Health and Human Services

Human Services Program Licensing

Rule 19A: Residential Treatment, Congregate Care

Effective Date: 07/30/2026

Admin. Code Reference: R501-19A

Rule Type: Current Rule

R501. Health and Human Services, Human Services Program Licensing.

R501-19A. Residential Treatment, Congregate Care.

R501-19A-1. Authority and Purpose.

(1) Sections 26B-2-104, 26B-2-124, and 26B-2-124.1 authorize this rule.

(2) This rule provides the basic health and safety standards for congregate care residential treatment licensure.

R501-19A-2. Definitions.

Terms used in this rule are defined in Sections 26B-2-101, 26B-2-120, 26B-2-124, and 26B-2-124.1 and Rule R380-600. Additionally:

(1)(a) "Body cavity search" means a visual or manual inspection of a body cavity in search of prohibited material.

(b) Body cavity search does not mean an inspection of a client's mouth after the client takes medication.

(2) "Chemical restraint" means any drug that:

(a) is administered to manage a client's behavior in a way that reduces the safety risk to the resident or another person;

(b) has the temporary effect of restricting the client's freedom of movement; and

(3)(a) "Child in crisis" means a child who is experiencing a situation where the child's mental health or safety is at immediate risk.

(b) A child in crisis may exhibit extreme behaviors or emotions that require immediate intervention and support, including:

(i) destruction of property;

(ii) engaging in self-injurious behavior;

(iii) experiencing severe aggression, agitation, or hostility;

(iv) expressing suicidal thoughts;

(v) extreme emotional changes including intense anger, irritability, or sadness;

(vi) hallucinating or experiencing delusions; or

(vii) withdrawal or isolation.

(4) "Clinical" means the type of treatment or services delivered by a mental health or medical professional who is licensed by the Division of Professional Licensing.

(5) "Clinical director" means a professionally licensed individual responsible for the oversight of a program's clinical processes who is appropriately qualified to supervise the program's professional staff.

(6)(a) "Confidential communication" means the unsupervised and unmonitored communication between a client in a congregate care program and the individuals referenced in Subsection 26B-2-123(6).

(b) Confidential communication does not allow for any outside entity to have access to view or hear information contained in the confidential exchange.

(7) "Direct Access Clearance System" or "DACS" means the online system used by Office of Background Processing (OBP) for processing and monitoring background checks for any applicant with direct access to a client in a human services program.

(8) "Direct care staff" means staff that works directly with a client.

(9) "Direct supervision" means when staff actively supervises a client in close physical proximity and with uninterrupted auditory surveillance and can immediately respond to the client if necessary.

(10) "Education entitled children" means the same as defined in Section 26B-2-116.

(11) "Individual treatment" means individualized therapy involving a client and a clinician that may include one or more family members as clinically indicated.

(12) "Intake assessment" means a formal review process following every new intake of a client into the program as described in Subsection R501-19A-7(4).

(13) "Mechanical restraint" means the use of a device, material, or equipment attached or adjacent to a person's body that restricts freedom of movement and normal access to the body.

(14) "On-duty" means an individual counted in a supervision ratio who is charged with supervising one or more clients as a primary job requirement.

(15) "Program" means the same as "program or facility" is defined in Section 26B-2-701.

(16) "Program director" means an individual responsible for day-to-day operations of a program.

(17)(a) "Restraint" means the use of a device, material, or equipment that physically restricts a client's freedom of movement, physical activity, or normal access to the body, including a chemical, mechanical, or passive restraint used as a last resort as a means to prevent harm to the client or another person.

(b) A restraint does not mean an escort used to direct, guide, or lead a client.

(18)(a) "Seclusion" means the same as defined in Section 26B-2-101 and applies to a client.

(b) Seclusion does not include a medically approved quarantine.

(19) "Settings final rule" means the Home and Community-Based Services Final Rule as established in 79 FR 2948 (2014).

(20) "Significant criminal activity" means any unlawful activity by or against any client of a provider or on-duty staff that poses a serious threat to the health, safety, or well-being of the client or staff, including:

(a) any criminal activity that involves law enforcement;

(b) illegal physical or sexual misconduct or assault;

(d) suspected exploitation; and

(e) suspected fraud.

(21) "Significant medical emergency" means an acute injury or illness which poses an immediate risk to a client or staff's life or health or requires emergency medical care.

(22) "Site" means a human services program identified by a single geographic location and linked to a parent program, if one exists.

(23) "Staff" means an individual who is employed by and providing services through a provider.

(24) "Strip search" means requiring a client to undress down to undergarments or complete nudity in view of another person.

(25) "Telehealth" means the use of digital information and communication technologies, including computers and mobile devices, to remotely access behavioral health or health care services.

(26) "Trauma-informed" means any practice that promotes an environment of healing and recovery rather than a practice that may inadvertently re-traumatize.

R501-19A-3. Scope.

Each provider shall comply with any applicable federal, state, or local law, rule, or ordinance, including:

(1) Section 26B-2-123;

(2) Section 26B-2-124;

(3) Rule R380-80;

(4) Rule R380-600;

(5) Rule R500-4;

(6) Rule R501-14; and

(7) this rule.

R501-19A-4. License Required.

(1) A license is required for any provider offering residential treatment, congregate care program services to any client:

(a) under the age of 12 with OL approval;

(b) ages 12 through 17; and

(2) A residential treatment, congregate care license is not required for:

(a) a youth shelter;

(b) a youth receiving center; or

R501-19A-5. Policies, Procedures, and Safe Practices.

(1) Each provider shall develop, implement, and comply with policies, procedures, and safe practices for:

(a) behavior management;

(b) gender non-discrimination;

(d) suicide prevention.

(2) The provider shall ensure staff receive training on the policies, procedures, and safe practices described in this section.

(3) The provider shall ensure compliance with the policies, procedures, and safe practices described in this section by:

(a) submitting the required policies, procedures, and safe practices to OL during initial and renewal licensure and when any policy change requires approval; and

(b) making any policy, procedure, or safe practice available upon request to OL and a client's parent or legal guardian.

(4) The provider shall ensure any policy, procedure, and safe practice is trauma-informed.

(5) The provider shall provide staff guidance regarding:

(a) the appropriate response to any inappropriate behavior from other staff or a client;

(b) the appropriate use of restraint, any emergency safety intervention, and seclusion;

(d) when a client poses a risk of violence;

(e) what constitutes contraband and how the provider ensures restriction of any contraband and dangerous weapon or material;

(f) appropriate client body cavity and strip search techniques, in alignment with Subsection 26B-2-123(1)(a), including that any body cavity or strip search:

(i) cannot be a standard practice; and

(ii) shall only be conducted by a licensed medical professional outside the view of any direct care staff;

(g) critical incident reporting policy, in alignment with Rule R380-600 and Subsection 26B-2-124(1)(c);

(h) any emergency procedure during any natural disaster, extreme weather event, fire, utility or structural failure, or other unexpected disruption, including:

(i) continuity of care;

(ii) critical incident reporting; and

(iii) transport, relocation, and client health and safety;

(i) how to recognize and report abuse and neglect;

(j) how to report and respond to significant criminal activity or any significant medical emergency;

(k) the least restrictive staff response to a client leaving the program without permission;

(l) how to file a staff grievance and how to direct a client grievance;

(m) the management of any unique provider circumstance regarding client supervision, the physical facility, community safety, and comingling populations;

(n) firearm policy;

(o) food service policy, including:

(i) how to identify and accommodate any client with special dietary needs;

(ii) if the program restricts access to food and kitchen equipment, an allowance for nutritious snacks to be available during restricted hours; and

(iii) if any client participates in meal preparation, a policy that addresses:

(A) any menu planning and procedure;

(B) any nutrition requirement;

(D) required training for safe food handling practices with a requirement for documented justification of each client's participation; and

(E) any program rule or privilege involving kitchen use;

(p) how to prevent and control any infectious and communicable disease, including coordination with and following the guidance of state or local health authorities, Center for Disease Control and Prevention, and the Department of Health and Human Services (department); and

(q) provider and client responsibility for medication, including how to:

(i) administer medication, including any self-administration process;

(ii) log each medication dose;

(iii) record and report any medication error;

(iv) monitor and record any intended effect and side effect of medication;

(v) record each medication dosage according to any prescription;

(vi) store and administer medication on-site;

(vii) store and administer medication when a client is in an off-site program-related activity;

(viii) properly dispose of any unused or expired medication; and

(ix) ensure the individual responsible for the discharge of a client is given any unused medication.

(6) The provider shall train staff and ensure the use of any alternative sleeping arrangement, outside the client's assigned bedroom, complies with the suicide prevention plan, as described in Subsection 26B-2-124(4)(a)(iii).

(a) Any alternative sleeping arrangement shall:

(i) preserve client dignity and confidentiality; and

(ii) be done on an individualized, time delimited basis.

(b) Any alternative sleeping arrangement may not be used:

(i) as a behavior management technique or as a consequence for behavior;

(ii) to address any staffing shortage; or

(iii) for staff convenience.

(7) The provider shall preserve the rights of each client who receives congregate care residential treatment services.

(8) The provider shall ensure there is a policy addressing management of client funds that requires documentation of each deposit and expense.

(9) The provider shall ensure there is a policy addressing the care, licensure, maintenance, and vaccination of any on-site animal in accordance with any local ordinance, including the:

(a) assessment of any pet allergy for any client interacting with any animal in the program;

(b) maintenance of any required examination, registration, and vaccination of each animal; and

R501-19A-6. Administration.

(1)(a) Each provider shall provide information through print or website sources, on any program service for any client to:

(i) OL;

(ii) the public;

(iii) any potential client; and

(iv) a client's parent or legal guardian.

(b) The information described in Subsection (1)(a) shall include:

(i) a description of each service;

(ii) each program requirement and expectation;

(iii) current and accurate program contact information;

(iv) the complaint reporting and resolution process;

(v) identification of each non-clinical, extracurricular, or supplemental service offered or referred; and

(vi) each cost, fee, and expense for a service and refund policy.

(2) The provider shall maintain a phone number to be used for the purposes described in Subsections 26B-2-124(4)(g) through 26B-2-124(4)(h).

(3) The provider shall make every reasonable effort to connect any authorized contact who calls the program in an attempt to contact a client with that client by phone.

(4) In conspicuous places where each visitor, staff, and client may see, the provider shall post:

(a) abuse reporting laws, as described in Sections 26B-6-205 and 80-2-609;

(b) an Americans with Disabilities Act notice;

(d) a civil rights notice;

(e) a client rights poster, except in a setting serving a client population governed by the settings final rule;

(f) a congregate care ombudsman notice form, in compliance with each requirement in Subsection 26B-2-124(7)(a);

(g) a provider code of conduct poster; and

(h) the program's license.

(5) In addition to posting the congregate care ombudsman notice described in Subsection (4)(f), the provider shall ensure each client, the client's parent or legal guardian, OL, and each sending agency or private agency receives a copy of the congregate care ombudsman notice.

(6) The provider shall:

(a) document notification to the local government for any new service or increased consumer capacity, as described in Section 26B-2-117;

(b) maintain compliance with, or documentation of any exemption from, requirements for:

(i) a food handler permit for any person preparing meals for any other person;

(ii) each capacity determination, including each staff and client on the premises, that does not exceed any capacity limit placed by a local authority;

(iii) fire clearance, if conducted separately from a business license; and

(iv) licensure and registration of any vehicle used to transport a client.

(7) Any provider with local requirements under dispute must resolve the dispute before OL may issue a license in good standing.

(8)(a) The provider shall maintain:

(i) fire insurance;

(ii) general liability insurance;

(iii) professional liability insurance, as applicable;

(iv) vehicle insurance and registration for any vehicle that transports a client; and

(v) any additional insurance as required to cover each program activity.

(b) The provider shall make documentation of insurance and registration described in Subsection (8)(a) available to OL upon request.

(9) The provider shall ensure:

(a) a manager is immediately available when the program is in operation and there is a qualified designee when the manager is absent or unavailable;

(b) the implementation of a quality improvement plan addressing any:

(i) client or staff grievance;

(ii) program feedback; or

(iii) trend in licensing noncompliance and incident reports;

(c) there is a means to communicate with each client, which may include a language interpreter being available or a referral to an appropriate resource;

(d) availability of a current staff list and client list;

(e) each entity associated with the provider understands and signs the provider code of conduct before working with any client; and

(f) the organizational and governance structure of the program is available to OL upon request and includes:

(i) each line of authority and responsibility; and

(ii) a job description for each job title, including each duty and qualification.

(10) The provider shall notify OL of any program change, as described in Section R380-600-4.

(11) Any provider serving or likely to serve any client with a substance use disorder shall ensure:

(i) there is an opioid overdose reversal kit on site; and

(ii) staff receive training on how to use the kit before being on-duty.

(12) Any provider serving a client who is classified as an education entitled child shall:

(a) comply, as applicable, with Section 26B-2-116, Rule R277-709, and Rule R277-926 regarding coordination of any educational service, including completion of youth education forms at initial and renewal licensure; and

(b) make any necessary accommodation to allow a client to continue that client's education with a curriculum approved by the Utah State Board of Education.

(13) Any provider that offers on-site school shall:

(a) ensure each client is taught at the appropriate grade level;

(b) ensure a staff-to-client ratio of one staff to every four clients in the school setting, unless the provider is an intermediate secure treatment program;

(d) keep the education record of each client;

(e) use a curriculum with an educational accreditation in good standing, including the Utah State Board of Education or the National School Accreditation Board; and

(f) during discharge, provide proof of high school graduation or equivalent to the client, the client's parent or legal guardian, and the local education agency (LEA).

(14) The provider shall ensure any:

(a) clinical and medical staff have the appropriate license or certification;

(b) clinical and medical staff are in good standing with any license or certification; and

(15) Any provider using telehealth for treatment shall operate within the scope of the provider's professional licensure in accordance with:

(a) Section 26B-4-704; and

(d) any applicable rule.

(16) Any provider offering any behavior intervention service to a client served by the Division of Services for People with Disabilities (DSPD) shall comply with Rule R539-4, which supersedes any conflicting rule under Title R501.

(17)(a) The provider shall ensure access to a medical clinic or a licensed medical professional familiar with the program and population served.

(b) A licensed medical professional shall oversee the medication management practices for the program.

(c) The provider shall ensure that each person involved with the prescription, administration, or dispensing of any controlled substance maintains the appropriate medical or pharmaceutical license and the Drug Enforcement Administration registration numbers, as described in 21 CFR 1301 (2021), published by the Office of the Federal Register, incorporated by reference in this rule.

(d) The provider shall ensure at least one CPR and first aid-certified staff is available when any staff or client is present, unless a licensed medical professional is present on site.

(18) Any provider that serves a client who has been placed in a Utah program from outside of Utah shall comply with Title 80, Chapter 2, Part 9, Interstate Compact on Placement of Children.

(19) The provider may allow a client to remain in the program after the client turns 18 years old, as described in Subsection 26B-2-104(1)(a)(iii), if:

(a) the client has remained in the custody of a state entity or the client was admitted and continuously resided in the program for at least 30 days before the client's 18th birthday;

(b) the client has a documented need to remain in the program;

(c) the provider maintains responsibility for discharge to an appropriate setting when clinically appropriate and no later than the client's 19th birthday;

(d) the provider outlines a plan for the protection of any client younger than 18 years old by supervising and separating the client who is 18 years old from any client who is under the age of 16; and

(e) the client signs a consent document outlining that:

(i) any criminal offense committed may result in being charged as an adult;

(ii) if the client is involved in any critical incident posing a risk to the health and safety of any other client, the client who is 18 years old may be discharged from the program; and

(iii) the client consents to remain in the program voluntarily and understands the client is not being required to remain in the program against the client's will.

(20) The provider shall ensure weekly, confidential communication between the client and any family member or authorized contact of the client, in accordance with Section 26B-2-123.

(a) A client's parent or legal guardian shall authorize, in writing, an alternate means of confidential communication when voice-to-voice communication is unavailable.

(b) The frequency or form of the confidential communication requirement may only be modified if the provider submits a voice-to-voice variance notification to OL, signed by the provider's clinical director, demonstrating:

(i) any extenuating circumstances that exist outside the client treatment plan that inhibit offering voice-to-voice communication;

(ii) an alternative that satisfies the requirement of weekly, confidential two-way communication;

(iii) the program primarily operates in an area of limited or unreliable phone accessibility or coverage; or

(iv) there is a significant risk of harm or danger to the client's emotional, mental, or physical safety by providing the client with unsupervised phone access.

(d) A standardized statement or practice applied to every treatment plan may not be used to satisfy the requirement of individualized documentation.

(21) A provider may offer any client step-down privileges, including authorized departures from the program and unsupervised time, if the provider:

(a) documents in the client record and communicates to each client's direct care staff:

(i) the individualized justification for the step-down privileges; and

(ii) which privileges are authorized by a licensed clinical professional;

(b) maintains a staff-to-client ratio of one direct care staff for every four clients present in the step-down setting;

(d) distributes a policy to each client, client's parent or legal guardian, and staff that includes:

(i) a description of how each step-down privilege may be achieved or rescinded;

(ii) a description of what constitutes authorized departure and unsupervised time;

(iii) a statement that no client with step-down privileges is allowed to perform any direct care staff duty; and

(iv) a statement that the provider will immediately communicate to each client, client's parent or legal guardian, and direct care staff when any step-down privilege has been rescinded.

(22) Any provider that serves any client with a substance use disorder shall ensure each staff and client is screened for tuberculosis as recommended by the local health authority.

(23) The provider shall make any program record in this section available to OL for review upon request.

R501-19A-7. Client Intake and Discharge.

(1) Each provider shall develop, maintain, and adhere to an admissions review process that:

(a) is approved by OL during initial and renewal licensure;

(b) aligns with the admissions criteria described in Section 26B-2-124;

(c) outlines the process for identifying a qualified candidate who can be safely served in the program, including an assessment of each candidate in consideration of:

(i) the candidate's behavior;

(ii) the candidate's diagnosis;

(iii) the candidate's individual situation;

(iv) the candidate's trauma history;

(v) the population and age of each client the provider already serves;

(vi) the physical facility;

(vii) the programming; and

(viii) the ability of current staff to manage the candidate; and

(d) outlines how to identify a person not considered a qualified candidate.

(2) The provider may not solicit or accept payment from, or on behalf of, a client, unless:

(a) the client meets the approved admissions criteria; and

(b) the client's parent or legal guardian has signed a contract for the provider's services.

(3) The provider shall develop, maintain, and adhere to:

(a) an outline of each behavior or presenting issue that would be a reason for:

(i) declining to classify a candidate as qualified for admission; or

(ii) discharging a current client from the program; and

(b) a statement, included in the provider's admissions marketing material, that the program does not accept placement of a client whose needs exceed the scope or ability of the program.

(4) Before accepting any client into a program, the provider shall complete an intake screening for each client that includes:

(a) a description of any presenting needs;

(b) a suicide risk screening;

(d) verification that the client meets the admission criteria of the program; and

(e) verification that the client does not meet any of the exclusionary criteria described in Subsection (3)(a).

(5) A provider serving any client with a substance use disorder may not admit a client who is unresponsive or unable to consent to care because the individual is experiencing convulsions or delirium tremens, in shock, in a coma, or unconscious.

(6) A provider serving any court-mandated, justice-involved client shall:

(a) conduct a criminogenic risk assessment during the client intake process; and

(b) physically separate high criminogenic risk populations from low criminogenic risk populations, including in any bedroom area.

(7) The provider shall ensure that the client, or the client's parent or legal guardian, signs and receives a copy of agreements to be maintained as client records, including the:

(a) determination of eligibility;

(b) fee agreement outlining the cost of services, including program and client, or the client's parent or legal guardian's, responsibility for payment; and

(i) the rights of the client;

(ii) any program expectation of a client and the client's parent or legal guardian;

(iii) licensing contact information;

(iv) insurance information and identification of any other entity that is billed for the client's services;

(v) the client's Medicaid number, if applicable; and

(vi) services to be provided.

(8) The provider shall ensure, upon admission, a disruption plan is tailored to each client and includes:

(a) any plausible reason identified in the admissions process for possible discharge or transfer;

(b) an aftercare plan for disruption, which includes any resource available to the client;

(i) any return to the client's state of origin;

(ii) to the client's parent or legal guardian;

(iii) to another licensed congregate care program; or

(iv) to a higher level of care program or setting, as needed, that:

(A) provides increased clinical treatment and enhanced supervision to address any client need; and

(B) excludes any receiving center, detention facility, and any immediate crisis stabilization setting, such as an emergency room or a short-term acute care hospital;

(d) a signed statement from the client's parent or legal guardian outlining the plan for the client in the event of an unplanned disruption in care;

(e) current emergency contact information of the client's parent or legal guardian, including the parent or legal guardian's:

(i) name;

(ii) address;

(iii) phone number; and

(iv) email address;

(f) each individual responsible for the client's return if placement at the facility disrupts; and

(g) a statement acknowledging the program retains jurisdiction and responsibility for the client while the client remains in Utah.

(9) The provider may not serve any client from out of state without a disruption plan, as described in Section 26B-2-124.

(10) A provider serving any client from out of state shall comply with Section 80-2-905, as applicable.

(11) The provider may demonstrate compliance with Subsection (9) by producing the ICPC-100A and ICPC-100B forms as required by the ICPC Regulations or a disruption plan.

(a) The provider shall report any out-of-state private placement to OL by completing the congregate care out-of-state placement report, available on the OL website, no later than the fifth business day of each month.

(b) Any provider that does not comply with the disruption plan requirements in Section 26B-2-124 shall pay for the cost of care incurred by any entity housing, locating, maintaining, or transporting the client.

(12) Any provider that transports an out-of-state client to a health care facility, as defined in Section 78B-3-403, shall comply with the payment requirements described in Subsection 26B-2-124(10).

(13) Before the provider may accept or discharge any client who is transported by a youth transportation company, the provider must ensure the youth transport company is registered with OL.

(14) The provider shall ensure the completion and documentation of an intake, following an approved admissions review process, no later than seven days after the admission date.

(15) Each client's intake assessment shall include:

(a) any developmental, educational, psychological, social, and vocational factor;

(b) a statement of how the client is a qualified candidate for admission;

(d) the client's cultural background;

(e) the client's health and medical history;

(f) the client's dominant language and mode of communication;

(g) the client's family history; and

(h) a suicide prevention plan that is:

(i) tailored to the client and;

(ii) maintained and revised as needed to support the client's safety.

R501-19A-8. Clinical Services.

(1) The provider shall ensure each client's treatment plan is:

(a) developed and signed by a licensed clinical professional within 30 days of admission; and

(b) followed by staff.

(2) Any staff working directly with a client shall be informed of the individual treatment needs of that client.

R501-19A-9. Client Records.

(1) The provider shall maintain a process for the retention of any client record for seven years or until a client turns 21 years old, whichever comes later.

(2) The provider shall make any client record available to OL upon request.

(3) The provider shall ensure each client record includes:

(a) the client name, date of birth, and identified gender;

(b) accurate parent or legal guardian contact information;

(c) a list of any client's authorized contact as identified by the client's parent, legal guardian, or sending agency or private agency, including each authorized contact's:

(i) name;

(ii) phone number; and

(iii) relationship to the client;

(d) any signed agreement and consent form;

(e)(i) consent for each treatment and non-clinical service signed by the client, or the client's parent or legal guardian; or

(ii) a court order of commitment to services in lieu of signed consent for each treatment and non-clinical service;

(f) any information that could affect the health, safety, or well-being of the client, including any:

(i) allergy;

(ii) chronic condition;

(iii) communicable disease; and

(iv) medication needs;

(g) any grievance or complaint made by or against the client and any action taken by a provider;

(h) each crisis intervention or critical incident report involving the client;

(i) an individualized assessment for restriction of access to any on-site item that could be used as a weapon, for self-directed violence, or as an intoxicant;

(j) an individualized disruption plan;

(k) an individualized suicide prevention plan, as needed;

(l) an intake screening and assessment;

(m) any progress note and service provided with date and signature of staff completing each entry;

(n) a summary of attendance and absence in each treatment service;

(o) the treatment or service plan;

(p) any referral arrangement made by the provider;

(q) discharge documentation; and

(r) an initial and annual client tuberculosis screening result for any client with a history of substance abuse.

(4) The provider shall disclose how any client and client's parent or legal guardian may access any educational or medical record following the client's discharge from the program, including how and where to locate records if the program is no longer licensed.

R501-19A-10. Staff Records and Training.

(1) The provider shall maintain staff information, including:

(a) a provider code of conduct with the signature of each staff, contracted employee, or volunteer;

(b) any approved and current OBP background clearance, except as excluded in Rule R501-14;

(d) any grievance or complaint made by or against the staff and action taken by the provider;

(e) any pre-service and annual training record, which includes the:

(i) date of completion;

(ii) topic; and

(iii) signature of each staff who completed the training;

(f) each crisis intervention or critical incident report involving staff; and

(g) documentation of the initial and annual tuberculosis screening, if serving a population with a substance use disorder.

(2) The provider shall ensure staff training is:

(a) completed within 30 days of hire and annually thereafter; and

(b) covers:

(i) CPR and first aid;

(ii) Rule R380-80; and

(iii) any policies, procedures, and safe practice, as described in Section R501-19A-5.

(3) The provider shall ensure staff behavior management training includes:

(a) client rights;

(b) the provider code of conduct;

(d) de-escalation techniques and least restrictive methods for managing behavior;

(e) the physiological and psychological impact of restraints or emergency safety intervention;

(f) any threshold for restraints or emergency safety intervention;

(g) the time limit for restraints or emergency safety intervention;

(h) appropriate monitoring of any use of restraints and emergency safety intervention;

(i) how to recognize the physical signs of distress or positional asphyxia and obtain medical assistance;

(j) the procedure:

(i) to intervene if another staff fails to follow procedure for restraints or emergency safety intervention;

(ii) for documenting and reporting any use of restraints or emergency safety intervention;

(iii) for processing restraints or emergency safety intervention with a client; and

(iv) for staff follow-up after use of restraints or emergency safety intervention; and

(k) the process for obtaining clinical approval for continued use of restraints or emergency safety intervention.

R501-19A-11. Physical Facility.

(1)(a) The provider shall maintain the facility in a clean and safe manner free from any hazard that could pose a risk to a client's health or safety.

(b) The provider shall keep each furnishing and finish clean and in good repair.

(c) The provider shall conduct a fire drill at least quarterly and document the response time and process for each fire drill.

(d) The provider shall ensure each appliance and electrical, HVAC, and plumbing system is maintained in operating order.

(2) The provider shall provide indoor space for informal client activities.

(3) The provider shall ensure that when a client is present, there is a phone available in each facility that can be used to call 911.

(4) The provider shall maintain a first aid kit at each facility.

(5) The provider shall have a separate space for any client who is showing symptoms of an infectious disease.

(6) The provider shall ensure there is designated space available for:

(i) records;

(ii) administrative work; and

(ii) confidential client phone calls.

(7) For each client bedroom, the provider shall ensure:

(a) there is at least 60 square feet per client;

(b) there is a source of natural light;

(d) any bedroom assignment is made in accordance with OL policy and individualized assessment, described in Section 26B-2-109;

(e) no client is locked in the client's bedroom;

(f) each client has a similar solid type of bed or sleeping equipment to any other client in the program;

(g) each client is allowed to decorate and personalize the client's bedroom, while maintaining respect for each other resident and the property; and

(h) each bedroom is comparable to other similarly used bedrooms with similar access, finishes, furnishings, location, and space.

(8) A provider serving any client receiving DSPD services may not house more than two clients in each bedroom.

(9) The provider shall ensure any bedding or towel provided to a client is laundered:

(a) weekly;

(b) any time the bedding or towel is soiled; and

(10) The provider shall supply each client with any hygiene item necessary to meet the client's needs.

(11) The provider shall ensure each client bathroom:

(a) allows for individual privacy;

(b) affords reasonable accommodation based on the client's gender identity;

(d) is properly equipped with toilet paper, soap, and a non-shared means to dry hands;

(e) is ventilated by mechanical means or equipped with a window that opens; and

(f) includes a mirror, or safety mirror, secured to the bathroom wall at a convenient height.

(12) The provider shall ensure any live-in staff has a dedicated bedroom and bathroom separate from any client bedroom or bathroom.

(13) If the program permits a client to do laundry, the provider shall ensure:

(a) any equipment and supplies for washing and drying laundry are available; and

(b) separate containers for soiled and clean laundry are provided, if the program provides common laundry for bedding, clothing, or towels.

(14) The provider shall maintain any on-site medication or potentially hazardous item lawfully, responsibly, and with consideration of the safety and risk level of the population served, including locked storage for each medication and hazardous chemical that is not in active use.

(15) The provider shall ensure the licensed medical professional responsible for administration and supervision of prescription medication reviews information and each dosage for each client at least weekly.

(16) For any on-site medication, the provider shall ensure the medication:

(a) is stored in the manufacturer's original packaging, including any directions and warning information; and

(b) is discarded when no longer required for a client.

(17) The provider may store any on-site medication, or medication for an off-site visit, outside of the manufacturer's original packaging if, at least weekly, the provider ensures:

(a) a licensed medical professional oversees the filling and administration of each medication package;

(b) each client's pill organizer includes:

(i) the client's name;

(ii) the medication's name;

(iii) any directions for medication administration;

(iv) dosage information; and

(v) the date filled; and

(18) For each seclusion room, the provider shall ensure:

(a) the seclusion room is not located in any bathroom, closet, unfurnished area, or other area outside the residential living space;

(b) a bedroom is not used as a seclusion room and a seclusion room is not be used as a bedroom;

(c) the seclusion room is at least 75 square feet and has a ceiling height of at least seven feet with no equipment, furnishing, or hardware that obstructs the staff's view of the client or presents a risk of harm;

(d) there is a break-resistant two-way mirror or camera for observation of the entire room;

(e) there is mechanical ventilation or a break-resistant window in the seclusion room; and

(f) the seclusion room does not have a locking capability.

(19) The provider shall accommodate a client with a physical disability as needed or refer the client to comparable services.

R501-19A-12. Background Checks.

(1) OBP shall conduct a human services program background check for each program staff or volunteer, in accordance with Section 26B-2-120 and Rule R501-14.

(2) The provider shall designate an individual who is responsible for:

(a) ensuring and documenting how each applicant is directly supervised for the entirety of that applicant's supervised employment term before receiving the eligible determination;

(b) ensuring an application is submitted in DACS within 14 days of each staff becoming associated with the provider;

(d) maintaining compliance with Rule R501-14;

(e) managing communications with OBP and OL;

(f) monitoring DACS and taking necessary action when staff eligibility status changes; and

(g) separating any staff in DACS within five days of that staff:

(i) no longer being associated with the provider; or

(ii) having an ineligible determination status from OBP on a background check with no pending appeal.

(3) The provider shall ensure each direct care staff, contracted staff, volunteer, and intern has an eligible background check determination before permitting that individual to work unsupervised with a client, except as excluded in Rule R501-14.

R501-19A-13. Client Care, Safety, and Supervision.

(1) The provider shall ensure:

(a) a staff-to-client ratio of one direct care staff to every four clients is maintained, except:

(i) to reduce the staff-to-client ratio during client sleeping hours to one direct care staff to every 16 clients;

(ii) in an intermediate secure program, as specified in Subsection R501-19A-14(2); and

(iii) as otherwise required by a department contract;

(b) a ratio of one staff to one client during any transport only occurs when the provider has conducted a safety assessment that demonstrates client and staff safety is reasonably assured;

(c) any direct care staff assigned to supervise a client one-on-one is not counted at the same time in the staffing ratio for any other client, except in an emergency situation;

(d) at least two direct care staff are on-duty and immediately available;

(e) direct care staff conduct and document line-of-sight check-ins at least every 15 minutes when the staff is outside the line of sight of any client;

(f) direct care staff conduct and document sign-of-life check-ins during sleeping hours and when a client is in the medical bay;

(g) continuous direct supervision of any client that meets supervision and ratio needs of the presenting population, including increasing the ratio for individual supervision as needed;

(h) on-site video surveillance is only used to directly supervise a client in time-out or seclusion or as an enhancement to minimum supervision ratio requirements;

(i) only direct care staff may perform direct supervision;

(j) staff conduct and document physical check-ins every 15 minutes when a client is being monitored by video;

(k) the staff-to-client ratio may only decrease during sleeping hours if:

(i) a minimum of two direct care staff are on-duty;

(ii) each client is appropriately supervised to ensure health and safety at the ratio; and

(iii) each direct care staff remains awake while on-duty;

(l) the staff-to-client ratio is increased as necessary to ensure the health and safety of the client population;

(m) there are enough staff on-duty each shift to safely supervise the client population, including adding more staff than required by the usual staffing ratio as needed to manage behaviors, dynamics, and individual client treatment and supervision needs;

(n) there is a phone accessible to each client, staff, or any other individual to place a direct call to the congregate care ombudsman:

(i) at any time;

(ii) without interference;

(iii) with sufficient privacy to preclude another individual from hearing the conversation; and

(iv) subject to the whistleblower protections in Section 26B-2-124.3; and

(o) video surveillance is only used in a client bedroom if:

(i) the provider monitors any camera footage or physically performs client checks in at intervals of at least every 15 minutes;

(ii) there is a documented need;

(iii) providing services to an individual served by DSPD, the video surveillance is compliant with Rule R539-3; and

(iv) the client, or the client's parent or legal guardian, provides written permission.

(2) The provider may not allow:

(a) any client, non-direct care staff, or direct care staff who does not have current behavior management training, or anyone unfamiliar to the client, to use any form of restraint on a client;

(b) any intervention that uses painful stimuli, unless as an individually justified and documented emergency safety measure;

(d) the use of restraints or seclusion as a convenience to staff, substitute for programming, or punishment.

(3) The provider may allow a client to be separated from the area of any activity or any other client, including a client's bedroom, if on-duty staff:

(a) provides direct line-of-sight supervision and monitors the client;

(b) does not prevent the client from leaving the area; and

(c) documents the separation, including the reason for the separation and the amount of time the client was separated from an activity or another client.

(4) The provider may only use any:

(a) body cavity search of a client in alignment with Subsection 26B-2-123(1)(a)(ii); and

(b) strip search of a client in alignment with Subsection 26B-2-123(1)(a)(i).

(5) For each critical incident, the provider shall:

(a) document the details of the critical incident in each client and staff record;

(b)(i) report to each involved client's parent or legal guardian no later than one business day after the incident; or

(ii) when the critical incident involves any client meeting the definition of a child in crisis, report to the client's parent or legal guardian no later than five hours after the crisis began; and

(6) During each shift, the provider shall:

(a) document and share with staff from the next shift and the administration any client illness, injury, or critical incident; and

(b) maintain and make available to OL upon request each staff shift list.

R501-19A-14. Additional Requirements for Intermediate Secure Care Programs.

(1)(a) Each intermediate secure treatment provider shall clearly define in policy any responsibility of the manager, as described in Subsection R501-19A-6(9)(a).

(b) The provider shall ensure the manager:

(i) is at least 25 years old;

(ii) has a bachelor's degree or equivalent training in a human service-related field; and

(iii) has at least three years of management experience in a residential or secure treatment setting.

(2) Each intermediate secure treatment provider shall maintain a staff-to-client ratio of one direct staff to every five clients.

(3) Each intermediate secure treatment provider shall ensure that each direct care staff working in an intermediate secure treatment program:

(a) receives training to work with a client with behavioral or mental health needs;

(b) works under the supervision of a licensed clinical professional; and

(i) client record and incident documentation;

(ii) each rule and regulation associated with serving clients;

(iii) interpersonal relationships and communication skills;

(iv) maintaining staff, client, and visitor safety in a secure setting;

(v) problem-solving and guidance;

(vi) the special needs of families; and

(vii) any universal precaution for bloodborne pathogens.

(4) Each intermediate secure treatment shall incorporate the use of any fixture and furnishing to limit client self-harm and suicide, including:

(a) non-exposed fire sprinkler heads;

(b) plexiglass or safety glass;

(d) recessed lighting; and

(e) sealed light fixtures.

R501-19A-15. Congregate Care Advisory Committee.

(1) The committee shall, in consultation with OL, advise as to whether each application for licensure or renewal meets each requirement in accordance with Subsection 26B-2-124.1(3)(c).

(2) The committee shall provide consultation to OL regarding:

(a) defining and assigning the levels of congregate care to new and existing programs; and

(b) setting the minimum safety requirements for each level of congregate care, considering any:

(i) facility;

(ii) policy;

(iii) procedure;

(iv) safe practice;

(v) program;

(vi) service;

(vii) staffing; and

(viii) other element or characteristic determined by OL and the committee to impact the safety to an admitted client.

R501-19A-16. Compliance.

Any person who violates this rule may be subject to the penalties in Rule R380-600 and Title 26B, Chapter 2, Part 7, Penalties and Investigations.

KEY: human services, licensing, congregate care, residential treatment

Date of Last Change: July 30, 2026

Authorizing, and Implemented or Interpreted Law: 26B-2-104; 26B-2-124; 26B-2-124.1