notes are considered to be sufficient for the treatment record except as otherwise prescribed by a specific program, service or payer.

1.6.6Transition/Discharge Summary and Aftercare Plan

A.An aftercare plan shall be developed in partnership with the individual before a planned discharge and he or she shall be offered a copy of the plan.

B.The aftercare plan shall include:

1.Services to be accessed following transition/discharge;

2.Activities to sustain the progress made during treatment; and

3.A crisis plan for the individual to follow after transition/discharge, when indicated.

C.A summary shall be formulated that records the most significant information regarding the individual’s treatment from the time of first contact until services have ended at the time of the person's discharge from services.

D.The summary shall be completed no later than fifteen (15) working days after the individual's discharge from the organization.

E.The transition/discharge summary shall include the following:

1.Circumstances of the discharge;

2.Presenting issues;

3.Current multiaxial Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses and International Classification of Diseases (ICD) codes, both written and coded;

4.All significant findings relevant to the person’s treatment and recovery;

5.Course and progress of treatment;

6.Outcomes in relation to the identified issues, goals, and treatment;

7.Recommendations and referrals for further services, if indicated; and

8.A risk assessment describing the course of treatment prior to discharge.

F.When a person served is not participating in a particular service or program, the director of such service or program may discharge the person from the program or the organization only when the following conditions have been met:

1.The program staff have worked with the person to resolve issues, made appropriate changes in his or her treatment plan, and have documented such efforts;

2.The program staff have assisted the person to access alternative services; and

3.The person has been given written notice of the pending discharge and has been informed of his or her right to appeal the decision.

G.Records shall remain open if it is determined that:

1.The individual is at risk for relapse, hospital level care, incarceration, or homelessness without services;

2.The person is prescribed medication by the organization and has not been transitioned to new providers; and/or

3.The individual has been receiving services through Assertive Community Treatment (ACT) or Integrated Health Homes (IHH) and is scheduled to be incarcerated for six (6) months or less.

H.When a person served does not participate in a planned discharge, the organization shall:

1.Provide information on how to access emergency services and the conditions, if any, of future care from the discharging organization; and

2.Provide follow-up contacts after discharge as required by specific programs or by State law.

I.The transition/discharge summary and aftercare plan are considered to be sufficient for the treatment record except as otherwise prescribed by a specific program, service or payer.

1.6.7Outpatient Services and Programs

A.Emergency, Crisis Intervention and Crisis Stabilization Services

1.All entities designated as a CMHC are required to operate a crisis intervention and stabilization program for adults who reside in the CMHC’s designated service area and who do not have a current behavioral healthcare provider in addition to the individuals they serve.

2.Organizations shall ensure that emergency services are available via telephone and/or face-to-face evaluation twenty-four (24) hours a day, seven (7) days a week.

3.Organization crisis programs and services shall establish policies and protocols that, at a minimum, describe the following:

a.Admission, treatment, and discharge criteria;

b.Physician or nurse-approved protocols for the provision of emergency medical and emergency behavioral healthcare;

c.Guidelines for the internal and external transfer, referral, and follow-up care of persons served, to include referrals for physical and medication evaluations;

d.The process for accessing internal and external resources; and

e.Procedures for the involvement of significant others during emergency situations.

4.The organization will register each person whose initial face-to-face clinical service is an emergency or crisis assessment according to the organization’s protocol.

5.The implementation of crisis intervention services in CMHCs shall include, but not be limited to, the following:

a.An accessible phone line for emergency contacts will be established and the organization shall ensure that a qualified clinician responds within ten (10) minutes of notification from an answering service or from a nonprofessional staff person; and

b.Procedures for transferring individuals assessed in the community who are experiencing a medical or psychiatric emergency to a hospital.

6.Staffing must include mental health professionals, including a Qualified Mental Health Professional (QMHP), who have the requisite training and experience to be able to assess whether an individual experiencing a behavioral health crisis may be in need of involuntary hospitalization.

7.Each CMHC performing psychiatric emergency services triage shall provide the Director of BHDDH with an annual list of its personnel who qualify under statute or Regulation as QMHPs as defined in § 1.3.1(A)(47) of this Part above.

8.Emergency certifications may only be done by a licensed psychiatrist licensed as a physician in Rhode Island or QMHP as defined in § 1.3.1(A)(47) of this Part above.

9.Each CMHC shall employ, either directly or on a consultation basis, the services of one (1) or more licensed psychiatrists to provide twenty-four (24) hour consultation.

B.General Outpatient Services and Programs (GOP)

1.Clinical services shall be delivered by adequately trained behavioral health professionals in accordance with applicable program specifications.

2.Organizations providing GOP shall develop and implement policies and procedures describing:

a.Admission, continuing care, and discharge criteria; and

b.Use of evidence-based (when available) and best practices for treatment of co-occurring disorders.

3.GOP shall provide or will have the capacity to arrange for the following counseling services:

a.Individual;

b.Group; and

c.Family.

4.The supervisor of GOP shall meet the requirements defined in § 1.6(C)(1) of this Part above.

5.For GOP clients receiving only medication services prescribed by a psychiatrist, the psychiatrist’s progress notes can be used for the treatment plan review.

C.Intensive Outpatient Services and Programs (IOP)

1.Organizations providing IOP shall, at a minimum, develop and implement policies and procedures describing:

a.Admission, continuing care, and discharge criteria;

b.Evidence based or best practices offered as part of their services; and

c.Mechanisms for providing services in the frequency and intensity appropriate to an individual’s needs and treatment goals.

2.The American Society of Addiction Medicine’s patient placement criteria (ASAM-PPC) shall be considered when providing services for persons with substance use disorder and/or dependence diagnoses.

a.IOP is considered a 2.1 program per the ASAM.

b.The following apply to substance use treatment programs providing IOP:

(1)A minimum of nine (9) hours per week of skilled treatment services shall be provided for each person served.

(2)At least one (1) hour each week shall be an individual counseling session.

3.An interdisciplinary team of addiction treatment professionals shall staff the IOP.

4.The initial individualized person-centered plan for each person served shall be developed within fourteen (14) days of his or her admission to the program. (If an individual has been referred from an inpatient-residential rehabilitation service, the referring agency's person-centered (treatment) plan may be utilized on a preliminary basis).

5.The person-centered plan shall be reviewed at least weekly during the individual's enrollment in the program and revised as goals are accomplished or new treatment issues arise. Such reviews will be documented in the progress notes and on the person-centered plan.

D.Partial Hospitalization Programs (PHP)

1.Facilities must have accreditation by a recognized national accreditation body.

a.The partial hospitalization unit shall operate as a separate, identifiable organizational unit with its own director, or supervisor, and staffing pattern.

b.When the unit is a portion of a larger organizational structure, the director or supervisor of the unit shall be identified and responsibilities clearly defined. The organizational structure of the unit will be described in an organizational chart.

c.A written description of all services provided by the unit shall be on file and available to the Department. The Department shall be notified of any major change in the organizational structure or services.

2.PHP shall offer twenty (20) hours per week of clinical treatment and scheduled programming to address the treatment needs of the individuals served.

a.PHP may operate seven (7) days per week and shall operate a minimum of five (5) full days a week.

b.Staff must be available to schedule meetings and sessions at a variety of times in order to support family/other involvement for the individual.

3.PHP can be provided in full-day increments of six (6) hours or half-day increments of three (3) hours. The following services should be offered to clients in all PHP and provided to those who have the clinical necessity:

a.Clinical treatment and scheduled programming based on the individual’s clinical needs;

b.Coordination of care with other care providers and social services;

c.Clinical assessment once each program day;

d.Individual, group or family therapy at least three (3) times per week;

e.Medication reconciliation and evaluation initiated within the first program day;

f.Activity therapies or psycho-education, when determined to be clinically appropriate;

g.Recreation and social services;

h.Access to community-based rehabilitation/social services that can be used to help the individual transition to the community; and

i.Crisis intervention.

4.Psychiatric PHP shall also provide the following:

a.At least one (1) psychiatric evaluation and more frequent medication evaluations as needed (based on a one (1) to two (2) week average stay);

b.Visits four (4) of five (5) days face-to-face psychiatrist or mid-level practitioner (such as physician assistant, nurse practitioner or advanced practice registered nurse under psychiatrist supervision).

c.Adult PHP shall have a minimum of two (2) hours of assigned psychiatric time per week for every five (5) patients of program capacity. This is to ensure adequate care and supervision for patients in the PHP; and

d.Substance evaluation within the first two (2) program days; and

e.Toxicology screen, self-help, twelve (12) step, and education groups, as needed.

f.The following requirements related to the person-centered (treatment) plan must be met:

(1)The plan will be reviewed at least weekly and more often as necessary, updated as medically indicated, and signed by the treatment team members including the individual being served;

(2)The plan will be developed within the first five (5) days of service and reviewed by the treatment team a minimum of once every twenty (20) days of service to the individual patient and modified as appropriate;

(3)The plan will be maintained and updated with signed daily case notes and kept in the patient’s medical record.

5.Substance use PHP are considered to be a level 2.5 program per the ASAM and shall also provide the following:

a.Substance evaluation on admission and at least once a week;

b.Discharge plan initiated upon admission;

c.Individual, group or family therapy at least three (3) times per week;

d.Psychiatric evaluation and management as needed;

e.Medical and medication evaluation at least once per week;

f.Recovery or education groups at least one (1) hour per day, at least three (3) times per week;

g.Twelve (12) step or other self-help group; and

h.Toxicology screen and/or breathalyzer as needed.

6.Staffing and personnel

a.PHP are staffed by an interdisciplinary team of credentialed addiction or mental health professionals including counselors, psychologists, social workers and board-certified physicians. A physician shall be available 24/7 for emergencies.

b.The following also apply to treatment team composition for psychiatric PHP:

(1)The program director shall be a licensed mental health professional and have a minimum of two (2) years of post-graduate clinical experience;

(2)A treatment team shall consist of a treatment team leader, a psychiatrist when the treatment team leader is not a psychiatrist, and other appropriate staff.

(3)The treatment team leader shall be a licensed mental health professional.

(4)The treatment team leader shall be a physician or psychologist for patients undergoing involuntary treatment.

7.Staff/patient ratio

a.Adult PHP shall have a minimum of one (1) full-time equivalent (FTE) clinical staff member to every six (6) patients. RN services are provided in a RN/client ratio sufficient to meet patient care needs, and other positions staffed in sufficient numbers to meet patient and program needs. Staff/patient ratio is to be determined on the basis of the designed program capacity, such as, a program with a program capacity of thirty (30) would require five (5) FTE staff.

b.When there are changes in the program capacity, appropriate staffing changes shall be made as required. Staff should be of appropriate disciplines and shall include at least one (1) member, other than program director, who is a licensed mental health professional or one (1) member who is a psychiatric nurse.

c.All clinical staff time devoted specifically to the PHP, including that of the program director and medical staff, will be included when calculating patient/staff ratio. If a staff member devotes their time to another program or facility, the time should reflect the amount of actual time spent at the specified facility; such as, if a full-time (thirty-two (32) hours weekly) psychiatrist spends fifty percent (50%) of her or his time consulting at an outpatient facility and fifty percent (50%) of time at the PHP, sixteen (16) hours or 0.5 FTE would be devoted to the PHP.

8.The treatment team leader shall assure that staff trained and experienced in the use of the modalities proposed in the person-centered (treatment) plan will participate in its development, implementation and review.

9.The treatment team leader is responsible for the implementation and review of the individualized person-centered plan, for the coordination of service delivery from other service providers and for the review of progress notes and discharge summary.

10.Combined programs. Facilities may be licensed for different types of programs at the same location; however, such facilities shall have clearly separate programs and shall meet all the staffing and other requirements for the projected program capacity of each program.

1.6.8Medication and Laboratory Services

A.The organization shall establish and implement policies and procedures that guide the safe and effective use of medication. These policies and procedures, at a minimum, shall address the following:

1.Ordering, procuring, storing, controlling, prescribing, preparing, dispensing, and documenting medications according to law and Regulation;

2.Storage, distribution and administration of controlled medications, including documentation and record keeping required by law;

3.Proper storage, distribution, and control of investigational medications and those used in clinical trials;

4.Qualification of "as needed" prescriptions or orders and times of dose administration;

5.Process and documentation of informed consent;

6.Control and distribution of sample drugs;

7.Distribution of medications to individuals at home visits, therapeutic outings, and at discharge;

8.Procurement, storage, control, and distribution of prepackaged medications obtained from an outside source when no on-site pharmacy service exists;

9.Process for documenting and reporting medication errors;

10.Protocols to follow when drug reactions and other emergencies related to the use of medications occur; and

11.Involuntary and administrative discharges of persons who are prescribed medications by the organization’s medical staff.

B.An individual who is receiving medication shall be seen at least quarterly by the prescribing physician or prescribing APRN, unless the physician or APRN documents that longer intervals are clinically appropriate.

1.For each meeting with the person served, the prescribing physician or prescribing APRN shall document the following in the person's record:

a.All medications he or she prescribes, renews, or discontinues at the meeting shall be recorded according to medical practice standards;

b.The reason for prescribing, continuing, or discontinuing a medication;

c.Any changes in medications or protocol;

d.The effectiveness of a continued medication;

e.Any signs or reports of side effects;

f.The treatment, if necessary, to address or prevent side effects;

g.Discussion with the person regarding risks and benefits of medications recommended or prescribed at the meeting;

h.Comments by the person served regarding his or her response to medication and, when indicated, the person's request to change or discontinue a medication; and

i.All other medications that the person is currently taking shall be reviewed and those that are new shall be documented, to ensure that the combination of medications is reasonable and safe.

C.Verbal orders may be given, received and transcribed only by qualified, licensed medical staff employed by the organization.

1.Each verbal order shall be recorded in writing, dated and identified by the names and credentials of the individuals who gave it and received it.

2.The person who gave the verbal order must sign it the next day he or she is working at the organization.

D.Medications shall not be used for the convenience of a program, as a reward, or for the behavioral control or punishment of persons served.

E.To minimize opportunities for error, medications shall be provided for persons served in the most ready-to-administer form possible in accordance with best practice guidelines of a particular program or service and all applicable statutes and regulations.

F.Medications provided to persons served shall be properly and safely labeled using a professional, standardized method.

G.Medications shall be administered as prescribed and only by persons authorized by state law and regulations to administer medications.

H.Medications shall be given only to the individuals for whom the medications are prescribed.

1.In Opioid Treatment Programs, responsible adults may be approved to pick-up the medication of a person served who, for medical reasons, is incapable of physically accessing the site of the program.

I.Medication that is administered by or at the organization shall be administered in accordance with the following provisions:

1.Persons served shall administer their own oral medications, unless contraindicated for therapeutic reasons.

2.As needed, persons served shall receive training in the self-administration of medications and this training shall be documented in the person's clinical record.

3.The assistance that non-medically licensed staff may provide to a person served shall be limited to reminding the person to take the medication and giving the person the opportunity to take the medication at the prescribed time.

4.For each dose of medication that is administered, the following information shall be documented:

a.The name, strength, and dose of the medication;

b.The time the medication was administered;

c.How the medication was administered, if other than orally; and

d.The signature of the person who administered the medication or such person’s ID when an automated dosing system is used.

5.Whenever a prescribed medication has not been administered or taken as ordered:

a.The prescribing physician or APRN shall be notified in accordance with standards of medical practice;

b.Notation of the missed medication and the reason for it shall be documented on the medication form.

J.Medications shall be administered only in accordance with a current medication order.

1.When a medication is administered at an organization site, a copy of the current medication order must be available at the site of the administration.

2.All medication orders shall be maintained in the individual’s treatment record.

K.The following information regarding medications is provided to persons served, to program staff, and, as appropriate, to family members:

1.The risks associated with each medication;

2.The intended benefits;

3.Potential side effects;

4.Contraindications;

5.Procedures to be taken to minimize risks and side-effects;

6.A description of the clinical signs and symptoms that indicate a medication may need to be discontinued;

7.The rationale for each medication;

8.Alternatives to the use of medications, as appropriate;

9.Alternative medications, as appropriate;

10.The proper storage of medications; and

11.The availability of financial supports and resources to assist the persons served with handling the costs associated with medications, when indicated.

L.Physicians and APRNs shall involve the person served in decisions related to his or her use of medications.

M.Prescribed medication shall be accounted for in accordance with local, State, and Federal laws. Any theft, loss, spillage, or error in administration of a medication shall be reported to the administrator of the organization, the Rhode Island Board of Pharmacy and the federal Drug Enforcement Administration, as applicable.

1.The Department shall be notified of any adverse event involving medications.

N.Organizations that provide substance use services shall have policies and procedures for drug testing. These policies shall be made available to the persons served and shall include the following:

1.Individuals may, at their own expense, have drug tests confirmed.

1.6.9Services for Persons with Co-occurring Mental Health and Substance Related Disorders

A.Organizations shall organize their services so that individuals with co-occurring disorders are identified as soon as possible and receive treatment in an integrated manner.

1.The organization shall develop and implement policies and procedures that ensure that individuals with co-occurring disorders receive timely services according to evidence-based practice standards.

2.The organization shall utilize guidelines from most current toolkits or resources from the SAMHSA, such as: Integrated Treatment for Co- Occurring Disorders Evidence-Based Practices (EBP) KIT and/or TIP 42: Substance Abuse Treatment for Persons With Co-Occurring Disorders as the source of the policies and procedures.

3.Policies and procedures should include at a minimum:

a.Screening for co-occurring disorders as part of the biopsychosocial assessment.

b.Education and training shall be provided for front line staff that includes, but is not limited to:

(1)Policies and procedures established by the organization to support individuals with co-occurring disorders;

(2)Identifying individuals with co-occurring disorders;

(3)Connecting individuals to the appropriate level of care; and

(4)Referral and active care coordination.

4.The following elements shall be in place in any specialized treatment program that serves individuals with co-occurring mental and substance-related disorders:

a.If services are provided by different practitioners, consultation among all of them must occur in a timely manner on a regular basis and documented in the record.

5.Staffing and Qualifications. The following qualifications are recommended for staff providing co-occurring clinical services:

a.Dual licensure in mental health and addictions; or

b.Certified Co-Occurring Disorder Professional-Diplomate or Certified Advanced Alcohol and Drug Counselor; or

c.Certified Co-Occurring Disorder Professional or Certified Alcohol and Drug Counselor.

d.Advanced Practice Registered Nurse as defined in § 1.3.1(A)(3) of this Part above.

6.Psychoeducational components of treatment shall address both disorders, and effects of each.

7.A psychiatrist, or Advanced Practice Registered Nurse as defined in § 1.3.1(A)(3) of this Part above, shall be available on-site or through consultation.

8.Prior to medication being prescribed, programs are required to:

a.Check the RIDOH Prescription Drug Monitoring Program, 216-RICR-20-20-3, in accordance with the provisions of R.I. Gen. Laws § 21-28-3.32 and obtain a toxicology screen; and

b.A pregnancy test must be given to all women of childbearing age and the effects of alcohol, psychiatric medications and recreational drugs on pregnancy and parenting shall be addressed.

9.Medication management and toxicology screenings shall be integrated into the person-centered plan unless otherwise indicated.

10.Interventions, goals, and objectives to treat both disorders shall be included in the person's individualized person-centered plan.

11.All interventions shall be consistent with and determined by the individual's stage of change and recovery from each disorder.

12.Group treatment shall be gender specific and designed to address both mental health and substance use issues.

13.Outreach and engagement activities shall be provided to family and significant others to promote understanding, involvement and support of the individual’s treatment and recovery.

1.6.10Support Services

A.Community Psychiatric Supportive Treatment/Case Management (CPST)

1.Organizations offering case management and/or community psychiatric supportive treatment for supported employment and substance use shall ensure that the following services are available and provided according to the specific needs and choices identified in the individualized person-centered treatment plan:

a.Assistance necessary for the person to attain the goals of his or her person-centered treatment plan for recovery.

b.Ongoing vocational and substance use assessments and review of supports and services to ensure the continuing availability of required services.

c.Substance use and vocational counseling, support, and treatment services identified in the person's individualized person-centered plan.

d.Assistance in further developing the competencies the person needs to increase his or her social support network and to minimize social isolation and withdrawal brought on by behavioral health issues.

e.Assistance in the development and implementation of a plan for accessing benefits and entitlements and for assuring income maintenance.

f.Assistance with securing and maintaining employment in an appropriate setting.

g.Assistance with engaging in personally meaningful activities, to include educational pursuits and volunteer work.

h.Assistance in developing and maintaining a tobacco, alcohol, and other drug-free lifestyle.

i.Assistance in developing the skills to self-manage his or her illness.

j.Assistance in accessing needed self-help and peer support services.

k.Assistance in learning specific skills and abilities related to effectively functioning in each major life area.

l.Assistance in locating and effectively utilizing all necessary community services in the medical, social, legal, and behavioral health areas and ensuring that all services are coordinated.

m.Development of a pre-crisis plan and assistance in crisis intervention and stabilization as needed.

n.Coordination with other providers to monitor the person's health status, medical conditions, and his or her medications and potential side effects.

o.Staff shall provide or help the individual access the services identified in the person's individualized person-centered treatment plan.

p.Families, significant others, and collaterals shall participate in case management services with the written authorization of the person served.

q.When the person is in need of, but avoiding treatment, outreach is conducted to encourage the person's participation in treatment.

r.All case management services are carried out in partnership with the person served.

2.Staffing

a.All staff providing case management services shall receive appropriate training on case management specific to supported employment and substance use.

b.Staff providing case management services shall have a minimum of an Associate’s Degree.

c.Clinical supervisors of case management or CPST services shall have, at a minimum, the qualifications listed in § 1.6 of this Part; or a Bachelor’s Degree in a relevant human service field and have a minimum of three (3) years full time experience providing behavioral healthcare services to the population served.

B.Clubhouse

1.A Clubhouse is organized to support people living with mental illness. During the course of their participation in a Clubhouse, members gain access to opportunities for friendships, family, employment, education and to the services and support they may individually need to continue their recovery.

a.Organizations with a Clubhouse shall be accredited by Clubhouse International.

b.Organizations seeking to start a Clubhouse shall apply for accreditation by Clubhouse International. http://clubhouse-intl.org/resources/accreditation/

c.Documentation for Clubhouse services shall follow requirements set forth by the Managed Care Organizations in collaboration with the Department.

1.6.11Specialty Services

A.Integrated Health Home (IHH)

1.Admission/Eligibility Criteria. Clients eligible for IHH services shall meet diagnostic and functional criteria established by the Department.

a.Diagnostic eligibility:

(1)Schizophrenia

(2)Schizoaffective Disorder

(3)Schizoid Personality Disorder

(4)Bipolar Disorder

(5)Major Depressive Disorder, recurrent

(6)Obsessive-Compulsive Disorder

(7)Borderline Personality Disorder

(8)Delusional Disorder, or

(9)Psychotic Disorder.

b.Functional Eligibility: Clients with a Daily Living Assessment of Functioning (DLA) score of > 3.0 – 5.0 are eligible for IHH services.

2.IHH Services – The description of services is in the IHH-ACT Manual. These are the core services to be provided:

a.Comprehensive Care Management;

b.Health Promotion;

c.Care Coordination – Chronic Condition Management and Population Management;

d.Comprehensive Transitional Care from inpatient to other settings, including appropriate follow-up;

e.Individual and Family Support services, which includes authorized representatives; and

f.Referral to Community and Social Support Services, if relevant.

3.Staffing requirements: IHH Baseline Staffing Model (per 200 clients):

4.Staff Composition Variances

a.There are ten (10) core positions that must be maintained. Flexibility is permitted for one (1) CPST Specialist and the Medical Assistant without prior approval, e.g., not filling these two (2) positions to add more nursing or increasing team salaries to increase retention.

b.Specific variance request for positions or required qualifications must be submitted to the Department.

5.Discharge Criteria

a.Discharge from the IHH occurs when clients and program staff mutually agree to the termination of services or transfer to a different level of care (ACT or GOP), or a different behavioral healthcare provider. This shall occur when clients:

(1)Have successfully reached individually established goals for discharge, and when the client and program staff mutually agree to the termination of services.

(2)DLA results indicate need for higher or lower level of care.

(3)Decline or refuse services and request discharge, despite the team’s best efforts to develop an acceptable treatment plan with the client.

B.RI Assertive Community Treatment (ACT)

1.The IHH-ACT manual serves as the best practice guidelines for implementation of ACT.

2.Admission/Eligibility Criteria. Clients eligible for ACT services shall meet diagnostic and functional criteria established by the Department.

a.Diagnostic eligibility:

(1)Schizophrenia

(2)Schizoaffective Disorder

(3)Schizoid Personality Disorder

(4)Bipolar Disorder

(5)Major Depressive Disorder, recurrent

(6)Obsessive-Compulsive Disorder

(7)Borderline Personality Disorder

(8)Delusional Disorder, or

(9)Psychotic Disorder.

b.Functional Eligibility: Clients with a Daily Living Assessment of Functioning (DLA) score of <3.0 are eligible for ACT services.

3.An ACT team is mobile and delivers the following core ACT services in the community (further description is in the IHH-ACT manual):

a.Service Coordination/Case Management;

b.Crisis Assessment and Intervention to be provided twenty-four (24) hours a day/seven (7) days a week/three hundred sixty-five (365) days a year;

c.Symptom Assessment and Management;

d.Medication Prescription, Administration, Monitoring and Documentation;

e.Co-Occurring Substance Use Disorder Services;

f.Work-Related Services;

g.Activities of Daily Living/ADL’s;

h.Social/Interpersonal Relationship and Leisure-Time Skill Training;

i.Peer Support Services;

j.Support services or direct assistance to ensure that clients obtain the basic necessities of daily life, including but not limited to:

(1)Medical and dental services;

(2)Safe, clean, affordable housing;

(3)Financial support and/or benefits counseling (e.g., SSI, SSDI, Food Stamps, Section 8, Home Energy Assistance);

(4)Social service;

(5)Transportation;

(6)Legal advocacy and representation;

(7)Education, Support, and Consultation to Clients’ Families and Other Major Supports.

4.Required Staffing Model per 100 clients:

5.Staff Composition Variances

Any requests for variance in staffing composition, whether position or qualifications, must be submitted in writing to the Department’s licensing unit for approval.

6.Discharge Criteria. Discharge from the ACT program can be based on the following criteria:

a.When clients and program staff mutually agree to the discharge;

b.Termination of services and transfer to a different level of care (IHH or GOP). This shall occur when clients:

(1)Have successfully reached individually established goals for discharge, and when the client and program staff mutually agree to the termination of services.

(2)DLA results indicate need for higher or lower level of care.

(3)Decline or refuse services and request discharge, despite the team’s best efforts to develop an acceptable treatment plan with the client.

(4)Do not participate in any services for a period of ninety (90) days, despite documented efforts to engage in treatment.

1.6.12Residential Services

A.Behavioral Health Stabilization Unit (BHSU). A BHSU shall provide the following services:

1.24-Hour Crisis Services: All staff shall be trained in risk assessment and crisis intervention services.

a.Upon arrival to the program, individuals are to receive a face-to-face initial triage review by a Licensed Independent Clinician or Practitioner to assess acuity, risk status, and client level of need for the interim period prior to a full assessment and development of an initial person-centered plan.

2.Hospital Step-Down Services: The unit must offer step-down services for clients who do not require inpatient hospitalization or detox but who require further stabilization before returning to the community.

3.Principal point of contact/accountability for each individual served.

4.Psychiatry Services

a.The unit must have available 24/7 a psychiatrist, or an A.P.R.N. as defined in § 1.3.1(A)(3) of this Part above, or other mid-level practitioner under the supervision of a psychiatrist, to respond to medication orders and any medical concerns.

b.The psychiatrist must also be scheduled to be on-site at the program for psychiatric assessments and medication reviews as required by the specific client mix at any given time.

5.Inpatient Psychiatric and Medical Admissions

a.The unit shall have a staff member meeting the requirements of the Mental Health Law, R.I. Gen. Laws § 40.1-5-7, on-site 24/7 to facilitate inpatient psychiatric admission from the unit site to an inpatient facility if required.

b.The unit shall also have an RN, or unit L.P.N. who has access to an RN or APRN, on-site 24/7 for medication services and to facilitate transfers for medical admissions.

6.Treatment for co-occurring mental health and substance related disorders shall meet the requirements of § 1.6.9 of this Part above.

7.Group and Individual Counseling: All individuals have access to participate in group and/or individual counseling as indicated by their treatment needs and person-centered plan.

8.Family Psychoeducation and Supportive Services

a.Services are available to family members to be involved in person-centered (treatment) planning and discharge meetings.

b.Education, information, and support is to be provided to family members.

9.Eligibility/Admission

a.Individuals must be eighteen (18) years of age or older and a resident of Rhode Island;

b.Individuals must have the capacity to safely stay in an unlocked facility;

c.Individuals must voluntarily agree to be admitted into the unit; and

d.Individuals must be medically stable.

(1)Disputes regarding medical clearance must be resolved at the physician level.

10.Exclusion Criteria. Clients exhibiting one (1) or more of the following may be excluded from the program at the discretion of the BHSU Program Director.

a.Acute substance intoxication;

b.Acute psychosis with evidence of impaired judgment or lack of impulse control as evidenced by psychiatric symptoms of command hallucinations or delusional thinking;

c.Acute mania impairing judgment and impulse control;

d.Gross functional impairment due to vegetative signs of depression such as remaining in bed all day, deterioration of cognitive ability and inability to perform self-care;

e.Assaultive ideation, evidenced by threats and likelihood to harm, kill or injure others;

f.Assaultive behaviors evidenced by threats and/or restraining orders combined with the likelihood to act on those behaviors;

g.Active self-injurious behaviors such as head banging, lacerating wrists, and threatening to elope from the unit;

h.Recent suicide attempt with a continued threat or plan to act on suicidal ideation; and

i.A determination that the client’s physical condition is too compromised for the unit to handle despite medical clearance at the point of the original evaluation must be made at the physician level and documented at the unit. All refusals based on this item must be reported to the Department within forty-eight (48) hours with full documentation being forwarded to the Department upon request.

11.Admission Procedures

a.The unit shall have the capacity to accept admissions 24/7.

b.The initial phone screening must be supervised by a Licensed Independent Clinician or Practitioner who shall have overall clinical responsibility for the screening process.

c.Upon completion of the phone screening, the unit must have the capacity to finalize the disposition with the referral source within sixty minutes.

d.The unit RN, or unit L.P.N. who has access to an RN or APRN, shall contact the referring emergency room to receive the nurse-to-nurse report prior to receiving the admission for emergency room referrals. The unit RN, or unit L.P.N. who has access to an RN or APRN, shall request copies of all pertinent medical information regarding the client including lab work, toxicology results, etc.

e.For community-based referrals or referrals not from an emergency room, all pertinent medical and clinical information requested by the unit RN, or unit L.P.N. who has access to an RN or APRN, shall be reviewed prior to admission.

f.Individuals shall receive a medical pre-screening or physical examination by the unit RN, or unit L.P.N. who has access to an RN or APRN, immediately upon arrival at the unit.

g.Once cleared by the unit RN, or unit L.P.N. who has access to an RN or APRN, individuals shall undergo a safety check including a trauma-informed search of the client and any belongings that the client brings with them at the time of admission unless clinically contraindicated.

(1)The search must be conducted by two (2) unit staff, be culturally sensitive, and include efforts to maximize the information given to the patient; maximize client choice wherever possible; assume a collaborative and respectful stance; and minimize coercion.

(2)A decision to bypass the safety search based on clinical grounds must be authorized by a Licensed Independent Clinician or Practitioner supervising the admission.

h.A Licensed Independent Clinician or Practitioner shall conduct an initial assessment within twenty-four (24) hours of admission and collaborate with the individual and treatment team to develop a person-centered (treatment) plan. This assessment should take into consideration any findings of the triage assessment and, if conducted upon the client’s arrival to the unit, may replace the triage assessment.

12.Discharge Planning

a.All individuals shall have a discharge plan, which shall be started within twenty-four (24) hours after admission;

b.Arranged follow up appointments are not to exceed forty-eight (48) hours for the first appointment from discharge;

c.A follow up medication appointment must be scheduled within fourteen (14) days;

d.Individuals referred to homeless shelters shall have scheduled follow up appointments with providers; and

e.Transportation issues are to be resolved and documented in the individual’s record describing how the individual shall attend the first appointment. (i.e., family member, self, public transit, staff to transport, etc.).

13.Discharge Criteria. Clients may be discharged if one (1) or more of the following criteria are met:

a.Treatment issues identified in the person-centered plan are resolved.

b.The crisis is stabilized and client can be referred to less intensive treatment.

c.A higher level of care is required.

d.The client exhibits physical aggression towards staff or other residents.

e.Involvement in criminal/antisocial activity while in the program, i.e., stealing, drug use, possession or distribution, threats or intimidating behavior towards others.

14.Length of Stay. Length of stay shall be individualized based on each individual’s service needs.

15.Staffing:

a.On-site coverage at all times 24/7 by nurses, counselors, and care managers, as well as access to a psychiatrist or other supervised prescriber available to respond within thirty (30) minutes.

(1)The program must have on-site scheduled psychiatry time as required by the client mix at any given time.

(2)The unit shall also have an RN, or unit L.P.N. who has access to an RN or APRN, on-site 24/7 for medication services and to facilitate transfers for medical admissions.

(3)Clinical supervisors of residential staff shall have, at a minimum, the qualifications defined in § 1.6(C)(1) of this Part above.

b.All staff providing direct services who are not Licensed Independent Clinicians or Practitioners shall receive clinical supervision on an ongoing basis, as specified in § 1.6 of this Part above.

16.Environment of Care

a.The maximum capacity that can be located in one (1) facility is sixteen (16) beds.

b.There should be no more than two (2) clients in one (1) room. Exceptions to this policy require prior approval of the Department and are limited to allowing one (1) room to have three (3) clients.

c.A program must have the capacity to supervise clients individually in a room if clinically necessary.

d.During all hours of operation in all residential programs, there are provisions for the availability of at least one (1) individual trained in basic First Aid and in cardiopulmonary resuscitation (CPR).

17.Required training for staff includes: safety drills, infection control policies, and risk management procedures.

B.Mental Health Psychiatric Rehabilitative Residences (MHPRR). Basic Mental Health Psychiatric Rehabilitative Residence (MHPRR) is a congregate licensed residential program with no more than sixteen (16) beds which provides twenty-four (24) hour staffing. This population includes individuals with refractory psychosis; dual diagnosis (individuals with developmental disabilities and mental health issues); addiction and mental health issues (co-occurring disorders), who cannot be treated in the community through outpatient supports. A physician must authorize all MHPRR services, based on the Psychiatric Rehabilitative Residence Individual Care Checklist.

1.The provider must provide staff on site coverage 24/7 as long as there are client(s) physically present in the residence.

a.Availability of 1:1 staffing when a resident is in crisis.

b.The minimum standard staffing pattern of direct care staff to residents approved by the Department is:

(1)Staffing can be based on the acuity of residents in the household. Preference is for one (1) direct care staff to eight (8) residents during periods when residents are awake (1:8).

(2)Direct care staff to resident ratio is at minimum one (1) to sixteen (16) between the hours of 11 p.m. and first shift (1:16).

(3)The Department reserves the right to require the BHO to have increased staffing levels based upon health and safety needs.

c.At least one (1) staff person trained in CPR.

2.The provider must abide by the Policy and Procedure for MHPRR (Group Home) priority list process.

3.The service elements offered by a residential program include the following based on each resident’s individualized recovery-focused, person-centered plan:

a.Mental health therapeutic and rehabilitative services for the resident to attain recovery;

b.Medication prescription, administration, education, cueing and monitoring;

c.Educational activities (appropriate to age and need);

d.Menu planning, meal preparation and nutrition education;

e.Skill training regarding health and hygiene;

f.Budgeting skills training and/or assistance;

g.Community and daily living skills training;

h.Community resource information and access;

i.Transportation;

j.Social skills training and assistance in developing natural social support networks;

k.Cultural/spiritual activities;

l.Counseling: Individual, group and family;

m.Social casework: Client-based advocacy; linkage to outside service providers; monitoring the use of outside services; individualized person-centered planning and skill teaching; income maintenance; and medical care assistance;

n.Limited physical assistance as required: Mobility; assistance with non-injectable medications; dressing; range-of-motion exercises; transportation; and household services; and

o.A comprehensive person-centered treatment plan shall be completed with each resident and, as appropriate, his or her family within thirty (30) days of admission. The treatment plans and treatment plan reviews of each resident of a MHPRR program must be signed by the psychiatrist who is treating the resident.

p.If a comprehensive medical history and physical examination have been completed within sixty (60) days before admission to the program, a durable, legible copy of this report may be used in the treatment record as the physical assessment. If not, a physical health assessment, including a medical history and physical examination, shall be completed by a qualified medical, licensed, independent practitioner, within thirty (30) days after admission to a residential program.

4.In addition, each residential program shall provide the following for its residents:

a.A homelike and comfortable setting;

b.Opportunities to participate in activities not provided within the residential setting;

c.Regular meetings between the residents and program personnel;

d.A daily schedule of activities;

e.Sleeping arrangements based on individual need for group support, privacy, or independence, as well as the individual's gender and age; and

f.Provisions for external smoking areas, quiet areas, and areas for personal visits.

5.Environment of Care

a.The maximum capacity that can be located in one facility is sixteen (16) beds.

b.There should be no more than two (2) clients in one (1) room. Exceptions to this policy require prior approval of the Department and are limited to allowing one (1) room to have three (3) clients.

C.Specialized Mental Health Psychiatric Rehabilitative Residence

1.Specialized Mental Health Psychiatric Rehabilitative Residence is a congregate licensed residential program with no more than sixteen (16) beds which provides twenty-four (24) hour staffing for populations with complex co-occurring conditions in which the clients receive a wide range of care management, co-occurring treatment of substance use and mental health, psychiatric rehabilitation and individual care services. A physician must authorize all MHPRR services, based on the Psychiatric Rehabilitative Residence Individual Care Checklist. Specialized services are meant to address populations that are difficult to maintain in traditional group home settings including: clients with co-occurring substance use and mental health disorders, those stepping down from Eleanor Slater Hospital, clients who are self-injurious or have personality disorders, and transitional-aged youth.

2.The provider must follow the policies, procedures, protocols as described in Basic MHPRR, § 1.6.12(B) of this Part above.

D.Supportive Mental Health Psychiatric Rehabilitative Residence Apartments (MHPRR-A)

1.Supportive Mental Health Psychiatric Rehabilitative Residence Apartment Is a licensed residential program with no more than sixteen (16) beds which provides twenty-four (24) hour staffing for clients to receive a wide range of care management, treatment, psychiatric rehabilitation and individual care services in an apartment setting. A physician must authorize all MHPRR services, based on the Psychiatric Rehabilitative Residence Individual Care Checklist.

2.The Provider must follow the policies, procedures, protocols as described in Basic MHPRR, § 1.6.12(B) of this Part above.

a.In all cases, response time to any individual unit (e.g., bedroom or apartment) shall be no greater than five (5) minutes.

3.Clients eligible for this program do not require constant staff supervision but do require availability of staff to respond quickly to meet needs.

4.Clinical Supervisors of residential staff shall have at a minimum, the qualifications defined in § 1.6(C)(1) of this Part above. Direct service staff in residential programs shall have the qualifications relevant to the service they are providing.

E.On-Site Supportive Psychiatric Rehabilitative Apartments. On-site Supportive Psychiatric Rehabilitative Apartments are site-specific, independent community apartment settings which serve as a step-down or alternative level of care to group home setting for individuals who do not require group home level of care, but need more than traditional Integrated Health Home services to maintain placement in the community.

1.To support clients in the community, the CMHC shall provide an average of one (1) hour of community intervention services per person per day.

2.Clients receive a wide range of care management, treatment, psychiatric rehabilitation and individual care services.

F.Enhanced Mental Health Psychiatric Rehabilitative Residence. The Department is authorized to issue a license for an Enhanced Mental Health Psychiatric Rehabilitative Residence (E-MHPRR) program upon sufficient verification that the program meets the criteria for BHO licensure and is a congregate licensed residential program with no more than nine (9) beds that provides 24/7 services to individuals who meet the admission and eligibility criteria in § 1.6.12(F)(1) of this Part below.

1.Admission and eligibility criteria for E-MHPRR: To be admitted to and eligible for E-MHPRR placement and services, a client shall meet the minimum criteria for admission to and eligibility for Basic MHPRR placement and services; shall be clinically determined to need placement in a more intensive environment than that provided by Basic or Specialized MHPRR; and shall meet at least one of the following conditions:

a.A history of being incarcerated, or institutionalized, or in a controlled environment of any kind, including but not limited to admission to the Eleanor Slater Hospital, Rhode Island State Psychiatric Hospital or the Adult Correctional Institutions;

b.A history of exhibiting dangerous behavior to self or others and/or a history of violence that requires close supervision and a highly structured setting to ensure the safety of the individual and/or the community;

c.Requires assistance to complete daily living and self-care tasks;

d.A co-occurring physical health problem, developmental disability, traumatic brain injury and/or substance use disorder that requires more intensive treatment, monitoring, and support than can be provided in a community setting less intensive than an E-MHPRR;

e.Received involuntary care and treatment pursuant to a Court Order for Inpatient or Outpatient Treatment and has demonstrated non-compliance with such an order; and/or

f.A history of repeated psychiatric hospitalization(s).

2.E-MHPRRs shall ensure that clients receive a wide range of care management, treatment, psychiatric rehabilitation, and individual care services in a congregate-care community setting.

3.The requirements, policies, procedures and protocols for Basic MHPRR, as described in § 1.6.12(B) of this Part above, apply to all E-MHPRRs except that in the event of a conflict between Basic MHPRR and E-MHPRR regulations, the provisions that are specific to E-MHPRR shall prevail as they relate to E-MHPRR.

4.Once the E-MHPRR admits a client, as a condition of the E-MHPRR to continue receiving E-MHPRR level of funding as their license allows, the E-MHPRR shall not discharge a client until the Department approves of such discharge and has identified a safe alternative placement.  Any proposed discharge plan completed by an E-MHPRR shall be submitted to BHDDH within three business days of completion.  BHDDH shall either approve/modify/reject in writing the proposed discharge plan within three business days following receipt of the proposed plan. The Department shall provide such written notice to the provider, who shall then provide a copy of the notice to the client or, if applicable, legal guardian.  If the Department denies an E-MHPRR’s request to discharge a client, the E-MHPRR and/or the client shall have the right to request an administrative hearing per EOHHS regulations.  The BHDDH decision will be stayed automatically until either the appeal hearing is concluded or the filing parties have resolved the appeal by agreement.  Nothing in this section shall prevent an E-MHPRR from sending a client to the hospital for any emergency or other temporary reason, but the E-MHPRR shall hold the bed open for the client until the Department approves the closing of the bed.

5.E-MHPRR Provider Requirements. In addition to the requirements for Basic MHPRRs, each E-MHPRR provider shall comply with the following:

a.Only Basic, Specialized or Enhanced MHPRRs that are in good standing with BHDDH and in compliance with all applicable MHPRR regulations contained in § 1.6.12 of this Part above, and other all state and federal regulations, may apply for and be issued an E-MHPRR license. An applicant for E-MHPRR licensure shall meet the criteria, and be approved by the Department, to provide services as a facility as defined in R.I. Gen. Laws § 40.1-5-2(6).

b.The Department’s licensing unit shall conduct health and safety audits every two (2) years, or more frequently if needed.

c.The E-MHPRR license shall expire two years from the date of issuance. An E-MHPRR provider must apply for license renewal in the period between four and two months prior to the expiration of its current E-MHPRR license.

d.The Department may, after the licensee’s opportunity for an administrative evidentiary hearing, suspend or revoke an E-MHPRR license due to repeated failure to cooperate with the Department to remedy identified statutory or regulatory violations or for permitting an unsafe environment for clients. The Department, after the licensee’s opportunity for an administrative evidentiary hearing, may also place an E-MHPRR license under provisional status with a plan of correction that must be followed as a condition of continued licensure. To the extent this paragraph might conflict with the provisions of R.I. Gen. Laws § 42-35-14(c), the statute shall prevail.

e.Discharges. No client shall be discharged to a lower level of care without prior written approval from the Department.

f.E-MHPRR Staffing / Supervision / Client Capacity

(1)The E-MHPRR program shall provide a minimum of one (1) staff member per shift who shall remain on-site at all times, even when there is no client present in the living quarters. In addition, each E-MHPRR must adhere to these staffing, bed capacity and/or supervision requirements:

(AA)Maximum of nine (9) clients.

(BB)24/7 staffing plan submitted to and approved by the Department based on a core staffing pattern of 3-3-2, which must be implemented as follows:

(i)First shift: three (3) direct care staff

(ii)Second shift: three (3) direct care staff

(iii)Third shift (overnight): two (2) awake direct care staff. The third shift may be staffed entirely by direct care staff who shall have immediate access to an on-call supervisor.

(CC)Each E-MHPRR is required to have a full time Residential Manager, Registered Nurse, and Licensed Occupational Therapist. These three required staff are in addition to, and not included in, the 3-3-2 daily core staffing count required by this section.

(DD)The Residential Manager shall meet at least one of the following qualifications:

(i)Licensed Independent Practitioner;

(ii)Licensed Chemical Dependency Clinical Supervisor with a Bachelor’s Degree;

(iii)Licensed Chemical Dependency Professional with a Bachelor’s Degree who as completed a Department-approved course in clinical supervision;

(iv)Clinician with relevant Master’s Degree and license and at least two (2) years full time experience providing relevant behavioral health services;

(v)Registered nurse with ANCC certification as a Psychiatric and Mental Health Nurse or at least two (2) years full time experience providing relevant behavioral health services; and/or

(vi)A combination of education and experience that is deemed by the E-MHPRR program to be a substantial equivalent to those qualifications in §§ 1.6.12(F)(5)(f)(1)(DD)(i) to 1.6.12(F)(5)(f)(1)(DD)(v) of this Part herein and has received written approval from the Department of the Residential Manager’s qualifications.

(EE)The Registered Nurse and Licensed Occupational Therapist must each be licensed by the Rhode Island Department of Health or otherwise have permission to practice in Rhode Island.

(FF)Direct care staff shall have at a minimum the following qualifications relevant to the service they are providing:

(i)A license as a Registered Nurse; or

(ii)An Associate’s Degree in a human services field; or

(iii)A combination of education and prior work or life experience that the E-MHPRR program determines is comparable and that has been approved in writing by the Department.

(GG)If the E-MHPRR has a client with a substance use disorder, either the Residential Manager or Registered Nurse, or any one of the direct care staff, must have experience in caring for clients with substance use disorder.

(HH)All E-MHPRR staff must pass a criminal background check.

(II)Any deviation from the staffing and/or scheduling requirements in these regulations must have clinical and financial justification that is approved in writing by the Department in advance.

(JJ)The licensed occupational therapist will provide services to clients that include but are not limited to:

(i)The evaluation and provision of treatment in consultation with the clients, family, or other appropriate persons;

(ii)Interventions directed toward developing, improving, sustaining, or restoring daily living skills, including self-care skills and activities that involve interactions with others and the environment, work readiness or work performance, play skills or leisure capacities or educational performance skills;

(iii)Developing, improving, sustaining, or restoring sensorimotor, oral-motor, perceptual or neuromuscular functioning; or emotional, motivational, cognitive, or psychosocial components of performance; and

(iv)Education of the individual, family, or other appropriate persons in carrying out appropriate interventions.

(v)Evaluation of need and the design, development, adaptation, application, or training in the use of assistive technology devices;

(vi)Design, fabrication or application of rehabilitative technology, such as selected orthotic devices; training in the functional use of orthotic or prosthetic devices; the application of therapeutic activities, modalities, or exercise as an adjunct to or in preparation for functional performance; the application of ergonomic principles;

(vii)Adaptation of environments and processes to enhance daily living skills; and/or

(viii)Promotion of health and wellness.

(KK)The E-MHPRR program shall offer the service elements required by § 1.6.12(B)(3) of this Part above. Additionally, the E-MHPRR program is required, if specified in a client’s treatment plan, to provide or arrange for the following services which are not included in the Medicaid per-diem rate:

(i)Physician and psychiatric medication prescribing and monitoring services;

(ii)Nursing activities (including, but not limited to medication administration, counseling, diet management) provided by a nurse who is not on the staff of any MHPRR for which Medicaid reimbursement is already being claimed;

(iii)Non-residence-based services provided to the client such as psychiatric rehabilitation or CMHC-based counseling and therapy, subject to any limitations on those services not provided by staff of any MHPRR for which Medicaid reimbursement is being claimed;

(iv)Community Psychiatric Support Treatment (CPST) interventions for Substance Use and Supported Employment on a unit-of-service basis;

(v)Assertive Community Treatment (ACT) pre-approved by the Department for which Medicaid is available on a case-by-case basis;

(vi)Applied Behavioral Analysis (ABA);

(vii)Additional rehabilitative, support, and supervision services, including but not limited to evidence-based psychotherapy approaches, such as Dialectical Behavioral Therapy (DBT);

(viii)Referral for neuropsychiatric testing and evaluation, housing, LTSS services, other social needs, benefits, and programs, and assistance for navigating the supportive housing system or exploration and navigation of other housing options;

(ix)Organized supported consumer-run or consumer-driven activities such as clubhouses;

(x)Behavioral health therapeutic and rehabilitative services recommended by a physician for the resident to attain improvement;

(xi)Individual, group and family counseling;

(xii)Medication prescription, administration, education, cueing and monitoring;

(xiii)Behavioral Management, including any intervention or treatment that utilizes positive reinforcement and/or restrictions to help an individual receiving services to restore and/or strengthen recovery-oriented behaviors and to address and correct targeted behaviors;

(xiv)Nutrition education and counseling;

(xv)Skill training regarding health and hygiene;

(xvi)Budgeting skills training and/or assistance; and/or

(xvii)Crisis intervention, including short-term emergency mental health services available 24/7 that meet all the applicable requirements of Rhode Island rules and regulations of behavioral health organizations.

(xviii)Community and daily living skills training

(xix)Community resource information and access

(xx)Social skills training and assistance in developing natural social support networks

g.Pursuant to § 1.6.12(B)(1) of this Part above, one-to-one (1:1) staffing may be provided to avert a crisis or when a client is in crisis. The Department reserves the right to require the E-MHPRR to have increased staffing levels based upon health and safety needs. Clients may receive one-to-one (1:1) supervision from direct care staff and/or Certified Nursing Assistants (CNAs) to address, reduce or redirect any of the following high-risk behaviors:

(1)Substance use

(2)Potential for fire setting

(3)Perpetrator behavior

(4)Self-Injurious behavior(s)

(5)Medical or dietary restrictions

(6)Smoking in inappropriate areas

(7)Stealing or destroying property; and/or

(8)Aggression towards other clients or staff.

h.Culturally and Linguistically Appropriate Services

(1)The E-MHPRR shall:

(AA)Provide services to persons for whom English is not their primary language;

(BB)Provide qualified sign-language interpreters and other accommodations that are necessary to communicate effectively with persons who are deaf or hard of hearing; and

(CC)Work effectively to be respectful and responsive to the health beliefs and practices of diverse population groups.

i.Clients placed in an E-MHPRR due to complex medical needs must be offered, as needed, rehabilitative services, support, supervision services, medical monitoring, personal care assistance and/or specialized environmental modifications, including one-to-one (1:1) supervision.

j.Clients placed in an E-MHPRR due to intensive behavioral needs -- including clients with non-acute suicidality with a high risk of self-harm who have been determined to no longer be appropriate for an inpatient setting; clients with fire-setting behavior or history; and clients with convictions for or history of sexual offenses -- shall be provided with increased therapeutic interventions and supervision, including one-to-one support that focuses on identifying triggers and precipitant behaviors, coping skills, improving communication skills, and addressing issues around substance use if any.

k.Clients placed in an E-MHPRR due to a pending criminal charge(s) and who have been recommended as or found to be incompetent to stand trial, or who are at risk of decompensating to the point of incompetency to stand trial and who do not meet the criteria for hospital level of care shall be provided support for competency restoration and community integration while the E-MHPRR manages the risk that the client presents to public safety. The E-MHPRR must maintain such a client in a highly structured environment while the client awaits the resolution of the criminal charge(s).

l.The E-MHPRR program shall maintain unexpired Naloxone (Narcan) in sufficient quantity to administer life-saving treatment for anyone suspected of experiencing an opioid overdose. The E-MHPRR program shall provide training on the administration of Naloxone (Narcan) to all of its staff twice per year and must document and maintain attendance records of such trainings.

G.Residential Programs for Substance Use Disorders

1.The provider must utilize the ASAM Patient Placement Criteria https://www.asam.org/resources/asam-criteria to determine the appropriate level of residential care and be able to provide the array of services based on the appropriate placement level, including medication assisted treatment options.

a.Biopsychosocial assessments must be completed forty-eight (48) hours after admission.

b.Justification for the selection of the ASAM level of care must be validated within the diagnostic summary of the assessment.

c.The individual’s treatment team must complete a person-centered (treatment) plan. In addition, the following requirements related to the person-centered (treatment) plan must be met:

(1)A review of the person-centered plan for each person served in a residential treatment program shall occur at least once a month and documented in the treatment file.

2.The program provides active treatment seven (7) days a week based on the needs of persons served in each of the following areas:

a.Individual counseling/therapy;

b.Group counseling/therapy;

c.Family/support system counseling/therapy;

d.Relapse prevention/crisis preparation work.

3.The residential treatment program shall provide a suitable service array for the ASAM level of care as described below. The minimum requirements for each level are described below.

a.Level 3.5 Clinically Managed, High-Intensity Residential provides a structured, therapeutic community environment focused on addressing life skills, reintegration into the community, employment, education, and recovery.

(1)The organization must have the ability to provide an appropriate service array for clients meeting 3.5 ASAM level criteria.

(2)The service array shall consist of at least twelve (12) clinical services per week including individual, group and family counseling based on the client’s need.

b.Level 3.3 Short-Term, Clinically Managed, Medium-Intensity is a non- acute residential level of care that focuses on stabilization, integration, employment, education, and recovery. A component of treatment may focus on habilitation due to discharge from institutional level of care.

(1)The organization must have the ability to provide an appropriate service array for clients meeting 3.3 ASAM level criteria.

(2)The service array shall provide at least twelve (12) clinical services per week including individual, group and family counseling, based on the client’s need.

c.Level 3.1 Clinically Managed, Low-Intensity Residential Services

(1)The organization must have the ability to provide an appropriate service array for clients meeting 3.1 ASAM level criteria.

(2)The service array shall include at least five (5) clinical services (one (1) hour per week of clinical treatment and four (4) group and/or family sessions) per week including individual, group and family, based on the client’s need.

4.Staffing

a.Services are provided by a coordinated treatment team that includes a qualified behavioral health practitioner who coordinates the plan of the person serviced at a minimum.

b.All non-licensed direct-care staff are required to be moving toward a certification as a Certified Advanced Alcohol and Drug Counselor (CAADC) Certified Alcohol and Drug Counselor (CADC) or at the least as a Provisional Alcohol and Drug Counselor (PADC).

c.The program provides on-site personnel support 7 days a week with assigned and trained residential personnel to meet the following staff/consumer engagement ratios:

(1)The minimum standard staffing pattern of direct care staff to residents approved by the Department is:

(AA)One (1) direct care staff to eight (8) residents during periods when residents are awake (1:8). Staffing can be increased based on the acuity of the residents in the household

(BB)Direct care staff to resident ratio is at minimum one (1) to twenty (20) overnight (1:20).

(2)The provider may submit an interim staffing plan to the Department in the event the direct care staff to resident ratio is not met.

5.Organizations that provide substance use services shall have policies and procedures for urine drug testing (UDT). These policies shall be made available to the persons served and shall include the following provision:

a.Individuals may, at their own expense, have drug tests confirmed.

b.UDT needs to be clinically appropriate and trauma informed.

c.Random UDT shall be conducted on a routine basis.

6.Residential Programs that Serve Minors. Residential programs that service minors, in addition to the licensing standards listed above, must follow these additional standards.

a.Substance Abuse residential programs that serve minors shall provide staffing that ensures constant adult supervision at all times, including the following:

(1)The minimum standard staffing pattern of direct care staff to residents approved by the Department is:

(AA)One (1) direct care staff to eight (8) residents during periods when residents are awake (1:8). Staffing can be increased based on the acuity of the residents in the household

(BB)Direct care staff to resident ratio is at minimum one (1) to twenty (20) overnight (1:20).

(2)The provider may submit an interim staffing plan to the Department in the event the direct care staff to resident ratio is not met.

b.Residential programs that serve minors for more than thirty (30) days, shall provide, or arrange through school districts, an academic and physical education program for each minor within fourteen (14) days of his or her admission.

c.Residential facilities and treatment services for minors shall be separate from those provided for the adult population, except for the following minors:

(1)Pregnant minors

(2)Children of adults undergoing residential treatment.

d.Parental consent shall be required for all minors treated in substance abuse residential programs, except as otherwise provided by R.I. Gen. Laws § 14-5-4.

e.Programs providing services to minors shall comply with R.I. Gen. Laws § 11-9-13 pertaining to the purchase, sale, or delivery of tobacco products to persons under the age of eighteen (18).

f.Residential programs shall have a written policy regarding staff responsibilities when a minor is absent without permission. The policy shall include:

(1)Immediate notification of the parent(s) or legal guardian(s);

(2)Immediate notification of the proper legal authorities; and

(3)Documentation in the minor's treatment record of the elopement and of the appropriate notifications as they were completed.

1.6.13Detoxification Programs

A.Medical Detoxification Programs. Medical detoxification programs provide services related to medical management of the physiological and psychological symptoms of withdrawal from alcohol and/or another drug of misuse that is provided in a hospital or free standing, appropriately equipped setting.

1.Medical detoxification programs shall develop and implement policies and procedures that include, but are not limited to, the following:

a.The program shall have established written admission, continuing care, and discharge criteria.

b.The program shall have a written agreement with a hospital for transferring individuals in cases of medical emergencies.

c.There shall be a written physician-approved detoxification protocol or standing detoxification orders for each substance for which the program provides a detoxification service.

d.There shall be a written policy to address individuals leaving detoxification treatment against the advice of staff. The policy shall include:

(1)The person served shall be informed, both verbally and in writing, of the risks of leaving treatment prematurely;

(2)The individual shall be provided a list of possible withdrawal danger signs particular to his or her detoxification protocol;

(3)The person shall sign an "Against Medical Advice" form; and

(4)The signature shall be witnessed by a staff member.

(AA)If the client refuses to sign the "Against Medical Advice" form the organization staff shall document this on the form and sign the form.

2.Staffing shall provide twenty-four (24) hour, awake, on-site care and the program shall be open seven (7) days a week. Adequate staffing levels shall be maintained to admit, treat, and discharge individuals.

3.A complete medical history and physical examination shall be performed and documented on each individual within twenty-four (24) hours of admission.

4.A biopsychosocial assessment shall be completed and documented within seventy-two (72) hours of admission. Assessments may be reviewed, revised, and updated if the person is readmitted within one (1) year of the first admission.

5.An initial individualized person-centered plan addressing short-term detoxification goals shall be completed within seventy-two (72) hours of admission.

6.To ensure that the appropriate rehabilitative services are provided, the person served shall be assigned a primary counselor who shall follow the person's progress during detoxification.

7.Staff shall provide a planned regimen of twenty-four (24) hour professionally directed evaluation, care, and treatment services, to include the administration of prescribed medications by medical staff.

8.Persons served shall remain in a medical detoxification program for the period of time determined and documented as medically necessary by the program's physician.

9.Medical specialty, psychological, psychiatric, laboratory, and toxicology services shall be available within the program or through consultation or referral.

10.The program shall have on staff a supervising physician who has responsibility for oversight of all medical and pharmaceutical procedures.

11.The program shall have a designated registered nurse, with at least two (2) years fulltime experience in substance use treatment, or a CARN or CARN-AP, who shall be responsible for the general supervision of the nursing staff.

12.There shall be no less than one (1) registered nurse, or one (1) L.P.N. under the supervision of an RN, APRN (as defined in § 1.3.1(A)(3) of this Part above) or physician, per twenty-five (25) individuals being treated in a detoxification program. One (1) registered nurse – or one (1) L.P.N. under the supervision of an RN, APRN (as defined in § 1.3.1(A)(3) of this Part above) or physician – shall be on-site in the program at all times.

13.All counseling staff in the program shall be licensed chemical dependency professionals or shall be working toward licensure.

14.All nurses shall receive annual training in the medical management and supervision of detoxification from alcohol and other drugs. Documentation of such training shall be retained on file and be available for review.

15.The program shall conduct training and education for clinical and support staff. The training shall include, but not be limited to, the following:

a.Appropriate screening protocols and procedures;

b.Use of ASAM-PPC placement and treatment criteria;

c.Medical aspects of substance use, abuse, and withdrawal, especially as it pertains to the acute care setting;

d.Pharmacology in the detoxification program setting;

e.Discharge or continuum of care;

f.Early interventions for individuals at high risk during intoxication and withdrawal;

g.Non-violent crisis intervention; and

h.Management of the individual with suicidal ideation.

B.Outpatient Detoxification. Outpatient detoxification programs are the medical management, provided through outpatient services, of the physiological and psychological symptoms of withdrawal from alcohol and/or another drug of abuse, to ensure that medical or psychological complications do not develop. This section applies to all outpatient detoxification services except opioid maintenance/detoxification programs.

1.Each Outpatient Detoxification Program shall have written policies and procedures that include, but are not limited to, the following:

a.Individuals may be admitted to the program after the program physician conducts a complete physical examination that includes the required blood work and determines the individual to be:

(1)Physiologically in need of detoxification from alcohol or other drugs according to current ASAM-PPC criteria;

(2)At minimal risk for severe withdrawal syndrome.

b.A biopsychosocial assessment shall be completed and documented within seventy-two (72) hours of an individual’s admission to the program.

c.An initial person-centered plan addressing short-term detoxification goals shall be completed within seventy-two (72) hours of an individual’s admission.

d.The program shall have a written policy that documents an affiliation agreement with a community hospital to provide support services in case of a medical emergency related to detoxification.

e.Each outpatient detoxification program shall establish medical protocols, under the direction and with the approval of the program’s medical director, that shall include, but not be limited to, the following:

(1)Written detoxification protocols shall be established for each substance for which the program provides detoxification services.

(2)Medical protocols shall be implemented by a program physician or other authorized, licensed, medical staff.

(3)All medication shall be administered and dispensed according to individualized person-centered plans and medical protocols.

f.To ensure that the appropriate rehabilitative services are provided, the person served shall be assigned a primary counselor who shall follow the client's progress during detoxification. Such assignment shall be documented in the treatment record.

g.All medical, nursing, and counseling staff shall have training in, and have the ability to recognize, medical conditions associated with trauma, illness, and detoxification.

h.Each program shall have a designated medical director who has the responsibility for supervising all medical services and who is licensed to practice medicine in good standing in Rhode Island.

i.A registered nurse – or one (1) L.P.N. under the supervision of an RN, APRN (as defined in § 1.3.1(A)(3) of this Part above) or physician – shall be on site to provide services to individuals who are receiving outpatient detoxification services.

1.6.14Medication Assisted Treatment

A.Opioid Treatment Program (OTP)

1.This section applies to all opioid treatment and maintenance programs that administer or dispense methadone and other approved medication as maintenance or detoxification treatment to a person dependent on opioids. Programs shall reference the State Methadone Treatment Guidelines/TIP1 (Treatment Improvement Protocol Series/CSAT) and Buprenorphine Treatment Guidelines. Programs must also comply with the Pharmacy Statute, R.I. Gen. Laws Chapter 5-19.1, Uniform Controlled Substance Act, R.I. Gen. Laws Chapter 21-28, Drug Abuse Control Act, R.I. Gen. Laws Chapter 21-28.2, and Drug Abuse Reporting System Act, R.I. Gen. Laws Chapter 21-28.3.

2.OTPs shall use only opioid replacement treatment medications that are approved by the Food and Drug Administration, and the federal Food, Drugs, and Cosmetic Act (21 U.S.C. § 355) for use in the treatment of opioid use disorder.

3.All federal laws and regulations that pertain to the handling of any opioid replacement medication shall apply in these regulations.

4.All OTPs shall be open seven (7) days per week – or have the capacity to arrange for dispensing medication(s) to clients on Sundays and holidays should the program be closed or have reduced hours. The State Opioid Treatment Authority must be notified by email in cases of emergency closing due to weather-related or other emergent conditions.

5.Staffing

a.The program director of the OTP, or his or her designee, shall assign the treatment of persons served according to best practice standards and ensure appropriate rehabilitative and nursing services are provided.

b.Each OTP shall have a designated medical director who has the responsibility for administering all medical services. He or she shall:

(1)Be licensed to practice medicine in Rhode Island;

(2)Have RIDOH Controlled Substance Registration; and

(3)Be DEA registered.

c.The medical director or other authorized OTP physician shall assume the following responsibilities:

(1)Evaluate each person to determine and to document his or her current physiological opioid addiction;

(2)Conduct the required physical evaluation and document the medical history for each person served;

(3)Ensure that the appropriate laboratory studies have been performed; and

(4)Document and sign or counter-sign all medical orders.

d.Clinical staff caseloads should not exceed an average staff to client ratio of 1:60.

(1)The provider shall submit an interim staffing plan to the Department in the event the clinical staff to client ratio is not met.

6.Each OTP shall have written policies and procedures describing admission requirements, to include:

a.Documentation of a one (1) year history of opioid addiction for persons eighteen (18) years of age and over. Exceptions may be granted by the program physician for applicants who have been released from prison or from chronic care facilities, are HIV positive, are pregnant, and/or have previously been treated for opioid addiction.

b.The OTP must verify a minimum of two (2) prior short-term detoxifications or drug free treatment episodes in a twelve (12) month period for individuals under eighteen (18) years of age and must obtain parental or legal guardian's consent.

c.No person under sixteen (16) years of age may be admitted to an OTP unless the program has received prior written approval of the admission from the State Opioid Treatment Authority.

d.All women of childbearing potential shall be tested for pregnancy:

(1)Before admission to an OTP;

(2)Before any detoxification or medically supervised withdrawal is initiated; and

(3)Medical staff shall document test results in the woman’s treatment record.

e.A physical health assessment, including a medical history and physical examination, shall be completed within the first twenty-four (24) hours of a person’s admission to the program and shall include:

(1)Possible infectious diseases, including human immunodeficiency virus (HIV), tuberculosis (TB), viral hepatitis and sexually transmitted diseases (including syphilis);

(2)Pulmonary, liver and cardiac abnormalities;

(3)Dermatological and neurological consequences of addiction; and

(4)Possible concurrent surgical problems.

7.Programs are required to check the RIDOH Prescription Drug Monitoring Program 216-RICR-20-20-3 in accordance with R.I. Gen. Laws § 21-28-3.32 and for each new admission and at each annual physical examination of the individual.

8.Prior to an individual's admission to an OTP, the following information shall be entered into the Department's BHOLD system:

a.The individual's initials (first, middle, last);

b.Date of birth;

c.Last four (4) digits of the person’s Social Security number;

d.Anticipated date of admission; and

e.Gender.

9.If the BHOLD system is inoperable, prior to admitting any individual, the OTP shall contact each of the other OTPs in Rhode Island to verify that the individual is not receiving services from another OTP.

a.The documentation of these contacts shall be noted in the individual's treatment record and the OTP shall submit the individual’s data to the BHOLD system as soon as it is operable.

10.Person-Centered (Treatment) Planning

a.An initial person-centered plan shall be completed within the ninety (90) days of each person's admission to the OTP reflecting patient/client goals and method for measuring these goals that meets criteria set out in Department service guidelines for person-centered (treatment) planning.

b.Person-centered plans shall be reviewed, revised, and updated every six (6) months.

c.A new person-centered plan shall be developed at least once every twelve (12) months.

d.The type and number of counseling sessions received by each individual in the program shall be based on a clinical assessment of the person’s service needs and goals as formulated in the person’s plan.

e.Rehabilitative counseling services (individual, group, and family) shall be provided by OTP staff and shall be consistent with the individual's person- centered plan. A minimum of one (1) session per month is required.

11.Medical Services and Care Coordination

a.An OTP must maintain a Diversion Control Plan to ensure quality care while minimizing the diversion of an opioid replacement medication from treatment to illicit use.

b.The following shall be confirmed and documented prior to the initiation of take-home privileges:

(1)The individual shall receive instructions regarding safety;

(2)Such instructions shall include but not be limited to, child safety measures and the storage of medications; and

(3)The individual shall obtain an agency approved locked box for storage of take-home medication.

c.Each OTP is required to have a Disaster Response policy for each location which should include a coordination of emergency care plan with other OTPs and other necessary facilities to ensure medication delivery in the event of an emergency.

d.The OTP shall have a written policy describing procedures to be implemented when a person served needs "Courtesy Dosing" while enrolled in an approved treatment program.

(1)Arrangements for “Courtesy Dosing” shall be made in advance, consistent with federal standards.

e.Each OTP shall have policies and procedures regarding the discontinuation of any opioid replacement medication that include, at a minimum, the following:

(1)The OTP physician shall approve all requests for voluntary withdrawal from an opioid replacement medication.

(2)All withdrawal schedules shall be determined on an individual basis and each individual’s progress shall be monitored by OTP staff.

(3)Withdrawal schedules shall adhere to proper medical guidelines without consideration of financial concerns.

f.Medical care, including referral for necessary medical service, and evaluation and follow-up of patient complaints must be compatible with current and prevailing community standards of medical practice.

g.All patients must receive a medical examination at least annually.

h.All other medical procedures performed at the time of admission shall be reviewed by the medical staff on an annual basis, and all clinically indicated tests and procedures shall be repeated.

i.Medical staff shall record the results of this annual medical examination and review of patient medical records in each patient's record.

j.When an individual is transferred to another program within the organization, the individual's treatment record with completed up-to-date documentation shall be transferred to the receiving program.

12.The OTP shall have written policies and procedures regarding drug testing.

a.All drug testing screen results shall be documented in the person's treatment record.

b.Required drug tests include screening for the following substances: opiates, methadone, cocaine, benzodiazepines, and substances prevalent in the community as determined by the OTP and the Department. Any additional drug tests ordered at the discretion of the program shall be specific to the individual's treatment needs.

13.The OTP drug testing policy and procedure shall be approved by the designated State Opioid Treatment Authority.

14.Random drug testing shall be conducted as clinically indicated, but no less than eight (8) times/year while an individual remains in treatment.

15.Specimens shall be collected in a manner that minimizes falsification and shall be stored in a secure place to avoid substitution.

a.Testing facilities shall be licensed by RIDOH pursuant to R.I. Gen. Laws Chapter 23-16.2 and qualified to do drug testing.

b.Results of drug testing shall not be used in a punitive manner, but rather, shall serve as one factor in making treatment decisions.

c.Each OTP shall have its own protocol regarding the increased frequency of drug testing.

16.A physician shall determine, and document in writing, the initial dose and schedule to be followed for each individual admitted to the OTP.

a.Initial doses of methadone shall not exceed thirty (30) milligrams and the total dose for the first twenty-four (24) hours shall not exceed forty (40) milligrams, unless the program physician documents in the individual’s treatment record that forty (40) milligrams did not suppress opiate abstinence symptoms.

17.The OTP shall develop and implement the following drug dispensing and administering procedures:

a.A standardized method that includes the use of identification by photograph shall be implemented to properly identify each individual before any opioid replacement treatment medication is dispensed. A dose shall not be administered or dispensed until an individual is identified and assessed to be medically and clinically appropriate.

b.The prescribed drugs shall only be administered and dispensed by licensed professionals authorized by law and regulations to do so.

c.Each opioid replacement treatment medication used by the OTP shall be administered and dispensed in accordance with its approved product labeling.

d.Methadone shall be dispensed in oral form in one (1) dose per container when liquid form is dispensed and in a multiple dose container when tablets are used. Buprenorphine shall be dispensed in accordance with product packaging.

18.OTPs shall develop policies and procedures that ensure compliance with federal and state regulations before take-home medication privileges are granted. In addition, prior to advancement to a new take-home phase, programs are required to review, for compliance purposes, the DOH Prescription Drug Monitoring Program, , in accordance with R.I. Gen. Laws § 21-28-3.32. The policies and procedures shall, at a minimum, include the following:

a.A take-home schedule that is consistent with Federal Certification Standards in 42 C.F.R. Part 8.

b.Take-home containers shall be labeled with the following:

(1)Individual’s name;

(2)Name and amount of medication;

(3)Directions for use, including route of administration;

(4)Date issued and date medication is to be taken;

(5)Program name and address;

(6)Program's telephone number.

c.Childproof caps shall be used on all take-home bottles of opioid replacement medication.

d.The OTP physician shall document in the treatment record the rationale for authorizing take-home privileges.

e.The individual shall return all take-home containers on their next day of program attendance. Prior to the person receiving his or her subsequent dose, bottles shall be inspected to ensure that they are coming from the appropriate person during the appropriate time-period.

f.Take-home privileges are not allowed during long or short-term opioid detoxification.

19.An OTP shall not admit a person for more than two (2) detoxification treatment episodes in one (1) year. Individuals with two (2) or more unsuccessful detoxification episodes shall be evaluated by the OTP physician for other forms of treatment.

20.The following security requirements shall be met:

a.Access to electronic alarm areas where drug stock is maintained shall be limited to a minimum number of authorized personnel. Each employee shall have his or her own individual code, which shall be erased upon the employee’s termination. A list shall be maintained that identifies all persons with access to the stock/safe and dispensing station and the type of access each has.

b.All stored controlled substances (powdered, liquid, tablet and reconstituted) shall be clearly labeled with the following information:

(1)Name of substance;

(2)Strength of substance;

(3)Date of reconstitution;

(4)Lot number;

(5)Reconstituted expiration date or manufacture date, whichever is earlier.

c.All stored poured doses shall have the following information:

(1)Name of substance;

(2)Strength of substance;

(3)Date of reconstitution;

(4)Lot number; and

(5)Reconstituted expiration date or manufacture date.

d.Containers shall be kept covered and stored in the appropriate locked safe with access limited through an electronic alarm system that conforms with the U.S. Drug Enforcement Administration (DEA) requirements in 21 C.F.R. Part 21 and 21 C.F.R. § 1301.71.

e.Following the initial opioid replacement treatment medication inventory at each OTP, an authorized licensed staff member shall conduct a bi-annual written inventory and document the results. The record shall be maintained for a period of two (2) years. The inventory shall contain:

(1)Name and address of the OTP;

(2)Date of inventory;

(3)Opening or closing of business day;

(4)Quantity of opioid replacement treatment medications on hand, amount used, and amount received;

(5)Total of all medications accounted for;

(6)Signature of person performing the inventory and a co-signature.

f.The Department shall be notified of any occurrence of theft, suspected theft, or any loss of any opioid replacement treatment medication. The form, authorized by the Department for reporting adverse events/incidents, shall be completed for each occurrence and shall be sent to the Department, along with a photocopy of DEA form 106.

g.OTPs shall have quality control procedures to track and trend all spillages of any medication.

h.The disposal of unused controlled substances shall be done in accordance with procedures provided by DEA Regulations, 21 C.F.R. § 1307.22, and RIDOH.

21.All pharmacists employed by an OTP shall be licensed in Rhode Island and must be authorized by the organization to dispense all opioid replacement treatment medications used by the program.

22.Clinical laboratories provided on the premises of the organization shall be licensed by RIDOH subject to the provisions of R.I. Gen. Laws Chapter 23-16.2. Testing not performed on the premises shall be performed by facilities licensed in accordance with R.I. Gen. Laws Chapter 23-16.2 or by a hospital laboratory in accordance with R.I. Gen. Laws Chapter 23-17.

23.All organizations shall provide HIV and Hepatitis C information and offer a referral for HIV testing for persons served who engage in related high-risk behaviors.

a.All testing pursuant to this section, conducted by an organization, shall be performed in accordance with R.I. Gen. Laws §§ 23-6.3-7 and 23-6.3-8, except where Federal confidentiality laws may supersede. The identity of the individuals tested under this section shall be maintained only at the site where the sample is drawn and shall not be released except as otherwise provided.

b.Each person who is offered a test and counseling shall be provided with an “Informed Consent Form" in accordance with R.I. Gen. Laws § 23-6.3-3, which he or she shall sign and date in acknowledgment of the offer, unless consent is agreed to be provided verbally.

c.All persons tested under this section shall be provided pre-test and post-test counseling in accordance with regulations adopted by the DOH and by R.I. Gen. Laws Chapter 23-6.3. All persons providing the pre-and/or post-test counseling must have completed the training provided by the DOH, Office of Sexually Transmitted Disorders and HIV, or an equivalent course.

B.Opioid Treatment Program (OTP) Health Homes provide integrated behavioral and physical health care services to individuals with an opioid use disorder. OTPs administer or dispense medications approved by the federal Food and Drug Administration (FDA) as maintenance or detoxification treatment to a person dependent on opioids. It provides, when appropriate or necessary, a comprehensive range of medical and rehabilitative services; is approved by the State authority and the SAMHSA; and is registered with the Drug Enforcement Administration to use opiate replacement therapy for the treatment of opioid use disorder. A Health Home is the fixed point of responsibility to provide person-centered care; providing timely post discharge follow-up, and improving patient health outcomes by addressing primary medical, specialist and behavioral health care through direct provision, or through contractual or collaborative arrangements with appropriate service providers, of comprehensive, integrated services. Emphasis is placed on the monitoring of chronic conditions, provision of preventative and education services around self-care and wellness.

1.OTP Health Homes shall meet all requirements § 1.6.14(A) of this Part above.

2.OTPs must offer and provide Health Home services to clients who meet eligibility requirements.

3.Admission Criteria: Patients with opioid dependence who meet state and federal criteria for Methadone Maintenance Treatment and are currently receiving financial support through Medicaid.

4.The following are the Health Home Service Provision requirements:

a.Have a physician(s) assigned for the purpose of Health Home team participation to each individual receiving OTP Health Home services;

b.Conduct wellness interventions as indicated based on individuals’ level of risk and willingness to participate;

c.Maintain a contract, Memorandum of Understanding (MOU), or other type of formal written agreement with regional hospital(s) or system(s) to ensure a formalized structure for transitional care planning, to include communication of inpatient admissions of Health Home participants, as well as maintain a mutual awareness and collaboration to identify individuals seeking Emergency Department services that might benefit from a connection with an OTP Health Home provider;

d.Maintain a contract, Memorandum of Understanding (MOU), or other type of formal written agreement with Federal Qualified Healthcare Centers (FQHCs) and/or primary care centers in the OTP area;

e.Coordinate care for Health Home participants among the OTP and primary and specialty care providers, including mental health treatment providers. This may include development of data sharing system that includes Electronic Medical Record (EMR) expansion, use of Direct Messaging through the State's Health Information Exchange to help safeguard privacy of this information and assure compliance with all related State and Federal confidentiality Regulations;

f.Use health information technology to link services, facilitate communication among team members, and between the health team and individual and family caregivers, and providing feedback to practices, as feasible and appropriate;

g.Establish a continuous quality improvement program, and collect and report on data that permits an evaluation of increased coordination of care and chronic disease-management on individual-level clinical outcomes, experience of care outcomes, and quality of care outcomes at the population level;

h.Develop treatment guidelines that establish clinical pathways for health teams to follow across risk levels or health conditions;

i.Monitor individual and population health status and service use to determine adherence to or variance from treatment guidelines;

j.Develop and disseminate reports that indicate progress toward meeting outcomes for patient satisfaction, health status, service delivery and costs;

k.Agree to convene regular, ongoing and documented internal health home team meetings with all relevant providers to plan and implement goals and objectives of practice transformation; and

l.Provide multiple contacts as needed for a team of one hundred twenty-five (125) patients. Contacts can include phone contact, such as coordinating care with other providers and support systems, as well as direct contact with the client.

5.Care Coordination:

a.Coordinate and provide access to high-quality health care services informed by evidence-based clinical practice guidelines;

b.Coordinate and provide access to preventive and health promotion services, including prevention of mental illness and other substance use disorders;

c.Coordinate and provide access to mental health and other substance abuse services;

d.Coordinate and provide access to comprehensive care management, care coordination, and transitional care across settings;

e.Coordinate and provide access to chronic disease management, including self-management support to individuals and their families, and referrals through the RIDOH Chronic Disease Self-Management Programs;

f.Coordinate and provide access to individual and family supports, including referral to community, social support, and recovery services;

g.Coordinate and provide access to long-term care supports and services;

h.Develop and implement a person-centered plan of care that is flexible and integrates all clinical and non-clinical healthcare related needs and services;

i.Ensure that all services, including mental health treatment, are coordinated across provider settings;

j.OTPs, in review of their Policies and Procedures, shall update all relevant Policies and Procedures to reflect Health Homes;

k.Changes in any aspect of an individual’s health must be noted, shared with the team, and used to change the plan of care, as necessary. All relevant information is to be obtained and reviewed by the team;

l.Facilitate timely and effective transitions from inpatient and long-term care settings to the community, as appropriate;

m.Health Home providers shall identify hospital liaisons to assist in the discharge planning of individuals, existing OTP patients and new referrals, from inpatient settings to OTPs and mental health treatment, if indicated;

n.Care coordination may also occur when transitioning an individual from a jail/prison setting into the community;

o.A member of the team of health professionals provides care coordination services between hospitals and community services;

p.Team members collaborate with physicians, nurses, social workers, discharge planners and pharmacists as needed to ensure that a person-centered plan of care has been developed, and work with family members and community providers to ensure that the plan is communicated, adhered to and modified as appropriate;

q.Provide assistance to individuals to identify and develop social support networks;

r.Provide assistance with medication and treatment management and adherence, to include referrals for mental health vocational and counseling services;

s.Connection to peer advocacy groups, wellness centers, National Alliance on Mental Illness (NAMI), RICARES, family psycho-educational programs, etc.;

t.Provide Individual and family support services to assist individuals to access services that shall reduce barriers to treatment and improve health outcomes. Support services may include advocacy, information, navigation of the treatment system, and the development of self-management skills; and

u.Referral to primary and or specialty care as requested by physician.

6.Discharge Criteria. An individual shall be deemed ready for discharge if one of the following exists:

a.The individual voluntarily elects to terminate participation;

b.The goals and objectives of the person-centered plan have been met and a referral is coordinated to a willing community-based physician; or

c.The individual is not benefitting from the treatment and requires a higher level of care.

1.6.15Overdose Prevention Education and Training

A.Overdose prevention education and training shall be provided to staff in all licensed BHOs and to persons served with a history of opioid use disorder and documented in either the personnel or treatment record.

1.Opioid overdose prevention training. Training shall be provided to staff and persons with a history of opioid use disorder that includes but is not limited to the following content areas:

a.Causes of an opioid overdose including identifying and avoiding high risk situations for overdose;

b.How to avoid an opioid overdose and risk reduction strategies;

c.How to identify and properly respond to an opioid overdose, including:

(1)Universal safety precautions;

(2)Rescue breathing;

(3)The importance of calling 9-1-1; and

(4)How naloxone works and proper administration of intramuscular (IM) or intranasal (IN) naloxone.

d.What to do and what to expect after naloxone administration;

e.Signs of withdrawal;

f.Placement in the rescue position;

g.Aftercare and referral information;

h.Contact information for how to access naloxone and naloxone refills; and

i.Information about R.I. Gen. Laws Chapter 21-28.9, the Good Samaritan Overdose Prevention Act of 2016.

2.If medically indicated and clinically appropriate, a person served with a history of an opioid use disorder shall be offered take-home naloxone as part of an overdose prevention intervention and it shall be indicated in the treatment records if the person accepted or declined.

A. It is the purpose of these rules and regulations to implement R.I. Gen. Laws § 40.1-1-10 and § 40.1-1-10.1, the Parent Deinstitutionalization Subsidy Aid Program subject to available funds.

B. The program is founded for the express purpose of providing financial assistance or subsidy aid to the qualified parent applicant, as defined herein, who is found and certified to be qualified by the Director of the Department to receive and take into his or her care, custody, and control an eligible person, as defined herein.

A. Authority: These regulations are promulgated pursuant to R.I. Gen. Laws § 40.1-1-10 and § 40.1-1-10.1.

B. Scope: These regulations shall apply only to persons receiving or applying to receive the parent subsidy.

C. Enforcement: Applicants for, or recipients of, the subsidy who do not conform to the regulations shall not receive the subsidy.

A. Terms as used herein are defined below.

1. “Care, custody and control” means that the certified parent(s) will take into his/her/their place of residence an eligible person who requires supervised living and further:

a. Care means personal care or supervision of activities essential to the eligible individual’s daily functioning, includes the following:

(1) assistance with or supervision in dressing, eating, bathing and other personal hygiene;

(2) maintenance of a medication schedule as directed and supervised by a physician and assistance to obtain medical/nursing and rehabilitation services;

(3) management of the individual’s social and behavioral needs.

b. Custody and control means that the parent shall have full responsibility for the welfare of the eligible individual and shall be aware of his/her whereabouts at all times.

2. “Department” means the Rhode Island Department of Behavioral Healthcare, Developmental Disabilities and Hospitals.

3. “Designated local agency” means a mental health agency authorized by the Department to evaluate, certify and monitor placements under R.I. Gen. Laws § 40.1-1-10.

4. “Director” means the Director of the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals.

5. “Eligible person” or “Eligible individual” means:

a. A person who is and has been a resident (or patient) for ninety (90) days of the Dr. Joseph H. Ladd Center, the Dr. U. E. Zambarano Memorial Hospital, the Institute of Mental Health or the General Hospital; or

b. Resident in an out-of-state institution who would have been eligible for placement in the Dr. Joseph H. Ladd Center, Dr. U. E. Zambarano Memorial Hospital, the Institute of Mental Health, the General Hospital for a period of time not less than ninety (90) days; or

c. A person who would be a resident (or patient) for ninety (90) days or more in one of the aforementioned facilities in the absence of the subsidy. It shall be found that this criterion is met when one (1) or more of the following conditions exist:

(1) the person’s disability causes him/her to be dependent on others for basic functions of daily living.

(2) the person’s severe behavior problems require constant supervision.

d. Disability means any of the disabilities served by the facilities named in § 1.3(A)(1)(a) of this Part.

6. “General service plan” or “GSP” means the final written document which states the treatment and management needs of the eligible individual, specifies provision for appropriate services, and includes a description of the intended use of the subsidy.

7. “Home evaluator” means the person who visits the home of the parent applicant and evaluates the home and family to determine suitability.

8. “Parent” means natural parent(s), adoptive parent(s), foster parent(s), or caretaker friend or relative, any of which may include a court appointed guardian.

a. In the situation where the natural or adoptive parents are divorced or separated, the word “parent” shall mean the parent with whom the eligible person lives.

b. Foster parent refers to a person licensed by the Rhode Island Department of Children, Youth and Families (DCYF) who has an eligible child in their home.

c. Caretaker friend or relative refers to a person certified by the Department to receive the subsidy for an adult.

9. “Parent applicant” means the person who has made application to receive subsidy aid.

10. “Subsidy aid” means payment or continued payments to a certified parent(s) to receive and take into his/her/their care, custody and control an eligible individual.

11. “Training” means monitoring and implementing activities designed to assist the eligible individual in his or her development of functional skills and adaptive behavior.

a. Adaptive behavior means the effectiveness or degree with which an individual meets the standards of personal independence and social responsibility expected of his/her age and cultural group.

A. Application to be certified for the subsidy aid program shall be made on Department forms and shall be signed by the parent applicant(s). Each division of the Department shall make forms available for their applicants.

B. The minimum age is eighteen (18) years. Otherwise, age of the parent applicant(s) will be considered only if it affects his/her/their physical capability, flexibility, and ability to care for and provide training for an eligible child or adult.

C. All family members should be in sufficiently good health to meet the needs of the adult or child placed with the family. In instances where there is a question that health may affect the ability of the parent applicant to care for the person, a written statement from a physician will be obtained as part of the home study evaluation process. Statements concerning health must be annually updated.

D. Income Limit (See also § 1.12(A) of this Part). Gross income shall not exceed four hundred (400%) percent of federal poverty level guidelines in the case of natural parents.

E. Employment of the parents outside the home.

1. There must be arrangements for adequate care and supervision of the eligible individual during the parents’ absence. Parents must demonstrate that employment does not detract from implementation of the eligible individual’s program plan.

F. Home Study - characteristics of the family unit and home.

1. There shall be a home study conducted by a Home Evaluator who shall be a social worker from the appropriate division of the Department or designated local agency, (See § 1.3(A)(3) of this Part). The most important requirements pertain to the personal characteristics of the family as a unit and as individuals. These characteristics must be consistent with the needs of each eligible person placed with a family.

2. Placements shall not be made in households which include more than one (1) non-relative, such as roomers, boarders or foster family members.

3. The Home Evaluator shall meet all members of the family to determine their views, feelings and opinions about providing care and assistance.

4. The home study shall include the Home Evaluator’s observations about the family members’ characteristics such as: patience, understanding, open-mindedness, adaptability, and stability. Other factors to be included in the study are: the physical aspects of the house and the environment of the community, (e.g. availability of recreation, education or work facilities, home health services, stores, churches, transportation and the general physical environment), and, in the case of natural and adoptive parents, the financial dependence of the parents on the subsidy in order to avoid placement. The Home Evaluator shall provide a written report summarizing significant factors.

5. The home study shall be kept on file with the parent(s) application.

G. Visits by the Department or designated local agency.

1. The applicant(s) shall indicate in writing acceptance that unannounced visits may be made to his/her/their home by a representative from the Department or a designated local agency for the purpose of monitoring the program and services being provided.

H. Training Sessions.

1. Parent(s) or parent applicant(s) shall indicate in writing willingness to participate actively in such training sessions as specified by the Department or designated local agency in order to receive the subsidy aid.

2. Such training shall be to train parent(s) and parent applicant(s) to become knowledgeable about developmental and/or functional disabilities and about care and treatment techniques needed to assist in the individualized service program.

I. Licensing prior to certification for Subsidy Aid by the Department or the designated local agency.

1. Natural or Adoptive parent(s) are not subject to licensure regardless of age of eligible person.

2. Foster parent(s) for children shall be licensed by DCYF. The Home Evaluator assists the parent applicant(s) by directing him/her/them to the licensing authority.

3. Caretakers for adults are not subject to licensure under existing State laws unless there are two (2) or more adults receiving care.

J. Marital Status - No restrictions.

A. The Department shall provide the form for certification which will be signed in conformance with the law and shall be signed by the Home Evaluator.

B. Waiting lists shall be maintained by each division of the Department for their own clients. Priority shall be given to families with members who have severe and multiple disabilities and who are experiencing a high degree of family stress.

C. When an application is rejected, there shall be a written response to the applicant, which includes a clear statement of the reasons for rejection and an offer of an opportunity to discuss the findings informally or by appeal.

D. Applicants shall not be certified for more than one (1) client in the home, with the exception of siblings. Authorized placements in excess of that number will be excepted from this Part.

A. Where subsidy aid is to be provided, a written agreement between the Department or designated local agency and the parent applicant(s), with clearly delineated terms, shall precede the subsidy payments.

B. The provisions shall be explained verbally to the parent applicant(s) who, after a period of study and consultation, shall sign the agreement jointly with the Department or the designated local agency. Included in the agreement shall be relevant sections contained in this Part and other content herein requiring written agreement.

C. A new written agreement shall be provided for the certified parent for each year.

D. Each agreement shall require progress reports. The certified parent(s) shall prepare and submit reports as to implementation of the plan and will discuss them with a representative from the Department or designated local agency. Monthly reports are mandatory for the first twelve (12) months; reporting may then be scheduled as the social worker deems necessary, but at least semi-annually.

A. The appropriate division of the Department or designated local agency shall have written procedures to determine eligibility of an individual as defined in § 1.3 of this Part.

1. Division of Behavioral Healthcare: This determination shall be made by the designated local agency in whose catchment area the individual resides using the admission criteria of the Institute of Mental Health.

2. Division of Developmental Disabilities: This determination shall be made by Department of Revenue Social Services Unit.

3. Division of Hospitals and Community Rehabilitative Services: This determination shall be made by the Division’s hospital admission teams.

B. The client record shall contain documentation of the decision that the subsidy was essential to avoid institutionalization or to achieve discharge.

C. For residents/patients being placed from a Department placement, the placement’s interdisciplinary team shall review the client’s status and confer with staff from the appropriate local agency services in order to design an effective placement plan.

D. For individuals not residents/patients of a Department placement, the responsibility for review shall be as follows:

1. Division of Behavioral Healthcare: The designated local agency.

2. Division of Developmental Disabilities: The Department of Revenue Social Service Unit.

3. Division of Hospitals and Community Rehabilitative Service: Admission teams of the hospitals.

E. A General Service Plan (GSP) shall be constructed to reflect and prioritize each individual’s needs. The plan shall provide a framework in which each individual's progress can be monitored, measured, and assessed periodically. The plan shall include a description of the intended use of the subsidy.

1. The GSP shall be based upon data from professionally accepted assessments of the client performed within the previous twelve (12) months.

2. The GSP shall address physical health needs, mental health needs, social needs, educational needs, vocational needs, and leisure needs.

3. The GSP shall include the names of the providers who will be responsible for meeting the needs. The portion of the plan which constitutes the subsidy aid plan shall be developed with the parent(s) and incorporated into the GSP upon completion.

A. Applicant or certified parents and eligible persons shall be reviewed by the responsible Department division or designated local agency to determine appropriateness of placement.

B. All staff assigned by the appropriate division of the Department or designated local agency shall confer to discuss the needs of the placement candidate and the characteristics of the applicant or certified person. Such conferring is in addition to the established discharge planning procedures of the placement for those candidates leaving a placement.

C. When a match is made, the plan will be explained to the parent and training will be provided as needed by the division or designated local agency arranging the placement.

D. When the parent has agreed to the placement, the contract or agreement shall be processed by the appropriate division of the Department.

A. The approved written plan for the use of the subsidy and the contract or agreement shall constitute such authorization.

B. The plan shall be signed by parent(s) and the division or designated local agency representative and shall be filed in the record.

A. The appropriate division of the Department or designated local agency shall name the social worker or other staff member, who is responsible for the on-going monitoring of the placement and activity related to approving the subsidy payments.

B. A copy of the plan shall be retained by the social worker from the division of the Department or designated local agency.

A. Quarterly reports to evaluate the placement shall be prepared by a social worker from the appropriate division of the Department or designated local agency. The reports shall be filed in the client’s record in the appropriate division or designated local agency.

B. Program plans shall be updated and revised at least every twelve (12) months and more often if indicated by the needs of the client. The social worker (as in § 1.10(A) of this Part) is responsible for related activity as designated herein.

C. The twelve (12) month revision of the plan shall be based on professional assessments performed by the professional staff of the program or agency providing services to the eligible person.

D. The parent(s) shall participate in the interdisciplinary case conference relating to the client held by said program or agency, if possible. Otherwise, the written report of the conference shall be discussed with the parents by assigned staff.

E. The social worker shall revise the program plan for the parent subsidy program to incorporate the results of the conference.

F. In the event that the eligible person has no involvement with a program or agency, it shall be the responsibility of the appropriate Department division, upon request of the social worker, to assign professionals for the purpose of assessment and recommendations.

G. At least monthly for the first three (3) months, there shall be a personal visit made by the social worker to the home to see the parent and the eligible individual to assure that the placement is satisfactory. Thereafter frequency of visits may be reduced to quarterly at the discretion of the division of the Department or the designated local agency.

H. The case record shall include the dates of the visits and the observation of the social worker.

I. The social worker shall submit all monthly and quarterly reports to his/her supervisor and shall forward the monthly payment authorization to the Central Office of the division of the Department involved.

A. Subsidy Aid payments will be given to parent(s) after they are certified and have received a contract from the State and have accepted the person into their home. Payments are stated in, R.I. Gen. Laws § 40.1-1-10.1.

1. Subsidy payments to parents/foster parents shall be for needs which SSI or other benefits and/or DCYF supplementary payments do not meet. It must be documented that without the subsidy, the eligible person could not be maintained in the home.

2. Payments shall not be made when the eligible individual or his/her parent(s) is(are) the recipient of a court awarded or out-of-court settlement related to the eligible person’s condition.

3. Payments shall not be made to natural parents whose gross income exceeds four hundred (400%) percent of the federal poverty level guidelines, for a family of their size, including the eligible person.

A. Each contract expires at the end of the State fiscal year, June 30th.

1. In keeping with the intent of the Subsidy Aid program, which is to avoid institutionalization of people with significant health care and/or psychiatric needs by providing a subsidy, there must be documentation that the level of care needed by the individual would qualify them for admission to the placement and that without continuation of the subsidy the certified parents could not maintain the eligible person in the home.

2. Provided the GSP recommends the placement/subsidy continue, a recertification form shall be processed.

3. A contract shall be prepared and processed for the new fiscal year when there is a current certification in place.

A. The parent may terminate participation in the program upon written notice to the social worker of the appropriate division of the Department or designated local agencies and, in foster child placements, to the DCYF worker as well.

B. The Department or the designated local agency shall terminate the subsidy aid as needed to conform to § 1.12(A)(1) through (3) of this Part or for any of the following reasons:

1. Substantiated charges of physical or emotional abuse of the individual by the parent(s) or foster parent(s) or other individuals residing in the home.

2. Inability and/or unwillingness of the parent(s) or foster parent(s) to cooperate with the Department concerning the eligible person’s basic care and training program.

3. Determination that the parent(s) or foster parent(s) is/are unable to meet physical, nutritional, emotional or behavior needs of the eligible person.

4. Determination by the appropriate Department division or designated local agency that the eligible participant’s level of functioning has changed from dependent to independent.

C. The Department shall inform the parent(s) or foster parent(s) when and if the subsidy aid is to be terminated by a thirty (30) day notice in writing, except in cases of emergency or when determination has been made that the eligible person’s physical or mental well-being is endangered. Said notice shall include a statement advising the parent(s) or foster parent(s) of their right to appeal the decision. Other appropriate legal action will be taken as the situation warrants.

All hearings and reviews required pursuant to these rules and regulations shall be held in accordance with the provisions of R.I. Gen. Laws § 42-35-1 et seq. and the Executive Office of Health and Human Services (EOHHS) rules and regulations for Appeal Process and Procedures for EOHHS Agencies and Programs, 210-RICR-10-05-2.

These rules and regulations are promulgated pursuant to R.I. Gen. Laws §§ 40.1-21-15 through 40.1-21-17 for the purpose of providing rules and regulations for the administration of the Self-Sufficiency Trust fund.

A. The Self-Sufficiency Trust is a comprehensive life-care planning option designed to meet the supplemental service needs of persons with disabilities. The Self Sufficiency Trust provides a mutually beneficial public/private working relationship between families of disabled individuals, the State and the community based service network.

B. Pursuant to enabling legislation, the Department is responsible for various administrative, programmatic and financial requirements. The Self-Sufficiency Trust Board, a private Board established in accordance with R.I. Gen. Laws § 40.1-21-15, is responsible for the Private Trust Fund and the Private Charitable Fund and shall control and disburse these funds in accordance with the trust documents. The State shall establish counterpart funds, the Self-Sufficiency Trust fund and the Fund for the Disabled, and shall be responsible for the disbursements from each of these funds.

C. Both the private and public sector funds shall be utilized to provide supplemental services to persons with mental illness, developmental disabilities, or persons otherwise eligible for Department services.

A. “Community provider” or “Provider” means those community agencies which are licensed or certified by the Department or other State agency to provide services to persons with developmental disabilities, mental illness, or other eligible individuals.

B. “Data profile” mean a document describing the details of the Life Care Plan in terms of specific services required by the Participant and projected dates on which these services are needed.

C. “Department” means the Rhode Island Department of Behavioral Healthcare, Developmental Disabilities and Hospitals.

D. “Director” means the Director of the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals.

E. “Financial plan” means a plan describing the amount of principal required to be contributed to the Self-Sufficiency Trust to pay for the services described in the Life Care Plan with earnings generated by the principal.

F. “Life care plan” means the plan developed between the donor and the Self-Sufficiency Trust which includes the services expected to be required by the Participant throughout his or her life. The plan projects when the services are likely to be needed and their anticipated costs.

G. “Participant" means an individual beneficiary enrolled with a Self-Sufficiency Trust for whom services and/or goods are being funded in whole or in part by the Self-Sufficiency Trust or an individual beneficiary of the Public-Sector Fund for the Disabled. An otherwise qualified Participant does not have to be eligible for or receiving services from the Department in order to be an enrolled beneficiary.

H. “Private charitable fund” means the fund established from residual assets of the Private Trust Fund of deceased beneficiaries and from other bequests, gifts, or monies which the Board may receive.

I. “Private trust fund” means the pooled assets of each family participating in the Self-Sufficiency Trust.

J. “Private vendor” means an agency or an individual able to provide goods and/or services not available through community providers. The Board may contract with private vendors to provide goods and/or services in accordance with the Participant’s Life Care Plan when the goods and/or services are not otherwise available from a community provider.

K. “Public-sector fund for the disabled” means the special restricted receipt fund established pursuant to R.I. Gen. Laws § 40.1-21-17. The Director may accept money from any source for deposit into the fund and the Director shall also receive earnings from the principal of the Private Charitable Fund. The money in this fund shall be used by the Department for the purpose of providing for the care and treatment of low-income, persons with mental illness, developmental disabilities, and persons otherwise eligible for Department services.

L. “Self-sufficiency trust” means the trust created pursuant to R.I. Gen. Laws § 40.1-21-15 to provide for the care, encouragement and treatment of persons with developmental disabilities, mental illness, or persons otherwise eligible for the services of the Department.

M. “Self-Sufficiency Trust Board of Trustees” or “Board” means the individuals who establish policies, contract for necessary services for the Self-Sufficiency Trust and control the Private Trust Fund and the Private Charitable Fund.

A. Services to be funded by the trust may include those services otherwise available to eligible individuals from community providers and other services only available from private vendors subject to the following provisions:

1. Trust fund dollars will not be used to meet basic food, shelter, clothing, personal needs, room/board and medical needs of the Participant; income paid for supplemental services and goods is exempt from determining eligibility for programs, services and means tested entitlements administered through any and all State agencies.

2. Trust fund dollars will not be spent on goods or services from private vendors if the services are otherwise available from community providers.

3. Trust fund dollars will cease if the Participant moves out of state, effective the date of the move.

4. All services and goods purchased from community providers with trust fund dollars will be purchased by way of a per diem or service rate that is consistent with the current Department rate-setting methodologies as appropriate, or in accordance with current negotiated local market rates. When the Department adjusts rates on cost of living, the Self-Sufficiency Trust fund per diems or service rates will be increased based upon the same percentage factor.

5. Trust fund dollars will not be used to supplement established rates determined by the Department.

A. An agreement between the Department and the Board has been developed which outlines the responsibilities and obligations of the Board and the Department with respect to the services and goods operated pursuant to R.I. Gen. Laws §§ 40.1-21-15 through 40.1-21-17.

B. This agreement is renewable for successive periods of one (1) year each and may be modified upon agreement of both parties.

C. This agreement may be terminated for the following reasons:

1. Pursuant to the law of the State of Rhode Island; or

2. Dissolution of the trust; or

3. By the terms of the agreement

A. The Board shall have all responsibility for the solicitation and enrollment of Participants into the Self-Sufficiency Trust. Specific responsibilities include:

1. Explaining the general trust activities to all those individuals, families/responsible relatives or Participants approaching the trust.

2. Enrolling those wanting to participate through the application process.

3. Gathering the necessary clinical assessment and evaluation data pertaining to the Participant and making the necessary referrals for such information.

4. Meeting with the family/responsible relative, legal guardian or interested individual and, when appropriate, the Participant, to refine and prioritize the service needs of the Participant.

5. Developing and maintaining a standard data profile on all service needs of the Participant and the projected date of such service.

6. Development of a Life Care Plan based on the standard data profile projecting specific services required, dates of such services and projected costs of such services.

7. Development of a financial plan itemizing the means by which services outlined in the Life Care Plan are to be funded through contributions to the Self-Sufficiency Trust.

8. Development and execution of all necessary contractual and legal requirements between the sponsor of the Participant and the Self-Sufficiency Trust.

B. The Board shall transmit and communicate to the Department all data profiles or other related information developed by the trust requested by the Department.

C. The Board shall meet with the Department prior to the beginning of each fiscal year to determine the following:

1. Specific Participants enrolled in the trust whose financial target has been reached or will be reached in the upcoming fiscal year.

2. Specific services requested by trust Participants.

3. The community provider and/or private vendor which will provide the specified services.

4. The amount of funds that will be transferred to the Self-Sufficiency Trust fund for services to be provided for individual rust Participants.

D. The Board controls the private pooled-income trust funds for the benefit of the named Participants and shall have all responsibility in managing its private trust to provide for sufficient earnings to fund those services, in whole or in part, that are described in each Participant’s Life Care Plan.

E. The Board controls the Private Charitable Fund and may transfer to the Public-Sector Fund for the Disabled earnings on the principal of the Private Charitable Fund. These private dollars may be used to provide for the supplemental benefit of eligible individuals, in accordance with these regulations.

F. The Board shall, before the 5th working day of each quarter, transmit funds from its private trust to the Self-Sufficiency Trust fund for the anticipated monthly required expenditures. Concurrent with this transfer, sufficient information will be given to the Department describing specific services/goods to be purchased for trust Participants, dates of service for which the amount of funds being transferred are to fund, in whole or in part, such services.

G. The Self-Sufficiency Trust shall submit an annual certified financial statement performed by its independent auditors to the Department.

A. The Department shall be responsible for accounting for the Self-Sufficiency Trust fund on behalf of those Participants for which funds have been deposited into such fund.

B. If a disagreement arises between the Board and a service provider regarding specific service issues or service levels, the Board and the service provider shall first attempt to resolve the dispute among themselves. If a satisfactory resolution cannot be reached, it shall be resolved pursuant to current Department procedures regarding disputes relating to the provision of services to clients.

C. The Department shall pay community providers at the negotiated or current approved rate of payment or reimbursement for providing services covered in the Life Care Plan. The Department will utilize its existing purchase of care and grant-in-aid agreements as the authorization for service provision and payment.

D. The Department shall, on a monthly basis conduct a reconciliation to determine any differences between the amount of funds received from the Board for services to be provided during the month and the amount the Department allows the providers to be paid based on the services actually provided. The Department shall provide the Board with periodic statements which identify any adjustments necessary to future fund transfers from the Board based upon the results of each reconciliation. Statements for the Self-Sufficiency Trust fund shall be provided not less frequently than quarterly.

E. The Department will ensure that the Participant’s provider agency is notified of the specific services to be provided to the Participant, effective dates of such services and the appropriate procedures to be followed for reimbursement under the Department’s community service system.

A. When the Charitable Trust Fund has sufficient earnings on the principal to enable supplemental services or goods to be provided to an indigent Participant or Participants, the Board shall notify the Department that such funds are available and the amount of such funds.

B. Upon such notification by the Board, the Department shall request the assistance of individuals and/or agencies concerned with the care and treatment of persons with mental illness, developmental disabilities, and other eligible individuals, to ascertain the manner in which the funds shall be used for the benefit of low-income individuals.

C. The Department may request proposals from individuals and/or agencies in order to ascertain the manner in which the funds may best be used for the benefit of low-income individuals.

D. The Department may utilize these moneys to expand services available through already existing state or federal programs.

E. The Department may utilize these moneys to provide supplemental services to a group of low-income individuals or may use these moneys to provide supplemental services to one or more individuals.

F. The Department shall inform the Board of the specific services or goods which the Department has determined shall be purchased with the funds. The Department shall provide the following information to the Board regarding the use of the funds:

1. The specific individual(s) to be served;

2. The type of service to be provided;

3. The provider of the services;

4. The period of time for which services will be provided.

A. Pursuant to R.I. Gen. Laws § 40.1-21-15, The Rhode Island State treasurer, ex officio, is the custodian of the Self-Sufficiency Trust fund.

B. The treasurer shall credit interest on the trust fund to the trust fund and the Department shall allocate such interest pro rata to the respective accounts of the named beneficiaries of the trust fund.

C. When the goods or services to the Participant are being provided by a community provider, the Board shall transfer the interest earnings on the private trust fund assets to the Self-Sufficiency Trust and these funds shall be disbursed by the State to the appropriate community provider. The controller of the State of Rhode Island shall direct payments transferred from the private trust fund to the Self-Sufficiency Trust upon vouchers properly certified by the Department.

D. Accompanying each transfer to the Self-Sufficiency Trust will be an itemized list which identifies the following:

1. Each individual for whom the funds are being transferred to provide services.

2. The total amount of funds transferred on behalf of each Participant

3. The period of time for which the transferred funds are to be paid to provide services.

4. An invoice identifying services and the amount to be paid.

E. When the goods or services to the Participant are being provided by the private vendor, the Board shall direct payment from the private trust fund to the private vendor in accordance with the Life Care Plan for the Participant.

F. The controller of the State of Rhode Island shall direct payments transferred from the Private Charitable Fund to the Public-Sector Fund for the Disabled for services provided to low income individuals upon vouchers properly certified by the Department.