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

R501-1. General Provisions for Licensing.

R501-1-1. Authority and Purpose.

(1) This rule is authorized by Section 26B-2-104.

(2) This rule clarifies the general compliance standards for programs licensed under Title R501.

(3) This rule provides definitions for Title R501.

R501-1-2. Scope.

(1) Rules R501-1 and R380-600 apply to any program subject to human services program licensure.

(2) Each licensee and person associated with the licensee shall comply with:

(a) Rule R501-14;

(b) any applicable categorical rule in Title R501; and

R501-1-3. Definitions.

(1) In addition to the definitions outlined in Section 26B-2-101 and Rule R380-600, the following definitions apply to each rule under Title R501.

(2)(a) "Body Cavity Search" means a visual or manual inspection of the body cavity in search of prohibited material.

(b) "Body Cavity Search" does not mean an inspection of a client's mouth after taking medication.

(3) "Category" means the type of human service license described in Section 26B-2-101.

(4) "Chemical Restraint" means any drug that is used to restrict an individual's freedom of movement for discipline, convenience, or immediate safety and not required to treat the individual's medical symptoms.

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

(6) "Compliant" means adherence to governing rule and statute.

(7) "Confidential communication" means communication between only the individuals referenced in Subsection 26B-2-123(6) that does not allow for outside entities to have access to information contained in the confidential exchange.

(8) "Conflict of Interest" means a situation where a person is in a position to derive personal benefit from actions or decisions made in their official capacity.

(9)(a) "Congregate Care Program" means the same as the term defined in Section 26B-2-101.

(b) "Congregate Care Program" does not mean a residential program licensed to serve adults that is approved by the office to serve a child for a limited time.

(10) "Direct Care Staff" means staff working directly with clients.

(11) "Direct Supervision" means in close physical proximity and actively supervising clients with the ability to immediately respond as necessary.

(12) "Education Entitled Children" means the same as the term is defined in Section 26B-2-116.

(13) "Licensee" means an individual or a human services program licensed by the office.

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

(15) "Medication-Assisted Treatment" means the use of medications with counseling and behavioral therapies to treat substance use disorders or prevent opioid overdose.

(16) "On duty" means individuals counted in supervision ratios and charged with supervising clients as a primary job requirement.

(17) "Parent program" means an applicant or licensee owning or directing multiple sites under the same general administrative organization.

(18) "Person" means:

(a) an individual;

(b) an association;

(d) a corporation;

(e) a company;

(f) a trust;

(g) a limited liability company;

(h) a partnership;

(i) a political subdivision;

(j) a government office, department, division, bureau, or other body of government; and

(k) any other organization or entity.

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

(20) "Residential program" means a program providing overnight care and includes the following license categories:

(a) recovery residence;

(b) residential support;

(d) outdoor youth;

(e) therapeutic school; and

(f) social detoxification.

(21)(a) "Restraint" means physically restricting a client's freedom of movement, physical activity, or normal access to their body; and includes passive, chemical and mechanical restraint used as a last resort as a means to prevent harm to self or others.

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

(22) "Seclusion" means, except for medically approved quarantine, the involuntary confinement of an individual in an area:

(a) away from the individual's peers; and

(b) in a manner that physically prevents the individual from leaving the room or area.

(23) "Settings Final Rule" means 42 CFR Parts 430, 431, 435, 436, 440, 441, and 447 that impacts Medicaid funding in residential settings that serve elderly and disabled populations.

(24) "Significant criminal activity" means any unlawful activity by or against any of the licensee's clients or on duty staff members that poses a serious threat to their health, safety, or well-being including:

(a) any criminal activity that involves law enforcement;

(b) illegal physical or sexual misconduct or assault;

(d) suspected fraud; and

(e) suspected exploitation.

(25) "Significant medical emergency" means an acute injury or illness posing an immediate risk to a person's life or health or requires emergency medical care.

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

(27) "Staff" means an individual who is associated with a licensee.

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

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

(30) "Trauma-informed" means overall practices that promote environments of healing and recovery rather than practices and services that may inadvertently re-traumatize.

R501-1-4. Program Policies, Procedures, and Safe Practices.

(1) The licensee shall submit to the office, before program implementation, policies and procedures that include:

(a) a description of what constitutes sex and gender abuse, discrimination, and harassment;

(b) procedures for preventing and reporting abuse, discrimination, and harassment; and

(c) procedures for teaching effective and professional communication with individuals of any sexual orientations and genders.

(2) The licensee shall develop, implement, and comply with safe practices that:

(a) ensure client health and safety;

(b) ensure the needs of the client population served are met;

(c) ensure that none of the program practices conflict with any administrative rule or statute before implementation; and

(d) inform staff of how to manage any unique circumstances regarding the specific site's physical facility, supervision, community safety, and mixing populations.

(3) The licensee shall submit any change to an office-approved policy or curriculum to the office for approval before implementing the proposed change.

(4) A congregate care program licensee shall submit to the office any policies and procedures that describe behavior management, suicide prevention, restraint, or seclusion used in the program as described in Section 26B-2-123, before implementation.

(5) In addition to complying with Section 26B-2-123, a congregate care program licensee shall ensure that the congregate care behavior management policy and practices reflect the following:

(a) a congregate care program licensee uses behavior management techniques that are trauma-informed and appropriate for the client's age, behavior, needs, developmental level, and past experiences and defer to the least restrictive method of behavior management available to control a situation;

(b) a congregate care program licensee only uses behavior management techniques that emphasize de-escalation and promote self-control, self-esteem, and independence;

(c) a congregate care program licensee identifies a behavior management curriculum that emphasizes de-escalation and is compliant with Section 26B-2-123;

(d) only direct care staff familiar with the child and the child's needs conduct passive physical restraint;

(e) restraint is only used if it does not cause undue physical discomfort, harm, or pain to the client;

(f) interventions that use painful stimuli are prohibited as a general practice;

(g) passive physical restraint is used only as an emergency, temporary means of physical containment to protect the consumer, other persons, or property from immediate harm;

(h) restraint only continues as long as the client presents an immediate danger to self or others;

(i) passive physical restraint is not used as a convenience to staff, a substitute for programming or associated with punishment in any way;

(j) a client, non-direct care staff member, or other unauthorized individual does not use any form of restraint;

(k) staff do not use physical work assignments or activities that inflict pain as behavior management techniques; and

(l) staff are trained to ensure the following safe practices:

(i) appropriate de-escalation techniques and alternatives to restraint or seclusion;

(ii) thresholds for restraints;

(iii) the physiological and psychological impact of restraint;

(iv) appropriate monitoring of restraint episodes;

(v) how to recognize the physical signs of distress, positional asphyxia, and obtaining medical assistance;

(vi) how to intervene if another staff member fails to follow correct procedures when using a restraint;

(vii) time limits for restraints;

(viii) the process for obtaining clinical approval for continued restraints;

(ix) the procedure for documenting and reporting restraints;

(x) the procedure for processing restraints with clients;

(xi) the procedure for following up with staff after a restraint;

(xii) how staff address injuries and complaints;

(xiii) department code of conduct; and

(xiv) client rights.

(6) A congregate care program licensee shall ensure that congregate care seclusion policy and practices reflect the following:

(a) seclusion is only used to ensure the immediate safety of the child or others and is terminated as soon as the risks have been mitigated, not to exceed four hours without clinical justification;

(b) staff who are familiar to the child directly supervise the child during the seclusion;

(c) staff supervising seclusion ensure that any potentially harmful items or objects are removed from the seclusion environment;

(d) seclusion rooms measure a minimum of 75 square feet and have a minimum ceiling height of seven feet with no equipment, hardware or furnishings that obstruct staff's view of the client or present a hazard;

(e) seclusion rooms have either natural or mechanical ventilation with break resistant windows and either a break resistant two-way mirror or camera that allows for observation of the entire room;

(f) seclusion rooms do not have locking capability and are not located in closets, bathrooms, unfurnished areas or other areas not designated as part of residential living space;

(g) bedrooms are not utilized as a seclusion room and seclusion rooms may not be utilized as bedrooms;

(h) seclusion episodes are documented in detail by the staff involved in initiating and supervising the seclusion episode;

(i) seclusion episodes of more than two in a 24-hour period are supported by clinical review and documentation regarding client suitability for remaining in the program; and

(j) client time-out is used when addressing behavioral issues only if:

(i) a client in time-out is never physically prevented from leaving the time-out area;

(ii) it takes place away from the area of activity or from other clients, such as in the client's bedroom;

(iii) staff monitors the client while in time-out; and

(iv) the reason for and duration of time-out is documented by staff on duty when it occurs.

(7) A congregate care program licensee shall develop and follow a suicide prevention policy that complies with Subsection 26B-2-123(5).

(8) A congregate care program licensee shall ensure that the program's licensed clinical professional conducts regular reviews of client restraints, seclusions, behavioral interventions, and time outs to inform processing discussions with clients and training for direct care staff.

(9)(a) Before a congregate care program licensee may accept a client or send a discharging client who is transported by a youth transportation company as defined in Section 26B-2-101, the licensee shall ensure that the transport company is registered with the office.

(b) A congregate care program licensee shall report private placements to the office as described in Section 26B-2-124 by completing the congregate care out of state placement survey on the office website no later than the fifth business day of each month.

R501-1-5. Residential Program Additional Safe Practices.

(1) A licensee that manages, stores, or administers client medications shall develop and ensure compliance with the following medication management safe practices:

(a) inform staff and clients of program and client responsibility for medication including storage and administration of medications on-site and, as applicable, when staff and clients are off-site in program related activities;

(b) if applicable, inform staff and clients of the medication self-administration process;

(d) how staff record medication dosages according to prescriptions;

(e) how staff monitor for and record effects and side effects of medications; and

(f) how staff log doses and record and report medication errors.

(2) The licensee shall ensure the care, vaccination, licensure, and maintenance of any animals on-site to include:

(a) assessment of pet allergies for any clients interacting with animals in the program;

(b) maintenance of required examinations, registrations, and vaccinations; and

(3) The licensee shall have separate space for clients who are showing symptoms of an infectious disease.

(4) The licensee shall ensure that a ratio of one staff to one client during transports is only utilized when the program has conducted a safety assessment that indicates that client and staff safety is reasonably assured.

R501-1-6. Program Administrative and Direct Service Requirements.

(1) The licensee shall clearly identify services to the office, public, potential client, parent, or guardian regarding:

(a) current and accurate contact information;

(b) the complaint reporting and resolution process;

(d) each program requirement and expectation;

(e) eligibility criteria outlining behavior, diagnosis, situation, population, and age that can be safely served, including:

(i) an outline of the behaviors and presenting issues that would be reason for discharge or exclusion from the program; and

(ii) a statement that the program may not take placement of a child whose needs exceed the scope or ability of the program to reasonably manage;

(f) each cost, fee, and expense for a service and refund policy; and

(g) identification of each non-clinical, extracurricular, or supplemental service offered or referred.

(2) The licensee shall post the following in conspicuous places where each visitor, staff, and client may view:

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

(b) civil rights notice;

(d) the program license;

(e) any office notice of agency action;

(f) a client rights poster in a residential setting except in a foster home or where prohibited by Settings Final Rule; and

(g) department code of conduct poster.

(3) The licensee shall maintain compliance with or documentation of an exemption from any of the following requirements:

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

(b) capacity determinations that include each staff and client on premises and may not exceed the capacity limits placed by local authorities;

(d) licensure and registration of any vehicles used to transport clients.

(4) The licensee whose local clearances are under dispute shall resolve any dispute before the office issues a license in good standing.

(5) The licensee shall maintain and make the following available to the department upon request:

(a) proof of financial viability of the program as verified by a financial professional;

(b) general liability insurance;

(d) vehicle insurance;

(e) fire insurance; and

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

(6) The licensee shall ensure:

(a) each entity associated with the licensee reads, understands, signs, and follows the current provider code of conduct before working with clients;

(b) current staff and client lists are available at each licensed site;

(i) line of authority and responsibility;

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

(iii) notification to the office of any program changes as described in Section R380-600-3;

(d) a quality improvement plan that is implemented and followed and that incorporates, at a minimum, client and staff grievances, feedback, trends in licensing noncompliance and incident reports;

(e) the licensee provides an interpreter or refers each client to appropriate resources as necessary to communicate with the client; and

(f) the licensee maintains an opioid overdose reversal kit on-site with on duty staff trained in its use if the licensee is serving, or is likely to serve, a client with a substance use disorder.

(7) A licensee serving education entitled children shall comply with Section 26B-2-116 regarding coordination of educational services to include completion of youth education forms at initial and renewal licensure.

(8) A licensee offering school on-site shall:

(a) maintain the established staff to client ratio with behavioral intervention trained staff in the school setting;

(b) ensure recognition in good standing by an educational accreditation organization such as the State Board of Education or the National School Accreditation Board; and

(9) The licensee shall ensure clinical and medical staff are licensed or certified in good standing and any unlicensed staff are appropriately supervised as described in Title 58, Occupations and Professions.

(10) A licensee that utilizes telehealth for treatment shall do so within the scope of their professional licensure in accordance with Section 26B-4-704 and Title 58, Chapters 60 Mental Health Professional Practice Act and 60a Counseling Compact and comply with each applicable rule.

(11) A non-residential licensee offering community-based services shall comply with each applicable rule, as determined by the office.

(12) A licensee that provides behavior interventions to people with disabilities shall comply with Rule R539-4, which supersedes any conflicting rule under Title R501, for the disabled populations served.

(13) The licensee shall maintain a record retention process that retains each client record for seven years or until a client turns 21 years of age, whichever comes later.

(14) If a licensee sells or arranges for client insurance coverage, the licensee shall:

(a) inform the client in writing of the licensee's role and responsibility;

(b) provide the insurer with any program licensee record;

(d) not provide unlawful substance abuse patient brokering as described in Subsection 26B-2-113(5).

R501-1-7. Residential Program Additional Administration and Direct Services Requirements.

(1) A residential program licensee shall additionally:

(a) ensure each staff shift list remains current and available to the office upon request;

(b) ensure that each shift documents any illness, injury or critical incident and passes it on to the next shift and administration;

(d) ensure access to a medical clinic or a medical professional familiar with the program and population served; and

(e) provide a separate space for clients who are showing symptoms of an infectious disease.

(2) A congregate care program licensee serving youth who have been placed in Utah from outside of Utah shall demonstrate compliance with Section 80-2-9, Interstate Compact on Placement of Children.

(3) A congregate care program licensee may allow an individual turning 18 to remain in the program as described in Subsection 26B-2-104(1)(a)(iii) if:

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

(b) the licensee has a documented need for the individual to remain in the program;

(c) the licensee maintains responsibility for discharge to an appropriate setting when clinically appropriate and no later than the day an individual reaches 19 years of age;

(d) the licensee outlines a plan for the protection of younger clients by supervising and separating 18-year-old individuals from youth who are more than two years younger; and

(e) the individual signs a consent document outlining:

(i) the individual is consenting to remain in the program voluntarily and understands the individual is not required to remain against their will;

(ii) that any criminal offenses committed may result in being charged as an adult; and

(iii) that if the individual is involved in any critical incidents posing a risk to the health and safety of other program residents they may be discharged from the program.

(4) A congregate care program licensee shall ensure weekly confidential communication with family in accordance with Section 26B-2-123 and shall ensure that:

(a) the frequency or form of the confidential communication requirement is only modified if the program submits a modification request that demonstrates the following to the office:

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

(ii) there is significant risk of harm or danger to client safety by providing youth with unsupervised telephone access;

(iii) the licensee offers an alternative that satisfies the requirement of weekly confidential two-way communication; or

(vi) extenuating circumstances exist outside the individual treatment plans that are prohibitive to offering voice to voice communication;

(b) a parent or guardian authorizes in writing an alternate means of confidential communication when voice to voice is unavailable; and

(5)(a) A modification to voice to voice communication is a program license-specific approval.

(b) An individual modification may only be made in accordance with Section 26B-2-123 and requires individualized documentation, or an individualized client treatment plan.

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

(d) A modification plan for confidential communication may not be implemented without written approval from the office.

(6)(a) A residential program licensee, excluding a residential treatment program, may allow for client independence and responsibility for their own supplies, food, laundry, or transportation by outlining in writing resources and responsibility for the provision of these items.

(b) Each residential program licensee shall assist clients on a limited basis if they are temporarily unable to provide the items or services listed in Subsection R501-1-7(6)(a) for themselves.

R501-1-8. Program Physical Facilities and Safety.

(1) The licensee shall ensure:

(a) the appearance and cleanliness of the building and grounds are maintained and free from health and fire hazards;

(b) any appliances, plumbing, electrical, HVAC, and furnishings are maintained in operating order and in a clean and safe condition;

(c) fire drills in non-outpatient programs are conducted at least quarterly and documented, including feedback regarding response time and process;

(d) a phone that can be used to call 911 is always available on-site when clients are present;

(e) bathroom facilities for staff and clients allow for individual privacy and afford reasonable accommodation based on gender identity;

(f) each bathroom is properly equipped with toilet paper, paper towels or a dryer, and soap;

(g) each bathroom is ventilated by mechanical means or equipped with a window that opens;

(h) non-prescription medication, if stored on-site, is stored in original manufacturer's packaging together with the manufacturer's directions and warnings; and

(i) prescription medication, if stored on-site, is stored in original pharmacy packaging or individual pharmacy bubble pack together with the pharmacy label, directions, and warnings.

(2) The licensee shall accommodate a client with physical disabilities as needed or appropriately refer to comparable services.

(3) The licensee shall maintain medication and potentially hazardous items on-site lawfully, responsibly, and with consideration of the safety and risk level of the population served to include locked storage for each medication and hazardous chemical that is not in active use.

(4) The licensee shall maintain a first aid kit that contains at least:

(a) bandages of different sizes;

(b) tweezers;

(d) disposable sterile gloves.

R501-1-9. Residential Program Additional Facilities and Safety Requirements.

(1) A residential licensee shall ensure:

(a) designated space is available for records, administrative work, and confidential phone calls for clients;

(b) bedroom assignments are made in accordance with agency policy and individualized assessment described in Section 26B-2-109;

(d) each bedroom designated for a client is comparable to other similarly utilized bedrooms with similar access, location, space, finishings, and furnishings;

(e) clients are not locked in bedrooms;

(f) a mirror or safety mirror is secured to each bathroom wall at a convenient height;

(g) each bathroom is placed to allow access to each client without disturbing any other client during sleeping hours;

(h) each bath or shower allows for individual privacy;

(i) each client is supplied with hygiene supplies;

(j) each sleeping area has a source of natural light and is ventilated by mechanical means or is equipped with a window that opens;

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

(l) each client is allowed to decorate and personalize their bedroom, while maintaining respect for other residents and property;

(m) there are separate containers for soiled and clean laundry, if the program provides common laundry for towels, bedding or clothing;

(n) bedding and towels are laundered weekly and after each client is discharged;

(o) equipment and supplies for washing and drying laundry are provided, if the program permits clients to do their own laundry; and

(p) there is at least 60 square feet per person in a multiple-occupancy bedroom and 80 square feet in a single occupant bedroom.

(2) A residential program licensee serving individuals with disabilities shall house no more than two clients in each bedroom.

(3) The licensee utilizing seclusion rooms shall ensure the following:

(a) seclusion rooms measure a minimum of 75 square feet and have a minimum ceiling height of seven feet with no equipment, hardware or furnishings that obstruct staff's view of the client or present a hazard;

(b) a seclusion room shall have either natural or mechanical ventilation with break resistant windows and either a break resistant two-way mirror or camera that allows for observation of the entire room;

(c) a seclusion room may not have locking capability and may not be located in closets, bathrooms, unfurnished areas or other areas not designated as part of residential living space; and

(d) a bedroom may not be utilized as a seclusion room and a seclusion room may not be utilized as a bedroom.

(4) The licensee shall ensure that dormitory space is only permitted in an emergency homeless shelter or a program serving only adults.

(5) The licensee shall train staff and ensure that the use of any alternate sleeping arrangements other than the client's assigned bedroom complies with Subsection R501-1-4(7) and:

(a) preserves client dignity and confidentiality;

(b) shall be done on an individualized, time delimited basis;

(d) may not be used as behavior management or consequence.

R501-1-10. Food Service Requirements.

(1)(a) A residential program licensee that provides meals for four to 15 clients shall comply with a local health inspection as described in Rule R392-110, Food Service and Sanitation in Residential Facilities.

(b) A residential program licensee that provides meals for more than 16 clients shall comply with Rule 392-100.

(c) A residential program licensee serving only adults or adults and children together shall comply with a general health inspection as required by the local health authority.

(2) A licensee that provides meals shall:

(a) ensure that meals are not used as incentive or punishment;

(b) provide nutritional counseling to staff and clients;

(i) maintain a current list of each client with special nutritional needs; and

(ii) ensure that each client with special nutritional needs has food storage and a preparation area that is not exposed to any identified allergen or contaminant;

(d) except in a day treatment program serving clients for less than ten hours a day, or outpatient programs serving clients for less than six consecutive hours a day, provide a variety of three nutritious meals a day that are:

(i) served from dietitian or nutritionist approved menus; or

(ii) for programs serving individuals experiencing homelessness, serve meals as required by USDA standard homeless settings;

(e) establish and post kitchen rules and privileges in a kitchen according to client needs and safe food handling practices; and

(f) provide adequate dining space for clients that is maintained in a clean and safe condition.

(3) A licensee that allows self-serve meals shall ensure that self-serve kitchen users are supervised, directed, and trained by a staff that has a food handler's permit or is trained by Serv-Safe, USDA, or a comparable program.

(4) A licensee that serves parents and their children may allow a consenting adult client to maintain full responsibility for their, and their child's, special dietary needs, if consent is maintained in writing in the client record.

(5) A licensee that offers meals for clients shall ensure there is documented training confirming staff are trained to and adhere to the following safe practices:

(a) how to identify and accommodate clients with special dietary needs; and

(b) allowances for nutritious snacks to be available during restricted hours if the program restricts access to food and kitchen equipment.

(6) If meals are prepared by clients, the licensee shall inform staff and clients in writing of the following:

(a) rules and privileges of kitchen use;

(b) menu planning and procedures;

(d) nutrition and sanitation requirements;

(e) schedule of responsibilities; and

(f) shopping and storage responsibilities.

R501-1-11. Program Client Record Requirements.

(1) The licensee shall maintain client information to include the following:

(a) client name, address, email address, phone number, date of birth and identified gender;

(b) emergency contact names, including legal guardian where applicable, and at minimum, the emergency contact's physical address, current email address or current phone numbers;

(c) a program serving substance use disorder clients shall maintain compliance with an initial and annual client tuberculosis screening results in each client record;

(d) any information that could affect health safety or well-being of the client including each medication, allergy, chronic condition or communicable disease;

(e) intake screening and assessment;

(f) discharge documentation;

(g) treatment or service plan;

(h) progress notes and services provided with date and signature of staff completing each entry;

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

(j) any referral arrangements made by the program;

(k) client or guardian signed consent or court order of commitment to services in lieu of signed consent for each treatment and non-clinical service;

(l) summary of attendance and absences in treatment services;

(m) any grievance or complaint made by or against the client and actions taken by the program;

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

(o) any signed agreement and consent form.

(2) The licensee shall document a plan detailing how each program staff and client file is maintained and remains available to the office and other agencies legally authorized to access the files for seven years regardless of whether the program remains licensed.

R501-1-12. Program Intake and Discharge Requirements.

(1) The licensee shall complete an intake screening before accepting a client into the program that includes at least:

(a) verification that the client meets the eligibility requirements of the program;

(b) verification that the client does not meet any of the exclusionary criteria that the program identified in policy as unable to serve;

(d) suicide risk screening.

(2) A licensee serving substance use disorder clients may not admit anyone who is unresponsive or unable to consent to care because the individual is experiencing convulsions, in shock, delirium tremens, in a coma, or unconscious.

(3) A licensee serving incarcerated or court-mandated justice involved clients shall:

(a) conduct a criminogenic risk assessment;

(b) comply with Justice Reinvestment Initiative certification requirements in accordance with Title R523; and

(4) The licensee shall ensure that , the client, parent, or guardian signs and receives copies of the following agreements to be maintained as client records:

(a) determination of eligibility;

(b) fee agreement outlining costs of services including program, client, parent, or guardian responsibility for payment; and

(i) rules of the program;

(ii) expectations of clients, parents, and guardians;

(iii) services to be provided;

(iv) Medicaid number, insurance information, and identification of any other entities that are billed for the client's services;

(v) client rights; and

(vi) licensing contact information.

(5) The licensee shall ensure that a discharge plan identifies resources available to a client and includes:

(a) reason for discharge or transfer;

(b) aftercare plan;

(d) progress evaluation.

R501-1-13. Residential Additional Program Intake and Discharge Requirements.

(1) A residential program licensee shall ensure an intake assessment is completed following an approved intake screening, no later than seven days from the admission date, and that the assessment considers and contains:

(a) gender identity and individualized assessment for bedroom and bathroom assignments;

(b) cultural background;

(d) family history and dynamics;

(e) current and past health and medical history;

(f) social, psychological, developmental, vocational, and, as appropriate, educational factors;

(g) suicide risk screening; and

(h) authorization to serve and obtain emergency care.

(2) A residential program licensee may not serve youth from out of state without a disruption plan as described in Section 26B-2-124 and, as applicable, Section 80-2-905, Interstate Compact Placement of Children (ICPC).

(3) A congregate care program licensee shall ensure that each congregate care disruption plan complies with the following:

(a) the program retains jurisdiction and responsibility for the youth while the youth remains in Utah; and

(b) the program completes an individualized disruption plan at the time of intake for each out of state client to include:

(i) who is responsible for the child's return if placement at the facility disrupts;

(ii) current emergency contact information to include the name, address, phone and email address of the parent or responsible person;

(iii) a signed statement from parent or responsible person outlining the plan for the youth in the event of an unplanned disruption in care; and

(iv) a plan for safe transportation either to the state of origin, the responsible person as identified in Subsection R501-1-13(3)(b)(i) or to another licensed congregate care program or higher level of care, as needed.

(4) A congregate care program licensee may demonstrate compliance with Subsections R501-1-13(2) and R501-1-13(3) by producing the 100A and 100B forms and disruption plan as required by the ICPC.

(5)(a) A congregate care program licensee shall report private placements to the office as described in Section 26B-2-124 by completing the congregate care out of state placement survey on the office website no later than the fifth business day of each month.

(b) A congregate care program licensee that does not comply with the disruption plan requirements stated in Section 26B-2-124 shall pay for the cost of care incurred by entities maintaining the youth for purposes of locating, housing, or transporting the youth.

R501-1-14. Program Clinical Services.

(1) A licensee that offers clinical treatment shall:

(a) assign a clinical director to ensure that assessment, treatment, and service planning practices are:

(i) regularly reviewed and updated;

(ii) individualized; and

(iii) designed to involve the participation of each client or each client's parent or guardian;

(b) ensure each person working directly with a client is informed of the client's individual treatment needs and advised of the best approach to working with that client;

(c) ensure client treatment plans are developed and signed by a licensed clinical professional within 30 days of admission;

(d) ensure discharge goals are identified in the initial treatment plan and treatment goals are structured around the identified discharge goals and objectives;

(e) ensure that each client identified for treatment receives individual treatment at least weekly; and

(f) ensure any missing individual weekly treatment is justified, approved, and documented by the clinical director.

(2)(a) A residential program licensee shall ensure that in addition to the required weekly individual therapy, frequency and need for family and group therapy and other clinical services are addressed in the individual's treatment plan.

(b) A non-residential program licensee who offers clinical treatment may alter the weekly therapy requirement as designated in the individual's treatment plan.

(4) A licensee who offers group counseling, family counseling, skills development, or other treatment shall offer and document these treatment services as prescribed in the treatment plan.

(5) The licensee shall make any records available to the department for review upon request.

R501-1-15. Program Staffing.

(1) The licensee shall ensure adequate staffing to safely supervise the current 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.

(2) The licensee shall identify a manager or qualified designee who is immediately available when the program is in operation or there is a qualified and trained substitute when the manager is absent or unavailable.

(3) A licensee that offers clinical services shall employ or consult with licensed professional staff that include an individual who is familiar with the program and the needs of each client.

(4) The licensee shall ensure that before allowing a direct care staff to work unsupervised they have an approved background clearance except as excluded in Section R501-14-17;

(5) A licensee who serves clients with substance use disorder shall ensure each staff is screened for tuberculosis.

(6) A licensee who serves a client with substance use disorder may not offer, entice, refer, or recommend medical cannabis as treatment for substance use disorder.

(7) A licensee who manages, stores, or administers client medication shall identify a medical professional to oversee the medication management, medication oversight, and staff training regarding medication management and administration.

(8) The licensee shall ensure that each person involved with the prescription, administration, or dispensing of controlled substances maintains appropriate medical or pharmacy licenses and DEA registration numbers as described in the 21 CFR Part 1301.

(9) The licensee shall create and maintain personnel information for each staff member, contracted employee, and volunteer.

(10) The licensee shall ensure that personnel information includes:

(a) any applicable qualification, experience, certification, or license;

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

(d) any pre-service and annual training records with the date completed, topic, and the individual's signed acknowledgment of training completion;

(e) any grievances or complaints made by or against the individual and actions taken by the program; and

(f) each crisis intervention or critical incident report involving the individual.

(11) The licensee shall ensure that at least one CPR and First Aid-certified staff member is available when staff and clients are present unless a currently licensed healthcare professional is present.

R501-1-16. Personnel Training Requirements.

(1) The licensee shall ensure that each staff receives pre-serving training on the following topics before being left unsupervised and within 30-days of hire:

(a) program policies, procedures and safe practices as outlined in Section R501-1-5;

(b) program emergency preparedness, response, and recovery plan, including at least:

(i) emergency procedures to instruct staff how to address incident reporting, continuity of care, transport, relocation, and client health and safety during natural disasters, extreme weather events, fire, utility or structural failures, or other unexpected disruptions to the program service; and

(ii) instructions to staff regarding how to report and respond to significant criminal activity and significant medical emergencies;

(d) client eligibility, emphasizing the behaviors and circumstances the program can safely manage;

(e) staff involvement and responsibility in the intake, discharge, and unplanned discharge processes;

(f) client rights;

(g) supervision and ratios;

(h) as applicable, medications management, storing, and administration;

(i) as applicable, food handling as outlined in Subsection R501-1-10(3);

(j) background checks;

(k) prevention, signs and symptoms of abuse and neglect, including sexual abuse, and legal reporting requirements;

(l) provider code of conduct as outlined in Rule 380-80;

(m) non-discrimination policy in accordance with Section 26B-2-109 that includes a prohibition of abuse, discrimination, and harassment based on sex, gender identity, or sexual orientation;

(n) staff and client grievance procedures;

(o) crisis intervention;

(p) appropriate use of restraint and seclusion;

(q) de-escalation techniques;

(r) appropriate searches;

(s) appropriate and inappropriate behaviors of clients;

(t) appropriate and inappropriate staff responses to client behaviors; and

(u) if applicable, staff response to a client leaving a program without permission.

(2) The licensee shall ensure each staff completes the following training topics each year, based on the program's license date:

(a) program policies, procedures and safe practices as outlined in Section R501-1-4;

(b) general provisions and applicable categorical licensing rule;

(c) client eligibility, as outlined in Subsection R501-1-6(1)(e), emphasizing the behaviors and circumstances the program can safely manage;

(d) staff involvement and responsibility in the intake, discharge, and unplanned discharge processes;

(e) provider code of conduct as outlined in Rule R380-80;

(f) program plan for the prevention or control of infectious and communicable disease to include coordination with and following any guidance of the state or local health authorities, Center for Disease Control, and the department;

(g) emergency procedures to instruct staff how to address incident reporting, continuity of care, transport, relocation, and client health and safety during natural disasters, extreme weather events, fire, utility or structural failures, or other unexpected disruptions to the program service;

(h) program rules regarding firearms that does not conflict with constitutional or statutory rights regarding concealed weapons permits as described in Title 53, Chapter 5, Part 7, Concealed Firearms Act;

(i) smoking rules in accordance with Title 26B, Chapter 7, Part 5, Regulation of Smoking, Tobacco Products, and Nicotine Products;

(j) how to manage clients who screen with elevated suicide risk levels;

(k) general incident reporting;

(l) prevention, signs, and symptoms of abuse and neglect, including sexual abuse, and legal reporting requirements;

(m) CPR and first aid;

(n) if storing and administering medications, training required to administer medication and the process to be followed;

(o) training to identify and address in a residential or congregate care program:

(i) clients who pose a risk of violence;

(ii) what constitutes contraband, possession of contraband, and how the program ensures restriction of client access to contraband and dangerous weapons or materials;

(iii) clients who are at risk for suicide;

(iv) managing clients with mental health concerns; and

(v) identifying the signs and symptoms of clients presenting under the influence of substances or alcohol;

(p) if the licensee manages funds for client allowances, training to document each expense; and

(q) appropriate use of any alternate sleeping arrangements in a residential or congregate care program.

R501-1-17. Compliance.

(1) A human services program licensee that is in operation on the effective date of this rule shall immediately comply with this rule.

(2) In accordance with Subsection 26B-2-113(2), the office may assess a civil money penalty for noncompliance with any rule under Title R501.

KEY: licensing, human services

Date of Last Change: April 24, 2025

Notice of Continuation: October 3, 2022

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