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New Licensing Standards - 2960


New Licensing Standards - 2960 DOC to license/certify: ALL Group Residential Detention Secure Restrictive Techniques Corrections Shelter DHS to license/certify: – PowerPoint PPT presentation

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Title: New Licensing Standards - 2960

New Licensing Standards - 2960
  • DOC to license/certify
  • ALL
  • Group Residential
  • Detention
  • Secure
  • Restrictive Techniques
  • Corrections
  • Shelter
  • DHS to license/certify
  • ALL
  • Group Residential
  • Chemical Dependency
  • Mental Health
  • Shelter
  • Transitional
  • Restrictive Techniques

Administrative Standards
  • ALL

2960.0010 Purpose And Applicability
  • Governs the licensing of providers of residential
    care for children in out-of-home placement.

2960.0010 - Providers
  • Unit of government
  • Individual
  • Corporation
  • Limited liability corporation
  • Partnership
  • Voluntary association
  • Other organization or entity
  • Controlling individual

2960.0010 Scope of the Rule
  • residential care on a 24-hour basis
  • treatment
  • detention
  • foster
  • rehabilitation service
  • Juvenile sex offender treatment programs also
    governed by MN Rule

  • Time out
  • Disciplinary room time

  • Not transferable to another
  • individual/entity
  • location

2960.0030 - Application
  • Form provided
  • applicant's name and address
  • name and location of the program
  • geographic area to be served
  • license or certification being requested
  • requested license capacity
  • age limits

  • Organizational chart depicting organizational

2960.0030 Subpart 2B-4 Application
  • The applicant must provide
  • description of the services
  • program's philosophy
  • target population
  • program outcomes

2960.0030 Subpart 2B-5 Approvals
  • Health Department of Health or local health
  • Local building code inspector
  • Local zoning authority
  • Fire State Fire Marshal or approved local code
  • or Document waiver

2060.0030 Subpart 2B-6 Community Analysis
  • Description of the neighborhood demographic
  • race
  • socioeconomic characteristics
  • crime statistics
  • vehicle traffic
  • proximity of the proposed facility to schools,
    day care providers

Neighborhood Demographics
  • public transportation
  • public and private recreation facilities
  • neighborhood religious and spiritual organizations

Neighborhood Demographics
  • Information about local business groups,
    community groups, block clubs, and service

2960.0030 Subpart 2B-7 County Role in Screening
  • The license holder must discuss with the county
    social services agency of the county in which the
    facility is located, the facility's policy
    regarding the county's role in screening facility

County Role in Screening
  • The facility must document the contact with the
    county and any agreement between the county and
    the facility regarding the county's role in
    screening facility residents.

2960.0030 Subpart 2D Fee
  • An applicant for Department of Human Services
    licensure or certification must pay a licensing
    fee which is calculated according to parts
    9545.2000 to 9545.2040.

2960.0030 Subpart 3 DOC Criteria
  • A. Primarily serve delinquent children who are
    at least ten years old, but younger than 21 years
    old, in a residential setting
  • B. Operate a detention or group residential
    facility for children alleged to be delinquent
  • C. Be certified to provide residential program
    services for residents who need correctional

2960.0030 Subpart 4 DHS Criteria
  • Serve children through the age of 19
  • Operate a group residential program with possible
    certifications in the areas of
  • chemical dependency treatment
  • treatment for severe emotional disturbance
  • shelter services
  • transitional services

2960.0030 Subpart 5 Multiple Program
  • The Department of Human Services and the
    Department of Corrections shall determine which
    commissioner will license or certify the

2060.0030 Subpart 6 Variance Request
  • The part or parts of the standard
  • Reason for the variance
  • Period of time of the variance
  • Written approval from the fire marshal, building
    inspector, or health authority as applicable
  • Alternative equivalent measures

2960.0030 Subpart 6E Variance Authority
  • Department of Human Services
  • M. S. 245A.04, subdivision 9.
  • Department of Corrections
  • M. S. 241.021.
  • The decision of the commissioner of human
    services or corrections to grant or deny a
    variance request is final and not subject to
    appeal under Minnesota Statutes, Chapter 14.

Denial of Application
  • compliance with laws or rules
  • health or safety deficiencies
  • hazardous condition
  • fire, building, zoning, health approval

Denial of Application Failure to comply may be
indicated by
  • Department of Education lack of approval of
    on-site school
  • Disqualification of the applicant/ controlling
  • Failure to submit a completed application
  • DHS Denial DOC Denial

2960.0030 Subpart 9 Drug and Alcohol Use
  • Includes prescription drugs
  • Policy required
  • Training in the drug policy

2960.0030 Subpart 11 Policy and Procedure Review
  • The license holder must submit the facility's
    program policies and procedures to the
    commissioner of human services or corrections for

2960.0030 Subpart 11 License/Certification Terms
  • name of the license holder
  • address of the program
  • effective date and expiration dates
  • type of license
  • maximum number and ages of residents
  • any special conditions of licensure
  • certification(s) granted

Subpart 12 Licensing Actions
  • Department of Human Services Minnesota Statutes,
    Chapter 245A.
  • Department of Corrections
  • Minnesota Statutes, Section 241.021.

2060.0040 Statement of Intended Use
  • Target population served
  • cultural background
  • gender
  • license holders expertise and qualifications to
    provide the services
  • age
  • medically fragile condition

Statement of Intended Use
  • legal status chips, delinquency, voluntary
    placement, self-referral
  • primary needs of residents met in the licensed
  • resident services provided by programs outside
    the setting

Statement of Intended Use
  • Specific extent and limitations of the program
  • Restrictive procedures-extent and limitations
  • Involvement of the resident's cultural or ethnic
    community to ensure culturally appropriate care

2960.0500 - Basic Rights
  • reasonable observance of cultural and ethnic
    practice and religion
  • reasonable degree of privacy
  • participate in development of the resident's
    treatment and case plan
  • positive and proactive adult guidance, support,
    and supervision

2960.0500 - Basic Rights
  • free from abuse, neglect, inhumane treatment,
    and sexual exploitation
  • adequate medical care
  • nutritious and sufficient meals and sufficient
    clothing and housing
  • clean, safe surroundings
  • public education

2960.0500 - Basic Rights
  • Reasonable communication and visitation, which
    may include
  • Attorney
  • Therapist
  • Physician
  • Religious- Spiritual advisor
  • Case manager
  • Parent
  • Extended family members
  • Siblings
  • Legal guardian
  • Caseworker

2960.0500 - Basic Rights
  • access to protection and advocacy services
  • state-appointed ombudsman
  • personal property
  • courteous and respectful treatment
  • Minnesota Statutes, Sections
  • 144.651 Patients Bill of Rights
  • 253B.03 Rights of Patients

2960.0500 - Basic Rights
  • grievance procedure
  • free from restraint or seclusion used for a
    purpose other than to protect the resident from
    imminent danger to self or others except for the
    use of disciplinary room time as it is allowed in
    the correctional facility's discipline plan
  • free from bias and harassment regarding race,
    gender, age, disability, spirituality, and sexual

2960.0500 - Basic Rights
  • nutritious and sufficient meals and sufficient
    clothing and housing
  • clean, safe surroundings
  • public education

2960.0500 License Holder Duties
  • provide basic services
  • develop operational policies and procedures which
    correspond to the basic rights
  • give the resident a written copy of the
    resident's basic rights

2960.0500 Basic Rights Information
  • explain to the resident in a language that the
    resident can understand
  • rights related to the resident's care explained
    within 24 hours of admission
  • procedures which correspond to the basic rights

2960.0500 Basic Rights Information
  • tell the resident's parent, guardian, or
    custodian within a reasonable time that the
    information regarding rules is available
  • Post resident rights in the
  • Residents and staff area
  • Staff station
  • how to contact the appropriate state-appointed
    ombudsman name, address, and telephone number

2960.0060 Statement of Program Outcomes
  • written policies that identify program outcomes
    and promote the resident's development as a
    physically and mentally healthy person
  • the program services offered by the license
    holder must be consistent with the resident's
    case plan

2960.0060 Outcome Measures
  • the measurement must document the degree to which
    the license holder's services provided to the
    resident, or the resident's family, have been
    successful in achieving the intended outcome of
    the services offered to the resident and the
    resident's family
  • measure the success in achieving statement
  • specific factors as required by DHS/DOC

2960.0060 Outcome Measures
  • specific factors as required by DHS/DOC
  • the program services offered by the license
    holder must be consistent with the resident's
    case plan

2960.0060 Program Evaluation
  • annually evaluate strengths and weaknesses of the
    program using at least the following performance
  • accidents
  • use of restrictive procedures
  • grievances
  • adverse maltreatment findings and legal actions
    against the license holder

2960.0060 Program Evaluation
  • satisfaction survey results
  • critical incidents
  • Must be kept for two licensing periods
  • Must use the program evaluation findings to
    make program improvement

Independent Program Audit
  • comply and cooperate with independent program
    audits DHS/DOC
  • comply with the findings
  • document with operational policies and procedures
  • retain demographic information on a resident
  • document the extent of the resident's program
    completion on designated form

Community Involvement
  • Board of directors or advisory committee that
    represents the interests, concerns, and needs of
    the residents and community served and comply
    with the findings
  • The Board or advisory committee must meet at
    least annually

Community Involvement
  • The license holder meet at least annually with
    community regarding
  • the nature of the program
  • types of residents served
  • results of the services the program provided to
  • number of residents served in the past 12 months
  • the number of residents likely to be served in
    the next 12 months.

2960.0070 Admission Process
  • The license holder must have written specific
    identifiable admission criteria consistent with
    the statement of intended use.
  • The License holder must
  • Have resources and qualified staff to respond to
    residents with disabilities

Admission Process
  • The license holder must

Admission Process
  • Consider placing a female resident when there are
    few other female residents in the facility
  • Whether the facility could offer gender-specific
    services for female residents

Admission Process
  • Consider placing a male resident when there are
    few other male residents in the facility
  • Whether the facility could offer gender-specific
    services for male residents
  • Seek approval of the commissioner of corrections
    to serve those over age 19

2960.0070 Subpart 3 Admission Documentation
  • Within 5 working days after admission
  • legal authority for resident placement
  • date and time of admission
  • name and nicknames
  • last known address and permanent address
  • name, address, and telephone number of parents,
    guardian, and advocate

Admission Documentation
  • date and place of birth
  • race or cultural heritage
  • languages the resident speaks and writes
  • tribal affiliation

Admission Documentation
  • description of presenting problem
  • medical problems
  • circumstances leading to admission
  • mental health concerns
  • safety concerns assaultive behavior,
    victimization concerns

Admission Documentation
  • resident assets and strengths and related
    information from the resident, family, and
    concerned persons
  • name, address, and telephone number for the last
    educational program contact person
  • spiritual or religious affiliation
  • placing agency's case plan goals for the resident

2960.0070 Subpart 4 Resident Property
  • inventory the resident's personal property
    (including clothing)
  • resident and the license holder sign the
    inventory upon admission
  • (resident refusal two staff sign)
  • ensure resident use and availability of personal
    funds/property unless restrictions justified in
    treatment plan

2960.0070 Subpart 4 Resident Funds
  • Whenever the license holder assists with
    residents funds they must
  • Keep separate facility and resident funds
  • When safekeeping funds/property
  • Document receipt and disbursement
  • Must have signatures of resident/
  • Return to the resident funds/property within 3
    working days request.

Funds-Must Nots
  • borrow money from a resident
  • purchase personal items from a resident
  • sell merchandise, except canteen-type service
  • sell personal services to a resident
  • require a resident to buy items for which the
    facility is reimbursed
  • use of funds that would violate part 9505.0425,
    subpart 3.

2960.0070 - Screenings Required
  • health screening
  • history of abuse
  • vulnerability to abuse
  • potential for self-injury
  • current medications
  • most recent physician's/clinic's
  • name
  • address
  • number

Screenings Required
  • mental health screening
  • education screening Minnesota Statutes, section
  • chemical abuse or chemical dependency screening
  • (The license holder will provide or contact the
    resident's case manager, if applicable, to
    arrange a screening to determine if the resident
    is chemically dependent)

Screenings Required
  • screening for sexually abusive behavior
  • written risk management plans (resident, other
    residents, staff, community)
  • vulnerability assessment
  • culture
  • gender-specific needs screening
  • psychosocial needs of the resident
  • needs regarding the gender of the staff

2960.0070 Subpart 5C Screening Time Lines
  • other screenings begin - 3 working days,
    completed - 6 working days
  • health screening - within 24 hours of admission
  • May substitute screening or assessment completed
    within the last 6 months
  • if on file
  • no reason to believe condition has changed

Screening Time Lines
  • If a resident is transferred from another
    facility - Request of sending facility records
    needs to be immediate
  • Screenings must include documented inquiries
    regarding the degree to which the family desires
    to be involved during the residents stay
  • (N/A to residents on detention status for less
    than 6 working days)

2960.0080 - Basic Services
  • Must provide services that fulfill the basic
    rights of the resident
  • Must have stated objectives and measurable
  • Must coordinate and ensure off-campus program
    services if applicable
  • Must meet the basic needs of the residents
    served by the facility.

2960.0080 Subpart 3 Cooperation
  • Cooperate with case manager/other appropriate
    parties in creating and delivering basic
  • resident
  • parent
  • legal representative
  • case manager
  • treatment team

2960.0080 Subpart 3A Implementation of Case Plan
  • coordinate facility plan with placing agency's
    case plan
  • work with the placing agency to identify
  • projected length of stay
  • conditions for family reunification or permanency
  • license holder actions to help carry out the plan

B - Identify and Share Information
  • (Per case plan)
  • about the resident's treatment
  • about major treatment outcome plans
  • including attaining developmentally
    necessary/appropriate life skills
  • communicate as necessary with previous school and
    current school

D - Identify and Share Information
  • report the resident's behaviors and other
    important information to the placing agency
  • recommend case plan changes to the placing agency

F - Identify and Share Information
  • Share information (as allowed by law)
  • resident's therapist
  • physician
  • professional treating the resident
  • agencies providing discharge services

Identify and Share Information
  • Provide records to parent/guardian
  • Respond to court orders and authorized
    information release requests in 3 business days

2960.0080 Subpart 4 Facility Rules/Due Process
  • communicate verbally to the resident and in
    writing facility's rules and due process system
  • acceptable and unacceptable behaviors and the
    reasons why
  • consequences applied in recognizing and rewarding
    acceptable behavior and modifying unacceptable

2960.0080 Facility Rules/Due Process
  • circumstances, if any, that will result in
    time-out or restrictive procedure use
  • due process system for disciplinary consequences
  • relationship of IEP discipline recommendations to
    the facilities

2960.0080 Subpart 5 Discipline Policy/Procedures
  • Policies and procedure must consider
  • Abuse history
  • Developmental needs
  • Culture needs
  • Disability needs
  • Gender needs

2960.0080 Subpart 5 Prohibition of Corporal
  • Rough handling
  • Shoving
  • Ear or hair pulling
  • Shaking
  • Slapping
  • Kicking
  • Kicking
  • Biting
  • Pinching
  • Hitting
  • Throwing Objects
  • Spanking

2960.0080 Prohibition of Verbal Abuse
  • name calling
  • derogatory statements about the resident/ family
  • race
  • gender
  • disability
  • sexual orientation
  • religion
  • culture

2960.0080 Prohibition of Verbal Abuse
  • statements intended to
  • shame
  • threaten
  • humiliate
  • frighten

2960.0080 Discipline Prohibited
  • punishment for lapses in toilet habits, bed
    wetting and soiling
  • withholding of
  • drinking water
  • clothing
  • hygiene facilities
  • normal sleeping conditions
  • nutritious diet

2960.0080 Subpart 5A-4 Discipline Prohibited
  • Withholding of
  • proper lighting
  • educational services
  • exercise activities
  • ventilation and proper temperature
  • mail
  • family visits
  • positive reinforcement
  • medical care
  • nurturing

2960.0080 Discipline
  • However, a resident who destroys bedding or
    clothing or uses these or other items to harm
    self or others, may be deprived according to the
    residents case plan

2960.0080 Discipline Prohibited
  • assigning work that is dangerous or not
    consistent with the residents case plan
  • disciplining one resident for the unrelated
    behavior or action of another, except recognized
    treatment program peer group restrictions

2960.0080 Discipline Prohibited
  • Inappropriate use of restrictive techniques or
  • as punishment
  • for the convenience of staff
  • as compensation for in adequate staffing
  • as a substitute for program services

2960.0080 Subpart 5A-9 Discipline Prohibited
  • communication restrictions beyond treatment/case
  • prohibited punishments such as
  • extended time in uncomfortable or fixed positions
  • march
  • stand
  • kneel
  • delegation of authority to punish another resident

2960.0080 Discipline
  • License holder must comply with 9525.2700,
    subpart 2, item G, regarding the use of aversive
    or deprivation procedures with a resident who has
    mental retardation or a related condition

2960.0080 Subpart 5D Time-out Requirements
  • time-out must be used as a non-emergency behavior
    management technique which is used to intervene
    in a resident's undesirable behavior and to allow
    the resident to reflect and become calm before
    returning to ongoing activities at the facility

2960.0080 Time-out Requirements
  • Must be used under the direction of
  • mental health professional
  • facility director
  • program manager
  • Must be consistent with treatment plan
  • A staff must escort a resident to safe unlocked
    room or other separate living space
  • Staff must assess at least every 30 minutes

2960.0080 Training Requirement Time-Out
  • Staff must be trained in the following
  • the needs and behaviors of residents
  • building relationships with residents
  • alternatives to time-out
  • de-escalation methods
  • avoiding power struggles with residents
  • documentation standards for the use of time-out

2960.0080 Time-out Requirements
  • Treatment team review of time-out use for each
    resident during the treatment plan review
  • Document use of time-out in record
  • cause factors
  • circumstances
  • resident's response
  • resident's ability to de-escalate
  • acceptable behavior after time-out

2960.0080 Subpart 5E Certification Required
  • Staff must have restrictive procedures
    certification (2960.0710) prior to the use of
    restrictive procedures with a resident

2960.0080 Subpart 6 Daily Resident Activities
  • written schedule of daily activities
  • know the whereabouts of each resident
  • immediately notify the referring or placing
    agency of runaway / missing resident

2960.0080 Subpart 7 Culturally Appropriate Care
  • document culturally appropriate care provided
  • opportunities to associate with culturally and
    racially similar adults, peers, and role models
  • opportunities to participate in positive
    experiences related to the resident's cultural
    and racial group

2960.0080 Culturally Appropriate Care
  • culturally appropriate program services that
    address the needs of all residents in care
  • cultural sensitivity, including the provision of
    interpreters and English language skill
  • ( Laws 1995, Chapter 226, article 3, section
    60, subdivision 2, paragraph (2), clause (v).)

2960.0080 Subpart 8 Spirituality
  • Opportunity for voluntary participation in
    spirituality services, activities, and counseling
  • A resident must not be required to attend the
    services or activities
  • Service/activities must be held in a location
    which allows choice
  • Attendance or lack of attendance cannot affect
  • Must arrange spiritual counseling if requested by
    a resident.

2960.0080 Subpart 8 Spirituality
  • Accommodate a resident or a resident's family's
    request regarding spiritual needs,
  • If unable document the reason.
  • Within reasonable safety and security rules
  • Allow private interviews or counseling regarding
    spiritual, personal, or family problems
  • Opportunity to meet with a spiritual or religious
    person of their choice.

2960.0080 Subpart 9 Educational Services
  • Facilitate the resident's admission to an
    accredited public school or other lawful school
  • Facility- on grounds school
  • Year-round basis, if required by law
  • Approval of the education services from the
    Department of Education
  • Cooperate with the school district.

Educational Services
  • Facilitate the resident's school attendance and
    homework activities
  • Inquire at least every 90 days
  • Report educational problems to the case manager
    or placing agency
  • Chemical health education to the resident with
    inappropriate chemical use problem

2960.0080 Subpart 11 Health and Hygiene Services
  • Timely access to
  • qualified persons that meet the resident's needs
  • basic
  • emergency
  • specialized medical
  • mental health
  • dental care
  • treatment services

Health and Hygiene Services Pregnant Resident
  • Ongoing and appropriate prenatal care from a
    medically licensed person
  • Prenatal, postnatal, and parenting information

Health and Hygiene Services
  • Ensure provision of appropriate medical and
    dental services
  • Compliance with medical or dental insurance

2960.0080 Subpart 11 Health Provider Gender
  • Consideration of resident's request for a male or
    female health care provider
  • If a female resident requests a female health
    care provider, and one is not available, the
    license holder must request permission from the
    health care provider that an adult female be
    allowed to be present during the health care
  • Likewise for male residents

2960.0080 Subpart 11B Health Records
  • Illness reported by the resident
  • Action taken by the license holder
  • Date of the resident's medical, psychological,
    or dental care

2960.0080 Subpart 11 Medication Plan
  • Maintaining stock supplies of prescription drugs
    at the facility is prohibited.
  • Medication plan (developed with medically
    licensed person) for the safe storage and
    delivery of medicine.

2960.0080 Subpart 11D-1 Medication Plan
  • Contact a newly admitted residents prescribing
    medically licensed person to verify
  • instructions about how to administer the
  • symptoms that the medication will alleviate
  • the symptoms that would warrant consultation with
    the physician

2960.0080 Subpart 11D-2 Medication Plan
  • Documentation of attempts to contact the child's
    parent or guardian to seek permission for the
    facility to administer the medication.
  • If permission is denied and the parent has the
    legal right to deny permission, then the
    medication will be discontinued under the
    supervision of a physician unless a court order
    to administer the medication is obtained.

Medication Plan
  • List of the side effects of medication
  • Document and follow the prescribing physician's
    directions for monitoring medications used by the

2960.0080 Subpart 11-5 Medication Training
  • Medication assistance training (non medically
    licensed person)
  • Medication aide program completion
  • Postsecondary institution
  • Formalized training program
  • Offered by the license holder
  • Taught by a registered nurse
  • Documented in staff personnel records

Medication Review
  • Monthly medication administration review by
    medically licensed person
  • Resident prescription drug record
  • quantity initially received from the pharmacy
  • amount of medication given
  • dosage
  • time taken
  • refusal to take prescription medication

  • Prescription medicine belonging to a resident
    must be given to the resident's parent or legal
    guardian upon the resident's release or must be
    disposed of according to a pharmacy-approved
  • The license holder must note the disposition of
    the resident's medicine in the resident's file.

  • Upon release, the license holder must give a
    resident who is 18 years of age or older the
    prescription medication prescribed for the

2960.0080 Subpart 12 Food and Nutrition
  • Balanced diet consisting of foods and beverages
  • palatable
  • adequate quantity and variety
  • prepared and served at appropriate temperatures
  • prevent food-borne illness
  • conserve nutritional value

Food and Nutrition
  • Provide a medically prescribed diet, if ordered
  • Offer a diet that does not conflict with the
    resident's religious or cultural dietary regimen.

2960.0080 Subpart 13 Clothing, Bedding, and
  • adequate amount of clean clothing appropriate for
    the season
  • appropriate sized, clean, fire-retardant
  • two sheets or one sheet and clean mattress cover
  • sufficient clean blankets to provide appropriate
    warmth for the season

Clothing, Bedding, and Laundry
  • One pillow and one pillowcase that is
  • Adequate bath towels and washcloths
  • Bedding and linens furnished upon admission
  • Bedding and linens cleaned once a week or more
  • No worn out/unfit bedding and linens

2960.0080 Subpart 14 Emergency Plan
  • Develop a written emergency plan
  • fire
  • natural disaster
  • serious illness
  • severe weather
  • disappearance of a resident
  • law enforcement/emergency response situation.

2960.0080 Subpart 14 Emergency Plan
  • Developed with the advice of local fire and
    emergency response authorities. Including
    emergency care/Special assistance if needed by a
  • Staff and residents plan review every six months.
  • Compliance documentation of the plan and the

Subpart 15 Communication and Visitation
  • Written communications and visiting policy
  • Use of the telephone
  • Mail
  • Adaptive communications devices
  • Other means of communication, compatible with
    needs/case plan

Subpart 16 Communication and Visitation
  • No restriction of the parents visiting rights
    beyond case plan/court order limitations(M.S.260C.
  • Accommodation of parent's schedule

Subpart 17 Critical Incident/Maltreatment Reports
  • Report critical incidents to licensing within 10
    days on approved forms
  • Maintain records of all critical incidents on
    file in the facility
  • Comply with mandatory maltreatment reporting
  • (Minnesota Statutes, sections 626.556 and

Maltreatment Policy
  • Policies and procedures to follow if maltreatment
    is suspected
  • Annual review of maltreatment policies
  • Policy revision
  • comply with changes in law
  • meet identified needs
  • review of incident quality assurance reports
    indicate a change is warranted

2060.0080 Subpart 18 Resident Family Grievance
  • Develop follow written grievance policy
  • Allow others in residents life to make a formal
    complaint or suggestion or express concern about
    any aspect of the residents care
  • Staff may not influence a residents statement
    about the facility in a grievance

Resident Family Grievance Procedures
  • The written grievance procedure must require
  • Must give resident forms and assistance to file
    the grievance
  • Identify the person authorized to resolve the
    complaint appeal information
  • Upon request, the grievance must be carried to
    the highest administration or placing agency

Subpart 19 Family Involvement
  • If family involvement is a goal in a resident's
    case plan, the license holder must
  • list procedures and program plans which are in
    accordance with a resident's case plan,
  • facilitate the involvement of the resident's
    family or other concerned adult, in the
    resident's treatment or program activities.

2960.0090 Subpart 2 No Eject Policy
  • Written no eject policy
  • Confer with other interested persons to review
    the issues
  • Review process must not exceed five working days
  • Any additional strategies to resolve the issues
    and prevent discharge

No Eject Policy
  • If discharge is warranted the reasons for it and
    the alternatives considered or attempted must be
  • A resident may be temporarily removed from the
    facility during the five-day review period
  • This subpart does not apply to a resident removed
    by the placing authority or a parent or guardian

Subpart 3 Property Return
  • The license holder must return all of the
    resident's personal property to the resident
  • Signed receipt upon discharge, unless prohibited
    to do so by law or case plan
  • Discrepancies between the resident's inventoried
    property turned over to the facility at admission
    and the property returned to the resident at
    discharge, and the resolution of the discrepancy,
    must be documented by facility staff

2960.0100 Staffing Plan
  • Approved by the Commissioner of Human Services or
  • Identifies the assignments of facility staff
  • Meets the cultural and ethnic needs of the
    facility residents to the extent permitted by law

2960.0100 Subpart 2 Recruitment of Culturally
Balanced Staff
  • To the extent permitted by law, it is the license
    holder's responsibility to actively recruit,
    hire, and retain full-time staff who are
    responsive to the diversity of the population
  • If the facility staffing plan does not meet the
    cultural and racial needs of facility residents
    the license holder must document the reasons

Recruitment of Culturally Balanced Staff
  • Work with cultural or racial communities to meet
    the needs of residents.
  • In addition, the license holder must contact a
    cultural or racial community group related to the
    resident's cultural or racial minority background
    and seek information about how to provide
    opportunities for the resident to associate with
    adult and peer role models with similar cultural
    and racial backgrounds on a regular basis.

2960.0100 Subpart 3 Orientation
  • The license holder must provide training for
    staff that is modified annually to meet the
    current needs of individual staff persons.
  • The training must be directly related to serving
    the program's target population and to achieving
    the program's outcomes.

  • The license holder must ensure that staff who
    will have direct contact with residents attend
    and successfully complete orientation training
    before having unsupervised contact with residents.

Orientation Training Emergency Procedures
  • evacuation routes
  • emergency telephone numbers
  • severe storm and tornado procedures
  • location of facility alarms and equipment

Orientation Training Statutes, Rules
  • Relevant statutes and administrative rules and
    legal issues
  • Reporting requirements for abuse and neglect
    specified in Minnesota Statutes, sections 626.556
    and 626.557
  • Other reporting requirements based on the ages of
    the residents

Orientation Training Diversity
  • Cultural diversity
  • Gender sensitivity
  • Culturally specific services
  • Information about discrimination and racial bias
    issues to ensure that caregivers have cultural
    sensitivity and will be culturally competent to
    care for residents

Orientation Training Diversity
  • General and special needs, including disability
    needs, of residents and families served
  • Operational policies and procedures of the
    license holder

  • Data practices regulations and issues.
  • The license holder must ensure that staff who
    have direct contact with residents receive
    ongoing training. Training must help staff meet
    the needs of residents and must include skills

2960.0100 Subpart 3B Ongoing Training
  • The license holder must ensure that staff who
    have direct contact with residents receive
    ongoing training.
  • Training must help staff meet the needs of
    residents and must include skills development.

Subpart 4 Specialized Training
  • If needed, license holders and staff must have
    specialized training to develop skills to care
    for residents
  • Specialized training must be directly related to
    serving the program's target population and to
    meeting the program's certification requirements

2960.0100 Subpart 5 Personnel Policies
  • Documentation of training. The license holder
    must document the date and number of hours of
    orientation and in-service training completed by
    each staff person in each topic area and the name
    of the entity that provided the training.

Subpart 6 Qualifications
  • The license holder and staff must have the
    education and experience required to meet the
    functions and program activities that the license
    holder declared in the facility statement of
    intended use according to part 2960.0040.

Staff Qualifications
  • Responsible, mature, healthy adult who is able to
    carry out the license holder's duties.
  • Able to accomplish the license holder's duties to
    the resident's case plan and treatment plan and
    meet the resident's needs.
  • Trained in gender-based needs and issues.
  • At least 21 years old.

Subpart 7 Background Study
  • A license holder and individuals identified in
    Minnesota Statutes,
  • DHS Minnesota Statutes, section 245A.04,
    subdivision 3.
  • DOC Minnesota Statutes, section 241.021,
    subdivision 6.
  • must submit to a background study.

  • The facility must be equipped and maintained in a
    manner that conforms to its statement of intended
  • The physical environment must provide for the
    comfort, privacy, and dignity of residents.

2960.0110 Subpart 3 Facilities
  • The license holder must ensure that food
    services, storage, housekeeping, laundry, and
    maintenance are operated on a consistent, healthy
  • If food service is contracted to a food service
    vendor, the food service vendor must meet health
    code requirements.

  • If the license holder provides educational
    services on site, the classrooms must provide an
    atmosphere that is conducive to learning and
    meets the resident's special physical, sensory,
    and emotional needs.
  • The license holder must provide adaptive
    equipment and furnishings to meet the resident's
    special needs.

Subpart 4 First Aid Kits
  • A facility must have first aid kits readily
    available for use by residents and staff. The
    kits must be sufficient to meet the needs of
    residents and staff.

2960.0120 Physical Plant Standards
  • Fire, health, zoning, and building code
  • Sleeping rooms for 4 or less
  • Multi-bed bedrooms ambulatory residents
  • 60 square feet per resident of useable flood
  • three feet between beds placed side by side
  • one foot between beds placed end to end

Subpart 2 Code Compliance
  • Multi-bed bedrooms non-ambulatory residents
  • 80 square feet per resident of useable floor
  • adequate space for clothing and personal
  • appropriate furnishings to accommodate these

Code Compliance
  • Outdoor recreational space
  • One shower or bathtub/sink/toilet per 8 residents
  • Hot and cold water
  • Heating plant providing comfortable temperature
    in all resident areas
  • Lighting appropriate to function of area

Code Compliance
  • Sufficient indoor space
  • For quiet group program activities
  • On site education Facility must meet the DOE
    provisions of educational services
  • Private intake admission area