TITLE 7 HEALTH
CHAPTER 30 FAMILY AND CHILDREN HEALTH CARE SERVICES
PART 13 CRISIS TRIAGE CENTERS
22.214.171.124 ISSUING AGENCY: New Mexico Department of Health (DOH), Division of Health Improvement (DHI).
[126.96.36.199 NMAC - N, 10/30/2018]
188.8.131.52 SCOPE: These regulations apply to public, profit and not for profit crisis triage centers providing the services specified in these regulations. Any crisis triage center providing services specified in these regulations must be licensed under these regulations.
[184.108.40.206 NMAC - N, 10/30/2018]
220.127.116.11 STATUTORY AUTHORITY: The regulations set forth herein are promulgated by the secretary of the New Mexico department of health, pursuant to the general authority granted under Subsection E of Section 9-7-6, NMSA 1978; and the authority granted under Subsection D of Section 24-1-2, Subsection I of Section 24-1-3 and Section 24-1-5 NMSA 1978.
[18.104.22.168 NMAC - N, 10/30/2018]
22.214.171.124 DURATION: Permanent.
[126.96.36.199 NMAC - N, 10/30/2018]
188.8.131.52 EFFECTIVE DATE: October 30, 2018, unless a later date is cited at the end of a section.
[184.108.40.206 NMAC - N, 10/30/2018]
A. To establish minimum standards for licensing crisis triage centers that provide quality crisis stabilization services outside of a hospital setting.
B. To ensure the provision of quality services which maintain or improve the health and quality of life to the clients.
C. To monitor compliance under these regulations through surveys and to identify any facility areas which could be dangerous or harmful.
[220.127.116.11 NMAC - N, 10/30/2018]
A. “Administrator” means the person who is delegated the administrative responsibility for interpreting, implementing, and applying policies and procedures at the crisis triage center. The administrator is responsible for establishing and maintaining safe and effective management, control and operation of the CTC and all of the services provided at the CTC including fiscal management. The administrator must meet the minimum administrator qualifications in these regulations.
B. “Advanced practice registered nurse” means a registered nurse that includes a certified nurse practitioner, or a clinical nurse specialist as defined and licensed under the Nursing Practice Act, as amended, and related regulations, and is currently in good standing.
C. “Applicant” means the individual or legal entity that applies for a CTC license to provide services in a particular facility. If the applicant is a legal entity, the individual signing the license application on behalf of the legal entity must have written legal authority from the legal entity to act on its behalf and execute the application. The license applicant must be the legal owner of the entity providing services, but not necessarily the facility.
D. “Basic life support” (BLS) means training and current certification in adult cardiopulmonary resuscitation equivalent to American heart association class C basic life support and in emergency treatment of a victim of cardiac or respiratory arrest through cardiopulmonary resuscitation and emergency cardiac care.
E. “Caregivers criminal history screen” means pursuant to the criminal history screening for Caregivers Act, Section 29-17-1 through Section 29-17-5 NMSA 1978, the process for health facilities and medicaid home and community-based waiver providers to complete a caregiver criminal history screening for all caregivers no later than 20 calendar days after the employment hire date. The screening or background check includes the submission of fingerprints required for obtaining state and federal criminal history used to conduct the fitness determination. The caregiver’s criminal history screening program receives and processes background check applications for criminal history screenings from care providers in the state of New Mexico. Caregivers may be prohibited from employment if the caregiver has a disqualifying condition.
F. “Chemical restraint” means a drug or medication when it is used as a restriction to manage a client’s behavior or restrict a client’s freedom of movement and is not a standard treatment or dosage for a client’s condition. If a drug or medication is used as a standard treatment to address the assessed current symptoms and needs of a client with a particular medical or psychiatric condition, its use is not considered a chemical restraint.
G. “CLIA” means clinical laboratory improvement amendments of 1988 as amended.
H. “Client” means any person who receives care at a crisis triage center.
I. “Compliance” means the CTC’s adherence to these regulations, as well as all other applicable
state and federal statutes and regulations. Compliance violations may result in sanctions, civil monetary penalties
and revocation or suspension of the CTC license.
J. “Crisis stabilization services” means behavioral health services that are provided to help the client return his baseline level of functioning before the crisis.
K. “CYFD” means the New Mexico children youth and families department.
L. “CYFD criminal records and background checks” means pursuant to the Criminal Offender Employment Act, Section 28-2-1 to Section 28-2-6 NMSA 1978, the New Mexico Children’s and Juvenile Facility Criminal Records Screening Act, Section 32A-15-1 to Section 32A-15-4 NMSA 1978, amended, and Section 8.8.3 NMAC, the process of conducting a nationwide criminal history records check, background check and employment history verification on all operators, staff and employees and prospective operators, staff and employees of treatment facilities and programs with the objective of protecting children/youth and promoting the children's/youth’s safety and welfare while receiving service from the facilities and programs. The process shall include submission of electronic fingerprints for those individuals to the department of public safety and the federal bureau of investigation for the purpose of conducting a criminal history and background check; identification of information in applicants’ background bearing on whether they are eligible to provide services; a screening of CYFD’s information databases in New Mexico and in each state where the applicant resided during the preceding five years; and any other reasonably reliable information about an applicant in order to identify those persons who pose a continuing threat of abuse or neglect to care recipients in settings to which these regulations apply.
M. “Deficiency” means a violation of or failure to comply with any provision(s) of these regulations.
O. “Employee” means any person who works at the CTC and is a direct hire of the owner entity or management company, if applicable.
P. “Facility” means the physical premises, building(s) and equipment where the crisis triage center services are provided, whether owned or leased and which is licensed pursuant to these regulations.
Q. “High risk behavior” means behaviors that place clients, staff or visitors’ physical and mental health and safety at risk.
R. “HSD” means the NM human services department.
S. “Incident” means any known, alleged or suspected event of abuse, neglect, exploitation, injuries of unknown origin or other reportable incidents.
T. “Incident management system” means the written policies and procedures adopted or developed by the CTC for reporting abuse, neglect, exploitation, injuries of unknown origin or other reportable incidents.
U. “Incident report form” means the reporting format issued by the department for the reporting of incidents or complaints.
V. “Level III.7-D: Medically Monitored Inpatient Detoxification” means the types of detoxification services described by American Society of Addiction Medicine (ASAM) in its Patient Placement Criteria, Second Edition, Revised (PPC-2R) Level III &-D includes 24-hour medically supervised detoxification services requiring 24-hour nursing care and physician visits as necessary, unlikely to complete detox, without medical, nursing monitoring and more intensive detoxification services.
W. “Licensee” means the person(s) or legal entity that operates the CTC and in whose name the CTC license has been issued and who is legally responsible for compliance with these regulations.
X. “Licensing authority” means the New Mexico department of health.
Y. “Licensed mental health professional” means a psychologist, social worker, physician, psychiatrist, physician assistant, registered nurse, practical nurse, advanced practice registered nurse, each shall have behavioral health training and shall be licensed in the state of New Mexico.
Z. “Management company” means the legal entity that manages the CTC program, if different from the legal owner of the facility.
AA. “NFPA” means the national fire protection association which sets codes and standards for fire and life safety. NFPA 101 and related standards, current edition as required by the department.
BB. “NMSA” means the New Mexico Statutes Annotated 1978 compilation and all subsequent amendments, revisions and compilations.
CC. “Outpatient services” means immediate crisis stabilization services provided to clients who are not admitted to the residential setting. Outpatient crisis stabilization services are not ongoing behavioral health treatment services.
DD. “Physical restraint” means the use of physical force, consistent with State and Federal laws and regulations, without the use of any device or material that restricts the free movement of all or a portion of a body, but does not include: briefly holding a client in order to calm or comfort the client; holding a client's hand or arm to escort the client safely from one area to another; or intervening in a physical fight.
EE. “Physician” means a licensed individual, currently in good standing, authorized to practice medicine as defined and licensed under the New Mexico Medical Practice Act, Section 61-6-1 to Section 61-6-34 NMSA 1978, as amended, and related regulations or osteopathic medicine as defined and licensed under Section 61-10-1 to Section 61-10-22 NMSA 1978, as amended, and related regulations.
FF. “Physician's assistant” means an individual, currently in good standing, who is licensed and authorized to provide services to patients under the supervision and direction of a licensed physician under the Physician Assistant Act, Section 61-6-7 to Section 61-6-10 NMSA 1978, as amended and related regulations, or is authorized and licensed to provide services to patients under the supervision and direction of a licensed osteopathic physician under the Osteopathic Physicians' Assistants Act, Section 61-10A-1 to Section 61-10-7 NMSA 1978 as amended, and related regulations.
GG. “Plan of correction” (POC) means the plan submitted by the licensee or its representative(s)
addressing how and when deficiencies identified through a survey or investigation will be corrected. A plan of
correction is a public record once it has been approved by the regulatory authority and is admissible for all purposes
in any adjudicatory hearing and all subsequent appeals relating to a CTC license, including to prove licensee
compliance violations or failures.
HH. “Policy” means a written statement that guides and determines present and future CTC decisions and actions.
II. “Premises” means all of the CTC including buildings, grounds and equipment.
JJ. “Primary source verification” means the act of obtaining credentials directly from the original or primary source(s).
KK. “Procedure” means the action(s) that must be taken in order to implement a written policy.
LL. “Quality assurance” means the CTC’s on-going comprehensive self-assessment of compliance with these regulations and other applicable statutes and regulations.
MM. “Quality committee” means a committee comprised at a minimum of the administrator, clinical director, director of nursing, licensed mental health professional, and psychiatrist. Other committee members may be specified by rules governing payor requirements. The committee shall establish and implement quality assurance and quality improvement systems that monitor and promote quality care to clients.
NN. “Quality improvement system” means systematic and continuous actions that lead to measurable improvement in services and focus on reduction and stabilization of crises for clients.
OO. “Registered nurse” means an individual, currently in good standing, who is licensed and authorized to provide nursing services under the Nursing Practice Act, Section 61-3-1 to Section 61-3-30 NMSA 1978, as amended, and related regulations.
PP. “Residential services” means any crisis stabilization services provided to a client admitted to the residential setting.
QQ. “Restraint clinician” means a New Mexico licensed medical doctor, doctor of osteopathy, advanced practice registered nurse, clinical nurse specialist, physician assistant or doctoral level psychologist (Psy.D., Ph.D., or E.D.), who is trained in the use of emergency safety interventions.
RR. “Sanitize clothes” means the use of water at a temperature of 212 degrees or use of a disinfectant agent to wash clothes.
SS. “Scope of practice” means the procedures, actions, and processes that a healthcare practitioner is permitted to undertake under the terms of their professional license. The scope of practice is limited to that which the applicable law allows for specific education, training, experience and demonstrated competency.
TT. “Seclusion” means the involuntary confinement of a client alone in a room where the client is physically prevented from leaving.
UU. “Short-term residential stay” means the limit of a client’s stay is eight days for the residential setting.
VV. “Staff” means any person who works at the CTC, and includes employees, contracted persons, independent contractors and volunteers who perform work or provide goods and services at the CTC.
WW. “U/L approved” means approved for safety by the national underwriter’s laboratory.
XX. “Violation” means all actions or procedures by the CTC or licensee that are not in compliance with these regulations and all other applicable state and federal statutes and regulations.
YY. “Variance” means a written decision, made at the licensing authority’s sole discretion, to allow a CTC to deviate from a portion(s) or a provision(s) of these regulations for a period that expires upon remodel of the CTC or change of ownership, providing the variance does not jeopardize the health, safety or welfare of the CTC’s clients, visitors and staff and is not in violation of other applicable state and federal statutes and regulations. A variance can be renewed upon approval of the licensing authority. A variance may be revoked at the discretion of the licensing authority due to changes in state or federal regulations and statutes, or change of circumstances that may jeopardy the health, safety or welfare of clients.
ZZ. “Waiver” means a written decision, made at the licensing authority’s sole discretion, to allow a CTC to deviate from a portion(s) or a provision(s) of these regulations for a limited and specified time period not to exceed the duration of the license, providing the waiver does not jeopardize the health, safety or welfare of the CTC’s clients, visitors and staff and is not in violation of other applicable state and federal statutes and regulations. A waiver can be renewed on an annual basis upon approval of the licensing authority. A waiver may be revoked at the discretion of the licensing authority due to changes in state or federal regulations, or change of circumstances that may jeopardy the health, safety or welfare of clients.
AAA. “Withdrawal management” means the immediate psychological stabilization, diagnosis and treatment of a client who is intoxicated, incapacitated, or experiencing withdrawal of alcohol or drugs.
BBB. “Youth” means residents 14 years of age and older up to age 18.
CCC. “Youth Staff” means a person who has contact with youth in a licensed facility and includes the owner, operator or director of a program, volunteers, full-time, part-time, and contract employees.
[18.104.22.168 NMAC - N, 10/30/2018]
22.214.171.124 STANDARD OF COMPLIANCE: The degree of compliance required throughout these regulations is designated by the use of the words “shall” or “must” or “may”. “Shall” or “must” means mandatory compliance. “May” means permissive compliance. The words “adequate”, “proper”, and other similar words mean the degree of compliance that is generally accepted throughout the professional field by those who provide services to the public in facilities.
[126.96.36.199 NMAC - N, 10/30/2018]
188.8.131.52 SCOPE OF SERVICES:
A. General scope of services: These regulations apply to crisis triage centers (CTC) which are health facilities offering youth and adult outpatient and residential care services. A CTC provides stabilization of behavioral health crises as outpatient stabilization or short-term residential stabilization in a residential rather than institutional setting, which may provide an alternative to hospitalization or incarceration. The CTC services may vary in array of services offered to meet the specific needs of different communities in New Mexico. A CTC may provide limited detoxification services but is differentiated from a detoxification center in that it does treat individuals who require treatment beyond Level III.7-D: Medically Monitored Inpatient Detoxification. The CTC provides emergency behavioral health triage and evaluation, and on a voluntary basis. The CTC may serve individuals 14 years of age or older who meet admission criteria. The CTC shall offer services to manage individuals at high risk of suicide or intentional self-harm. The CTC shall not refuse service to any individual who meets criteria for services.
B. Type of services:
(1) a CTC structured for less than 24-hour stays providing only outpatient withdrawal management or other stabilization services;
(2) a CTC providing outpatient and residential crisis stabilization services; and
(3) a CTC providing residential crisis stabilization services.
C. Limitations on scope of services:
(1) the CTC shall not accept involuntary commitments or individuals who are not voluntarily seeking treatment;
(2) the CTC shall not provide detoxification services beyond Level III.7-D: Medically Monitored Inpatient Detoxification services;
(3) the CTC shall not provide medical care not related to crisis triage intervention services beyond basic medical care of first aid and CPR;
(4) the CTC shall not provide residential services in excess of 14 calendar days;
(5) the CTC shall not provide ongoing outpatient behavioral health treatment;
(6) the CTC shall not exceed the capacity for which the CTC is licensed;
(7) a CTC with both adult and youth occupants must locate youth rooms and restrooms in a unit or wing that is physically separated from the adult facilities;
(8) A CTC shall not administer emergency psychotropic medications as described in Subsection M of 43-1-15 NMSA 1978.
D. License required:
(1) a CTC shall not be operated without a license issued by the department;
(2) any facility providing the services described in these regulations on the effective date of these regulations, shall apply for a CTC license within 180 days;
(3) a CTC licensed under these regulations shall not assert, represent, offer, provide or imply that the CTC is or may render care or services other than the services it is permitted to render under these regulations and within the scope of all applicable professional license(s);
(4) if an unlicensed CTC is found to be providing services for which a license is required under these regulations, the secretary may issue a cease-and-desist order, to protect human health or safety or welfare. The unlicensed facility may request a hearing that shall be held in the manner provided under these regulations and all other applicable regulations.
[184.108.40.206 NMAC - N, 10/30/2018]
220.127.116.11 INITIAL LICENSE PROCEDURES: These regulations should be thoroughly understood and used by the applicant, when applying for the initial CTC license. The applicant for an initial CTC license under these regulations must follow these procedures when applying for a license.
A. Notification and letter of intent: The owner shall advise the licensing authority of its intent to open a crisis triage center pursuant to these regulations by submitting a letter of intent. The letter of intent must be on the applicant's letterhead and signed by a person with authority to make legal decisions for the owner and the CTC and at a minimum, include the following:
(1) the name of CTC;
(2) the name of the legal owner and licensee and the type of legal entity under which the CTC shall be owned;
(3) the name of the management company, if any;
(4) the type of facility license requested;
(5) the name and resume of the proposed administrator;
(6) the anticipated number of residential and non-residential clients to be served;
(7) the intended population and age range of the clients to be served;
(8) the number of residential beds in the proposed CTC;
(9) the physical address of CTC including building name or suite number;
(10) the mailing address, if different from physical address;
(11) the applicant’s contact name(s), address, e-mail address, and telephone number(s);
(12) the anticipated payers and sources of reimbursement; and
(13) a list of all services to be provided at the CTC location which is requesting the license.
B. License application and fees: After review by the department of the letter of intent for general compliance with these regulations and verification that an application is appropriate under these regulations, the owner shall be required to complete a license application on a form provided by the department. Prior to any construction, renovation or addition to an existing building and after review and approval of the letter of intent by the department, the applicant must submit to the licensing authority an application form provided by the department, fully completed, printed or typed, dated, signed, and notarized accompanied by the required fee. If electronic filing of license applications is available at the time of application, the applicant will be required to follow all electronic filing requirements, and may forgo any notary requirements, if specifically allowed under the applicable electronic filing statutes, regulations and requirements. The licensing authority will provide current fee schedules. The department reserves the right to require additional documentation to verify the identity of the applicant in order to verify whether any federal or state exclusions may apply to the applicant. Fees must be paid in the form of a certified check, money order, personal, or business check, or electronic transfer (if available), made payable to the state of New Mexico, and are non-refundable. The applicant must also attach to the application and submit to the department, a set of building plans which includes all of the information required by these rules, accompanied by proof of zoning approvals by the applicable building authority.
C. Building plans: The CTC building plans must be of professional quality, prepared and stamped by an Architect licensed by the state of New Mexico pursuant to Subsection B of Section 61-15-9 NMSA 1978. One copy of the building plans must be submitted, printed on substantial paper measuring at least 24 inches by 36 inches and drawn to an accurate scale of at least one-eighth inch to 1 foot. The building plans for renovated or building additions to an existing building must include sufficient information to clearly distinguish between new and existing construction, for the department to make a compliance determination. The following plans are the minimum required for all facilities in new and /or renovated construction:
(1) Site plan: showing the location of the building on a site/plot plan to determine surrounding conditions, driveways, all walks and steps, ramps, parking areas, handicapped and emergency vehicle spaces, accessible route to the main entrance, secure yard for clients, any permanent structures, including notes on construction materials used.
(2) Life safety and code compliance plan: noting applicable code requirements and compliance data, locations of rated fire walls, smoke partitions (if any), exit paths & distances, fire extinguishers locations.
(3) Floor plans: showing location use of each room, (e.g., waiting room, examination room, office, client (resident) rooms, kitchen, common elements, door locations (swings), window locations, restrooms, locations of all restrooms, plumbing fixtures (sinks, toilets, tubs-showers; location a of all level changes within and outside the building (e.g. steps or ramps, etc.); and all other pertinent explanatory information addressing the requirements in applicable regulations.
(4) Dimensioned floor plan: showing all exterior and interior dimensions of all rooms, spaces, and corridors, etc.
(5) Exterior building elevations: noting all building heights, locations of exterior doors, and any operable and fixed windows (sill heights).
(6) Building and wall sections: showing at least one building or wall section showing an exterior and interior wall construction section including the material composition of the floor, walls, and ceiling/roof construction.
(7) Schedule sheets: room finish: noting all room finishes, (e.g., carpet, tile, gypsum board with paint, etc); door schedule; noting door sizes/thickness, door types & ratings; window schedule, noting sizes, type and operation; skylight schedule, noting size, type.
(8) Special systems plan: location of fire extinguishers, heat and smoke detectors, nurse call systems, and operational elements of alarm system.
(9) Mechanical plans: noting location of heating units, furnaces, hot water heaters, and fuel type and source; all heating, ventilating and air conditioning/cooling systems including locations of fire dampers.
(10) Plumbing plan: noting all plumbing fixture locations, fixture types.
(11) Electrical plan: noting power and lighting layouts, exit lighting, emergency lighting fixtures, emergency power systems (if any), electrical panel information.
(12) Other plans: As necessary (ie; phasing plan) to describe compliance with the other requirements in applicable regulations.
D. New construction: Building plans must be submitted, and will be reviewed by the department for compliance with these licensing regulations, and applicable building and fire safety codes. If the department approves the CTC’s building plans and local building officials have issued a construction permit, construction may begin. This provision is an ongoing requirement and applies to, and includes all construction at the CTC, which occurs before and after issuance of the initial license. This provision does not generally apply to maintenance and repair. However, if the maintenance or repair impacts or alters any of the CTC requirements under these regulations, the applicant or licensee must notify the department and verify ongoing compliance with these regulations. The department shall not be liable for any costs or damages incurred by the applicant relating to construction in the event the applicant incurs costs or damages in order to comply with these regulations or to obtain a license under these regulations. For all new and proposed construction, the applicant or licensee must submit for building plan approval by the department before construction begins.
E. Existing or renovated construction: If the proposed CTC includes any remodeling, renovations or additions or new construction of any type, the building plans and specifications covering all portions of the proposed work delineating all existing construction and all new or proposed construction shall be and submitted to the department for review and approval. Submit phasing plan if project construction will be phased. New facilities proposed for licensure in existing buildings must comply with all requirements building requirements as if it were completely new construction. If the CTC is located within another licensed facility such as a hospital, the life safety inspection will still be required for compliance with 7.30.13 NMAC requirements. For residential CTC programs, the bed count must be separate from the licensed bed count of the original licensed facility. If a CTC is a separate building associated with an existing license, requirements of this regulation apply to that building.
F. Completed construction: All new or renovated construction completed shall comply with the plans and specifications approved by the department in the plan review process and prior to construction, these rules, and all other applicable rules and codes; and any of the department’s approval(s) shall not waive any other rules or other applicable building and code requirements enforceable by other authorities having jurisdiction. Applicant must receive initial life safety code approval and a temporary license from this department prior to accepting or admitting any clients into the CTC.
G. Additional documents required for license application: The department reserves the right to require an applicant to provide all additional documents, as part of its license application, in order for the department to determine whether the applicant and the CTC are in full compliance with these regulations, as well as all other applicable statutes and regulations. At minimum, additional documents required to be provided as part of the initial licensure process prior to the issuance of a temporary license, include, but are not limited to:
(1) Building approvals: The applicant must submit all building approvals required for the CTC to operate in the jurisdiction in which it is located, including but not limited to:
(a) written zoning approval, building permit final approval, or certificates of occupancy from the appropriate authority (state, city, county, or municipality) for business occupancy; and
(b) written fire marshal approvals from the fire safety authority having jurisdiction.
(2) Environment department approvals: If applicable or required, the applicant must provide written approval from the New Mexico environment department for the following:
(a) private water supply;
(b) private waste or sewage disposal;
(c) kitchen/food service:
(d) x-ray equipment (if any).
(3) Board of pharmacy approvals: A copy of CTC’s drug permit issued by the state board of pharmacy must be provided.
(4) Program description: The applicant must submit with its license application a program outlines consistent with these regulations which includes at a minimum, the following information:
(a) a list and description of all services and the scope of those services to be provided by the proposed CTC;
(b) projected number of clients to be served monthly, both residential and non-residential;
(c) a list of staffing and personnel requirements and duties to be performed;
(d) proposed staffing plans for both residential and non-residential programs;
(e) photocopies of written operating agreements with the following: treatment facilities for behavioral health and physical health care needs that are beyond the scope of the CTC;
(f) admission and discharge criteria; and
(g) an organizational structure diagram or chart including the administrator, governing body, clinical director, director of nursing, direct care staff, and other staff.
(5) Policies and procedures: The applicant must submit with its license application a copy of the CTC’s policies and procedures with a crosswalk to these regulations to show compliance.
[18.104.22.168 NMAC - N, 10/30/2018]
22.214.171.124 LICENSE TYPES, VARIANCES & WAIVERS:
A. Temporary license:
(1) The licensing authority may, at its sole discretion, issue a temporary license prior to the initial survey, or when the licensing authority finds partial compliance with these regulations.
(2) The licensing authority may, at its sole discretion, issue a temporary license before clients are admitted, provided that the CTC has:
(a) submitted a license application, with required supporting documents;
(b) has met all of the applicable life safety code requirements; and
(c) its program, policies, and procedures have been reviewed and approved for compliance with these regulations.
(3) a temporary license is not guaranteed under these regulations and shall be limited and restricted to:
(a) a period, not to exceed 120 days, during which the CTC must correct all specified deficiencies;
(b) no more than two consecutive temporary licenses shall be issued in accordance with applicable statutes and regulations;
(c) a finding that the applicant is qualified and in full compliance with life safety code requirements;
(d) the CTC being allowed to accept clients and provide care services, subject to any requirements and restrictions attached to the temporary license;
(e) a statement from the applicant that they are qualified and in full compliance with these regulations and the owner has requested an initial health survey from the licensing authority.
B. Annual license: An annual license is issued for a one-year period to a CTC which has met all requirements of these regulations. If a temporary license is issued, once the department has issued a written determination of full compliance with these regulations, an annual license will be issued with the renewal date of the annual license based upon the initial date of the first temporary license.
C. Amended license: A licensee must apply to the licensing authority for an amended license when there is a change of administrator or when there is a change of name for the CTC, but an amended license shall only be issued if the administrator is not an owner. If the administrator is also the owner, a new license application must be submitted as provided in this regulation. The amended license application must:
(1) be on a form, or filed electronically if available, as required by the licensing authority;
(2) be accompanied by the required fee for the amended license; and
(3) be submitted within 10 working days of the change.
D. Variances and waivers: At the licensing authority’s sole discretion, an applicant or licensee may be granted variances and waivers of these regulations, provided the granting of such variance or waiver shall not jeopardize the health, safety or welfare of the CTC’s clients, patients and staff and is not in violation of other applicable state and federal statutes and regulations. Variances and waivers are non-transferrable. Waivers and variances may be revoked at the discretion of the licensing authority due to changes in state or federal regulations, or change of circumstances that may jeopardy the health, safety or welfare of clients.
(1) all variances shall be in writing, attached to the license and shall expire upon remodel of the CTC or change of ownership;
(2) all waivers shall be in writing, attached to the license and shall be limited to the term of the license. Upon renewal of a license, waivers shall only be extended or continued at the sole discretion of the licensing authority.
[126.96.36.199 NMAC - N, 10/30/2018]
188.8.131.52 LICENSE RENEWAL:
A. Licensee must submit a renewal application, electronically, if available, or on forms authorized by the licensing authority, along with the required license fee at least 30 days prior to expiration of the current license. The applicant shall certify that the CTC complies with all applicable state and federal regulations in force at the time of renewal and that there has been no new construction or remodeling or additions, which differ from the plans provided and reviewed with the prior license application. If there has been any construction, remodeling, or additions to the CTC since issuance of the last license, and the construction has not been previously approved by the department, the license renewal applicant shall be required to comply with all construction documentation requirements under these regulations when applying for the license renewal. The department reserves the right to require that a renewal applicant provide all additional documents, including any necessary proof of current compliance, as part of its license renewal application for the department to determine whether the applicant and the CTC are in full compliance with these regulations.
B. Upon receipt of the renewal application and the required fee, the licensing authority will issue a new license effective the day following the date of expiration of the current license, if the CTC is in substantial compliance with these regulations and all other applicable state and federal regulations.
C. If the existing license expires and the licensee has failed to submit a renewal application, the department may charge the applicant a civil monetary penalty of one hundred dollars ($100) for each day, in accordance with Paragraph (2) of Section 24-1-5 NMSA 1978, as amended, that the CTC continues to operate without a license providing that during such time the CTC remains in full compliance with these regulations. If the CTC does not renew its license and continues to operate without paying civil monetary penalties and without being in full compliance with these regulations, the CTC shall cease operations until it obtains a new license through the initial licensure procedures, and shall still be required to pay civil monetary penalties. Under Section 24-1-5 NMSA 1978, as amended, no crisis triage center shall be operated without a license and any such failure may subject the operators to various sanctions and legal remedies, including at a minimum the imposition of civil monetary penalties.
D. It shall be the sole responsibility and liability of the licensee to be aware of the status, term and renewal date of its license. The licensing authority shall not be responsible to notify the CTC of the renewal date or the expiration date of the CTC’s license.
E. After issuance of the initial license, if there has been no construction, remodeling or additions to the CTC and the CTC is in substantially the same condition as the plans on file with the department, and the CTC is in substantial compliance with these regulations and provides an application and fee the CTC may be issued a license renewal. The department, at its sole discretion, reserves the right to require additional documentation of compliance with these regulations and all applicable state and federal statutes and regulations by the licensee at the time of license renewal.
[184.108.40.206 NMAC - N, 10/30/2018]
220.127.116.11 POSTING OF LICENSE: The CTC's official license must be posted in a conspicuous place on the licensed premises in an area visible to the public.
[18.104.22.168 NMAC - N, 10/30/2018]
22.214.171.124 NON-TRANSFERABLE RESTRICTION ON LICENSE: A license granted under these regulations is not transferable to any other owner, whether an individual or legal entity, or to another location. The department shall not guarantee or be liable for or responsible for guaranteeing the transfer of the license to any other owner or other location. The existing license shall be void and must be returned to the licensing authority when any one of the following situations occurs:
A. any ownership interest in the CTC changes;
B. the CTC changes location;
C. the licensee of the CTC changes; or
D. the CTC discontinues operation.
[126.96.36.199 NMAC - N, 10/30/2018]
188.8.131.52 CHANGE OF OWNERSHIP: When a change of ownership occurs, an initial license application must be submitted by the new owner per the requirements in this section. The new owner must demonstrate compliance with these regulations the instant it takes responsibility of the CTC. The licensing authority may, at its sole discretion, approve a change of ownership. In addition to the requirements in Section 184.108.40.206 NMAC - application for licensure, the new owner must submit the following at least 60 days prior to completion of the change of ownership:
A. An explanation of terms of the change of ownership and the date the ownership will change.
B. Documents evidencing the change of ownership such as proof of sale or donation, lease of any portion of the CTC or other relevant documents.
C. Building plans of the current structure with any modifications known to the current or new owner.
D. A continuity of care transition plan that describes how the new owner will maintain the provision of services and continuity of care, keep residential clients safe and meet the requirements of these regulations at the instant it takes responsibility of the CTC. The plan must state the actions that will occur, the party responsible for taking each action, and the expected date of completion for each action. The plan must include the following:
(1) list of all residential clients at the time of notice to the licensing authority;
(2) review and update of all residential client assessments. All assessments must be current and accurate;
(3) review and update of all crisis intervention plans for clients receiving service at the time of transition and for all residential clients. All plans must be current and accurate;
(4) staffing as required in Section 220.127.116.11 NMAC of these rules and the number and positions of current staff that will be hired by the new owner;
(5) staff training as required in Section 18.104.22.168 NMAC;
(6) identification of all waivers or variances held by the current owner, and submission of any necessary waivers or variances. All waivers or variances held by the current owner are void upon the change of ownership;
(7) signed transfer agreements as required in Section 22.214.171.124 NMAC of these rules.
(8) Failure by any individual or entity to apply for and obtain a new license while continuing to operate under these regulations, shall be considered in violation of these regulations and the secretary may issue a cease-and-desist order, to protect human health or safety or welfare. The unlicensed CTC may request a hearing that shall be held in the manner provided under these regulations and all other applicable regulations.
[126.96.36.199 NMAC - N, 10/30/2018]
188.8.131.52 AUTOMATIC EXPIRATION OR TERMINATION OF LICENSE: An existing license shall automatically expire at midnight on the day indicated on the license, unless it is renewed sooner, or it has been suspended or revoked.
A. If a CTC discontinues operation, is sold, leased or otherwise changes any ownership interest or changes location, the existing license shall automatically expire at midnight on the date of such action.
B. Failure by any owner or new owner to apply for a renewal or new license, while continuing to operate under these regulations, shall be considered a violation and subject to the imposition of civil monetary penalties, sanctions or other actions for operating without a license, allowed under these regulations and all other applicable statutes and regulations.
[184.108.40.206 NMAC - N, 10/30/2018]
A. Suspension of license without prior hearing: If immediate action is required to protect human health and safety, the licensing authority may act in accordance with Section 24-1-5 NMSA 1978, as amended, and suspend a license pending a hearing, provided such hearing is held within five working days of the suspension, unless waived by the licensee.
B. An initial license application or a renewal license application may be denied, or an existing license may be revoked or suspended, or intermediate sanctions or civil monetary penalties may be imposed, after notice and opportunity for a hearing, for any of the following:
(1) failure to comply with any provision of these regulations;
(2) failure to allow access to the CTC and survey(s) by authorized representatives of the licensing authority;
(3) allowing any person to work at the CTC while impaired physically or mentally or under the influence of alcohol or drugs in a manner which harms the health, safety or welfare of the clients, staff or visitors;
(4) allowing any person, subject to all applicable statutes and regulations, to work at the CTC if that person is listed on the employee abuse registry, nurse aid registry, or considered an unemployable caregiver or has a disqualifying conviction under the caregiver’s criminal history screen act, as amended, and related regulations, as amended.
(5) the list above shall not limit the department from imposing sanctions and civil monetary penalties under all applicable statutes, regulations and codes.
[220.127.116.11 NMAC - N, 10/30/2018]
18.104.22.168 HEARING PROCEDURES: Hearing procedures for an administrative appeal of an adverse action taken by the department against a CTC's license will be held in accordance with applicable rules relating to adjudicatory hearings, including but not limited to, Section 7.1.2 NMAC, as amended. A copy of the above regulations will be furnished at the time an adverse action is taken against a CTC’s license by the licensing authority, if the regulations cannot be obtained from a public website.
[22.214.171.124 NMAC - N, 10/30/2018]
126.96.36.199 FACILITY SURVEYS:
A. Application for licensure, whether initial or renewal, shall constitute permission for unrestricted entry into and survey of a CTC by authorized licensing authority representatives at times of operation during the pendency of the license application, and if licensed, during the licensure period.
B. Surveys may be announced or unannounced at the sole discretion of the licensing authority.
C. Upon receipt of a report of deficiency from the licensing authority, the licensee or his/her representative shall be required to submit a plan of correction to the licensing authority within 10 working days stating how the CTC intends to correct each violation noted and the expected date of completion. All plans of correction for deficiencies, if any, shall be disclosed in compliance with applicable statutes and regulations. A plan of correction is not confidential once it has been approved and is admissible for all purposes in any adjudicatory hearing and all subsequent appeals relating to a CTC license, including to prove licensee compliance violations. The plan of correction must contain the following:
(1) what measures will be put into place or what systematic changes will be made to ensure the deficient practice does not recur;
(2) the anticipated implementation date (a reasonable time-frame is allowed);
(3) how the corrective action will be monitored to ensure compliance;
(4) what quality assurance indicators will be put into place;
(5) who will be responsible to oversee their monitoring; and
(6) plan of correction shall be signed and dated by the administrator or authorized representative.
D. The licensing authority may at its sole discretion accept the plan of correction as written or require modifications of the plan by the licensee.
[188.8.131.52 NMAC - N, 10/30/2018]
184.108.40.206 REPORTING OF INCIDENTS: All CTC’s licensed under these regulations must comply with all incident intake, processing, training and reporting requirements under these regulations, as well as with all other applicable statutes and regulations. All facilities shall report to the licensing authority any serious incidents or unusual occurrences which have threatened, or could have threatened the health, safety and welfare of the clients, including but not limited to:
A. fire, flood or other man-made or natural disasters including any damage to the CTC caused by such disasters and any incident which poses or creates any life safety or health hazards;
B. any outbreak of contagious diseases and diseases dangerous to the public health;
C. any human errors by staff and employees which may or has resulted in the death, serious illness, hospitalization, or physical impairment of a client or staff; and
D. abuse, neglect, exploitation, and injuries of unknown origin and other reportable incidents in accordance with 7.1.13 NMAC, as may be amended from time to time.
[220.127.116.11 NMAC - N, 10/30/2018]
18.104.22.168 GOVERNING BODY: All CTC’s licensed under these regulations must have a formally constituted governing body or operate under the governing body of the legal entity, which has ultimate authority over the CTC.
A. The governing body shall:
(1) establish and adopt bylaws that govern its operation;
(2) approve policies and procedures;
(3) appoint an on-site administrator or chief executive officer/administrator for the CTC; and
(4) review the performance of the administrator/chief executive officer at least annually.
B. The governing body may appoint committees consistent with the size and scope of the CTC.
[22.214.171.124 NMAC - N, 10/30/2018]
126.96.36.199 POLICIES AND PROCEDURES: The CTC shall establish written policies and procedures that are reviewed annually and approved by the governing body, which govern the CTC’s operation. The administrator shall ensure that these policies and procedures are adopted, administered and enforced to provide quality services in a safe environment. At a minimum, the CTC’s written policies and procedures shall include how the CTC intends to comply with all requirements of these regulations and address:
A. the establishment, composition, and responsibilities of the governing body;
B. administration including the minimum qualifications of the administrator, the process to hire an administrator, and define the administrator’s authority, responsibility, and accountability including plans for the administrator’s absence;
C. quality assurance and improvement systems;
D. incident management system;
E. the maintenance of the CTC, equipment and supplies; inspection and maintenance of emergency equipment; maintenance of emergency supplies; maintenance, upkeep and cleaning of the building(s) and equipment; fire and emergency evacuation procedures; and proper disposal of waste liquids used for cleaning contaminated areas;
F. quality of care and services including appropriate and inappropriate admission and discharge criteria; and client risk assessment;
G. referral of clients for services; transfer of clients to a hospital or other CTC or program; ambulance transfer services; and emergency procedures and resuscitative techniques;
H. infectious waste and biohazard disposal in accordance with all applicable statutes and regulations;
I. infection control and prevention;
J. staffing plan, personnel records, and personnel including written job descriptions for all staff with necessary qualifications consistent with these rules; minimum staffing; and staff development;
K. maintenance of the client health record including protection of client confidentiality and privacy as required by law; secure release of medical information and records; and safe handling and storage of client records including appropriate document destruction procedures;
L. the retention, maintenance, security and destruction of client, personnel and CTC records;
M. research procedures for any research being conducted at the CTC in compliance with these regulations;
N. dietary services including: meal service; staff in-service training; dietary records; clean and sanitary conditions; and food management;
O. housekeeping services to keep the CTC safe, clean, and free of hazards and clutter;
P. laundry services for the CTC’s laundry and resident’s laundry including handling, process and storage of clean and dirty laundry;
Q. pharmacy practices including the storage, administration, and disposal of medications; medication management; and documentation;
R. laboratory services;
S. client’s personal belongings including locked storage and contraband;
T. client rights;
U. safety management plan including, but not limited to, risk assessment, control of potentially injurious items, crisis prevention and intervention, physical restraint, and mitigation of high risk behaviors including suicide and assault. The safety plan shall follow a least to most restrictive sequence;
V. authorized entry to or exit from the CTC including the residential and outpatient components;
W. withdrawal management services; and
X. primary source verification of licenses, credentials, experience and competence of staff.
[188.8.131.52 NMAC - N, 10/30/2018]
184.108.40.206 QUALITY IMPROVEMENT SYSTEMS: Each CTC shall establish and maintain quality improvement systems including policies and procedures for quality assurance and quality improvement and have a quality committee.
A. The CTC shall establish a quality committee comprised at a minimum of the administrator, clinical director, director of nursing, licensed mental health professional, certified peer support worker, and psychiatrist. Other committee members may be specified by rules governing payor requirements. Members may participate on the quality committee by teleconference. The committee shall establish and implement quality assurance and quality improvement systems that monitor and promote quality care to clients. The systems are approved by the governing body and updated annually.
(1) the quality improvement systems must include:
(a) chart reviews;
(b) annual review of policies and procedures;
(c) data collection, and other program monitoring processes;
(d) data analyses;
(e) identification of events, trends and patterns that may affect client health, safety or treatment efficacy;
(f) identification of areas for improvement;
(g) intervention plans, including action steps, responsible parties, and completion time; and,
(h) evaluation of the effectiveness of interventions.
(2) when areas of concern or potential problems are identified by the committee, the CTC shall act as soon as possible to avoid and prevent risks to clients.
(3) the quality committee shall take and maintain meeting minutes.
B. The quality committee shall review at a minimum, the following:
(1) high-risk situations and critical incidents (such as suicide, death, serious injury, violence and abuse, neglect and exploitation) within 24 hours;
(2) medical emergencies;
(3) medication variance;
(4) infection control;
(5) emergency safety interventions including any instances physical restraints; and
(6) environmental safety and maintenance.
C. The quality committee is responsible for the implementation of quality improvement processes.
D. The quality committee shall submit a quarterly report to the governing body for review and approval.
E. The governing body shall evaluate the CTC’s effectiveness in improving performance.
[220.127.116.11 NMAC - N, 10/30/2018]
18.104.22.168 RISK ASSESSMENT:
A. The CTC shall develop policies and procedures addressing risk assessment and mitigation including, but not limited to: assessments, crisis intervention plans, treatment, approaches to supporting, engaging, and problem solving, staffing, levels of observation and documentation. The policies and procedures must prohibit seclusion and address physical restraint, if used, and the CTC’s response to clients that present with imminent risk to self or others, assaultive and other high-risk behaviors.
B. Use of seclusion is prohibited. The use of physical restraint must be consistent with federal and state laws and regulation.
C. Physical restraint, as defined in these regulations, shall be used only as an emergency safety intervention of last resort to ensure the physical safety of the client and others, and shall be used only after less intrusive or restrictive interventions have been determined to be ineffective.
D. Physical restraint shall not be used as punishment or for the convenience of staff.
E. Physical restraint are implemented only by staff who have been trained and certified by a CYFD or HSD recognized program in the prevention and use of physical restraint. This training emphasizes de-escalation techniques and alternatives to physical contact with clients as a means of managing behavior and allows only the use of reasonable force necessary to protect the client or other person from imminent and serious physical harm. Clients and youth do not participate in the physical restraint of other clients and youth.
F. Crisis intervention plans must document the use of physical restraints and address: the client’s medical condition(s); the role of the client’s history of trauma in his/her behavioral patterns; specific suggestions from the client regarding prevention of future physical interventions.
G. All clients physically restrained shall be afforded full privacy away from other clients receiving services.
H. A chemical restraint shall not be utilized under any circumstance. A chemical restraint is a drug or medication when it is used as a restriction to manage the client’s behavior or restrict the client’s freedom of movement, and is not a standard treatment or dosage for the client’s condition. If a drug or medication is used as a standard treatment to address the assessed current symptoms and needs of a client with a particular medical or psychiatric condition, its use is not considered a chemical restraint.
I. Mechanical restraint shall not be utilized under any circumstances. Mechanical restraint is the use of a mechanical device(s) to physically restrict a client’s freedom of moment, performance of physical activity or normal access to his or her body and is distinct from physical restraint.
J. The staff implementing the physical restraint shall conduct a debriefing, with the client present if possible, immediately following the incident to include the identification of the precipitating event, unsafe behavior and preventive measures with the intent of reducing or eliminating the need for future physical restraint. The debriefing shall be documented in the client’s record.
K. The client’s crisis intervention plan shall be updated: within 24 hours of admission or prior to discharge, whichever comes first; and following physical restraint use to incorporate the debriefing and changes needed to lessen the chance of the situation reoccurring.
L. Each incident of physical restraint shall be documented in the client’s record including:
(1) the less intrusive interventions that were attempted or determined to be inappropriate prior to the incident;
(2) the precipitating event immediately preceding the behavior that prompted the use of physical restraint;
(3) the behavior that prompted the use of a physical restraint;
(4) the names of the mental health professional who observed the behavior that prompted the use of the physical restraint;
(5) the names of the staff members implementing and monitoring the use of physical restraint; and
(6) a description of the of the physical restraint incident, including the type and length of the use of physical restraint, the client’s behavior during and reaction to the physical restraint and the name of the supervisor informed of the use of physical restraint.
M. Physical restraints orders are issued by a restraint/clinician within one hour of initiation of physical restraint and include documented clinical justification for the use of physical restraint.
(1) if the client has a treatment team physician or advanced practice registered nurse and he or she is available, only he or she may order physical restraint;
(2) if physical restraint is ordered by a restraint clinician, not the client’s treatment team physician or advanced practice registered nurse, the restraint clinician will contact the client’s treatment team physician or advanced practice registered nurse as soon as possible to inform him or her of the situation requiring the physical restraint, and document in the client’s record the date and time the treatment team physician or advanced practice registered nurse was consulted and the information imparted;
(3) if the order for physical restraint is verbal, the verbal order must be received by a restraint/clinician or a New Mexico licensed registered nurse (RN) or practical nurse (LPN). The restraint/ clinician must verify the verbal order in a signed, written form placed in the client’s record within 24 hours after the order is issued;
(4) each order for physical restraint must be documented in the client’s record and must include:
(a) the name of the restraint/clinician ordering the physical restraint;
(b) the date and time the order was obtained;
(c) the emergency safety intervention ordered, including the length of time;
(d) the time the emergency safety intervention began and ended;
(e) the time and results of one-hour assessment(s), if ordered;
(f) the emergency safety situation that required the client to be physically restrained; and
(g) the name, title, and credentials of staff involved in the emergency safety intervention.
N. Suicide risk interventions must include the following:
(1) a registered nurse or other licensed mental health professional may initiate suicide precautions and must obtain physician or advanced practice registered nurse order within one hour of initiating the precautions;
(2) modifications or removal of suicide precautions shall require clinical justification determined by an assessment and shall be ordered by a physician or advanced practice registered nurse and documented in the clinical record;
(3) staff and client shall be debriefed immediately following an episode of a suicide attempt or gesture, identifying the circumstances leading up to the suicide attempt or gesture;
(4) an evaluation of the client by a medical, psychiatric or independently licensed mental health provider must be done immediately, or the client must be transferred to a higher level of care immediately.
[22.214.171.124 NMAC - N, 10/30/2018]
126.96.36.199 CLIENT ACCEPTANCE, ADMISSION AND DISCHARGE CRITERIA:
A. The CTC shall develop admission and discharge criteria related to stabilization of behavioral health crises including out-patient and short-term residential stabilization.
B. The CTC shall post operating and admission hours in a location visible from the exterior of the facility.
C. If a client is not admitted to the CTC, the CTC shall maintain documentation of the rationale for the denial of services to the individual and any referrals made.
D. Admission criteria for adults and youth must be available in writing to all clients and visitors to the CTC.
E. Materials describing services offered, eligibility requirements and client rights and responsibilities must be provided in a form understandable to the client with consideration of the client’s primary language, and the mode of communication best understood by persons with visual or hearing impairments, as applicable.
F. The CTC shall not refuse to admit a client solely on the basis of the individual living in the community on a court ordered conditional release.
G. The CTC shall conduct an assessment for each client presenting for admission. The admission assessment shall contain an assessment of past trauma or abuse, how the individual served would prefer to be approached should he become dangerous to himself or to others and the findings from this initial assessment shall guide the process for determining interventions.
H. All residential admissions of youth 14 years of age and older must comply with applicable state and federal laws.
I. Staff shall inspect clients, their clothing, and all personal effects for contraband and weapons before admission to the residential component to ensure the safety of the patient and staff.
J. Discharge planning shall begin upon admission.
K. Prior to a client returning to a less restrictive environment, staff, with the consent of the client, shall work with the client’s support system, as appropriate, to prepare the client for discharge.
L. Discharge plan and summary information shall be provided to the client at the time of discharge that includes:
(1) significant findings relevant to the client’s recovery;
(2) client crisis stabilization plan and progress;
(3) recommendations and documentation for continued care, including appointment times, locations and contact information for providers;
(4) recommendations for community services if indicated with contact information for the services;
(5) documentation of notification to the client’s primary care practitioner, if applicable;
(6) evidence of involvement by the client as documented by his signature or refusal to sign; and
(7) signatures of all staff participating in the development of plan.
M. A copy of the discharge plan shall be provided to post discharge service provider(s).
[188.8.131.52 NMAC - N, 10/30/2018]
184.108.40.206 PROGRAM SERVICES: A licensed mental health professional must assess each individual with the assessment focusing on the stabilization needs of the client. It must be done in a timely manner congruent with the urgency of the presenting crisis, and consistent with the policies and procedures. The assessment must include: medical and mental health history and status, the onset of illness, the presenting circumstances, risk assessment, cognitive abilities, communication abilities, social history and history as a victim of physical abuse, sexual abuse, neglect, or other trauma as well as history as a perpetrator of physical or sexual abuse.
A. The CTC shall provide education and clinical programing designed to meet the stabilization needs of each client and implement crisis stabilization plans.
B. Crisis stabilization plan - A licensed mental health professional must document a crisis stabilization plan to address needs identified in the assessment.
(1) the crisis stabilization plan shall include at a minimum:
(a) diagnosis, a problem statement or statement of needs to be addressed;
(b) identification of behavioral health crisis leading to intake;
(c) goals that address the presenting crisis, and are consistent with the client’s needs, realistic, measurable, linked to symptom reduction, and attainable by the client during the client’s projected length of stay;
(d) specific treatment(s) provided, method(s) and frequency of treatment, and staff responsible for delivering treatment;
(e) criteria describing evidence of stabilization;
(f) discharge planning;
(g) evidence of involvement by the client and legal guardian as documented by his signature or refusal to sign; and
(h) signatures of all staff participating in the development of plan.
(2) A copy of the individual crisis stabilization plan shall be provided to the client, and guardian if applicable.
(3) When program services are offered in a group setting, groups for adults and groups for youth must be separate.
[220.127.116.11 NMAC - N, 10/30/2018]
18.104.22.168 CLIENT RIGHTS:
A. All licensed facilities shall understand, protect and respect the rights of all residents. Prior to admission to a CTC, a client, parent, shall be given the applicable written description of the adult’s or youth’s legal rights, translated into client’s preferred language, if necessary, to meet the client’s understanding.
B. A written copy of the adult client's legal rights shall be provided to the adult client, or agent, if applicable, or to the most significant responsible party in the following order:
(1) the client's spouse;
(2) significant other;
(3) any of the client's adult children;
(4) the client's parents;
(5) the client’s advocate.
C. The client rights shall be posted in a conspicuous public place in the facility and shall include the telephone numbers to contact the department to file a complaint.
D. To protect client rights, the CTC shall:
(1) treat all clients with courtesy, respect, dignity and compassion;
(2) not discriminate in admission or services based on gender, gender identity, sex, sexual orientation, client's age, race, color, religion, physical or mental disability, or national origin;
(3) provide clients written information about all services provided by the CTC and their costs and give advance written notice of any changes;
(4) provide clients with a clean, safe and sanitary living environment;
(5) provide a humane psychological and physical environment of care for all clients;
(6) provide the right to privacy, including privacy during assessments, examinations, consultations and treatment;
(7) protect the confidentiality of the client’s clinical record;
(8) protect the right to personal privacy, including privacy in personal hygiene; privacy during visits with a spouse, family member or other visitor; and reasonable privacy in the client's own room;
(9) protect the client's right to receive visitors during designated visiting hours except when restricted for good cause pursuant to a physician’s order;
(10) protect the client's right to receive visits from his attorney, physician, psychologist, clergyman, or social worker in private irrespective of visiting hours;
(11) provide clients the ability to send and receive private correspondence, as well as reasonable private access to telephone calls and, in cases of personal emergencies, reasonable use of long-distance calls;
(12) ensure that clients:
(a) are free from physical and emotional abuse, neglect, and exploitation;
(b) are free to participate or abstain from the practice of religion and shall be afforded reasonable accommodations to worship;
(c) have the right to reasonable daily opportunities for physical exercise and outdoor exercise and shall have reasonable access to recreational areas and equipment;
(d) have the right to voice grievances to the CTC staff, public officials, any state agency, or any other person, without fear of reprisal or retaliation;
(e) have the right to prompt and adequate medical attention for physical ailments;
(f) have the right to have their grievance addressed within five days;
(g) have the right to participate in the development of their crisis stabilization plan;
(h) have the right to participate in treatment decisions and formulate advance directives such as living wills and powers of attorney;
(i) have the right to refuse treatment and to be free from unnecessary or excessive medication; and
(j) have the right to manage and control their personal finances.
[22.214.171.124 NMAC - N, 10/30/2018]
126.96.36.199 CLIENT CLINICAL RECORD: The client clinical records maintained by a crisis triage center in a paper-based or electronic system shall document the degree and intensity of the treatment provided to clients who are furnished services by the CTC. A client’s clinical record shall contain at a minimum:
A. the client’s name and address;
B. name, address, and telephone number of agent, or representatives;
C. the source of referral and relevant referral information;
D. all reports from client assessment (see program services assessment);
E. the signed and dated informed consent for treatment including all medications and transfers;
F. all additional medical and clinical documentation;
G. the original crisis stabilization plan and all revisions;
H. documentation of all treatment;
I. laboratory and radiology results, if applicable;
J. documentation of physical restraint observations, if utilized;
K. a record of all contacts with medical and other services;
L. a record of medical treatment and administration of medication, if administered;
M. an original or original copy of all physician medication and treatment orders signed by the physician;
N. signed consent for the release of information, if information is released;
O. discharge plan.
[188.8.131.52 NMAC - N, 10/30/2018]
184.108.40.206 STAFFING REQUIREMENTS:
A. Minimum staffing requirements:
(1) The CTC shall have an on-site administrator, which can be the same person as the clinical director.
(2) The CTC shall have a full time clinical director appropriately licensed to provide clinical oversight.
(3) The CTC shall have an RN present on-site 24 hours a day, seven days a week or as long as clients are present in programs that do not offer residential services, to provide direct nursing services.
(4) An on-call physician or advanced practice registered nurse shall be available 24 hours a day by phone, and available on-site as needed or through telehealth.
(5) Consultation by a psychiatrist or prescribing psychologist may be provided through telehealth.
(6) The CTC shall maintain sufficient staff including direct care and mental health professionals to provide for supervision and the care of residential and non-residential clients served by the CTC, based on the acuity of client needs.
(7) At least one staff trained in basic cardiac life support (BCLS) and first aid shall be on duty at all times. In addition, one staff trained in the use of the automated external defibrillator (AED) equipment shall also be on duty.
B. Other staff requirements:
(1) The CTC shall ensure that the type and number of professional staff are:
(a) licensed, certified or credentialed in the professional field as required, and practice within the scope of the license;
(b) present in numbers to provide services, supports, care, treatment and supervision to clients as required; and
(c) experienced and competent in the profession they are licensed or practice.
(2) The CTC shall comply with all applicable laws, rules and regulations governing caregivers’ criminal history screen requirements and employee abuse registry requirements.
(3) The CTC shall ensure that, within the first sixty days of providing direct care to individuals, all staff, volunteers and contractors having direct contact with clients shall receive required training.
(4) The CTC shall be staffed to ensure the safety of clients when staff are accused of abuse, neglect or exploitation.
[220.127.116.11 NMAC - N, 10/30/2018]
18.104.22.168 MINIMUM STAFF QUALIFICATIONS:
(1) Must be at least 21 years of age.
(2) The administrator shall possess experience in acute mental health and hold at least a bachelor’s degree in the human services field or be a registered nurse with experience or training in acute mental health treatment.
B. Clinical director:
(1) Be at least 21 years of age.
(2) Be a licensed independent mental health professional or certified nurse practitioner or certified nurse specialist with experience and training in acute mental health treatment and withdrawal management services, if withdrawal management services are provided.
C. Registered nurse:
(1) Must be at least 18 years of age.
(2) Must have a current NM Registered Nurse license.
(3) Must possess experience and training in acute mental health treatment, and withdrawal management services if withdrawal management services are provided.
D. Direct service staff must be at least 18 years of age.
[22.214.171.124 NMAC - N, 10/30/2018]
126.96.36.199 PERSONNEL RECORDS:
A. The CTC shall have policies and procedures for managing personnel information and records.
B. Staff scheduling records shall be maintained for at least three years.
C. Employee records shall be kept at the CTC and include:
(1) employment application;
(2) training records;
(3) licenses and certifications;
(4) caregiver criminal history screening documentation pursuant to Section 7.1.9 NMAC; and
(5) employee abuse registry documentation pursuant to Section 7.1.12 NMAC.
[188.8.131.52 NMAC - N, 10/30/2018]
184.108.40.206 STAFF TRAINING:
A. Training for each new employee and volunteer who provides direct care shall include a minimum of 16 hours of training and be completed prior to providing unsupervised care to clients.
B. At least 12 hours of on-going training shall be provided to staff that provides direct care at least annually; the training and proof of competency shall include at a minimum:
(1) behavioral health interventions;
(2) crisis interventions;
(3) substance use disorders and co-occurring disorders;
(4) withdrawal management protocols and procedures, if withdrawal management is provided;
(5) clinical and psychosocial needs of the population served;
(6) psychotropic medications and possible side effects;
(7) ethnic and cultural considerations of the geographic area served;
(8) community resources and services including pertinent referral criteria;
(9) treatment and discharge planning with an emphasis on crisis stabilization;
(10) fire safety and evacuation training;
(11) safe food handling practices (for persons involved in food preparation), to include:
(a) instructions in proper storage;
(b) preparation and serving of food;
(c) safety in food handling;
(d) appropriate personal hygiene; and
(e) infectious and communicable disease control.
(12) confidentiality of records and client information;
(13) infection control;
(14) client rights;
(15) reporting requirements for abuse, neglect or exploitation in accordance with Section 7.1.13 NMAC;
(16) smoking policy for staff, clients and visitors;
(17) methods to provide quality client care;
(18) emergency procedures; and
(19) adverse medication reactions;
(20) the proper way to implement a crisis intervention plans.
C. Documentation of orientation and subsequent trainings shall be kept in the personnel records at the facility.
[220.127.116.11 NMAC - N, 10/30/2018]
18.104.22.168 MINIMUM SAFETY REQUIREMENTS:
A. The CTC shall have policies and procedures regarding authorized entry to or exit from the CTC including the residential component.
B. Control of potentially injurious items shall be clearly defined in policy to include:
(1) prohibition of flammables, toxins, ropes, wire clothes hangers, sharp pointed scissors, luggage straps, belts, knives, shoestrings, or other potentially injurious items;
(2) management of housekeeping supplies and chemicals, including procedures to avoid access by individuals during use or storage. Whenever practical, supplies and chemicals shall be non-toxic or non-caustic;
(3) safeguarding use and disposal of nursing and medical supplies including drugs, needles and other “sharps” and breakable items;
(4) the use of durable materials for furniture not capable of breakage into pieces that could be used as weapons or present a hanging risk.
C. To the fullest extent permitted by law, weapons shall be prohibited at the CTC.
D. All law enforcement officers or other individuals authorized by law to carry firearms shall be asked to leave their firearms locked in their vehicles or placed in a secure lockbox in an area in the CTC which is not accessible to clients.
E. The CTC shall develop and implement policies and procedures that describe interventions that prevent crises, minimize incidents when they occur, and are organized in a least to most restrictive sequence. The written policies and procedures shall:
(1) emphasize positive approaches to interventions;
(2) protect the health and safety of the individual served at all times; and
(3) specify the methods for documenting the use of the interventions.
[22.214.171.124 NMAC - N, 10/30/2018]
126.96.36.199 NUTRITION: The CTC shall provide planned and nutritionally balanced meals to its residential clients and any client treated at the CTC for 8 hours or longer from the basic food groups in accordance with the “recommended daily dietary allowance” of the American dietetic association, the food and nutrition board of the national research council, or the national academy of sciences. Meals shall meet the nutritional needs of the residents in accordance with the current USDA dietary guidelines for Americans, vending machines shall not be considered a source of snacks. Dietary services: The CTC will develop and implement written policies and procedures that are maintained on the premises. All CTC food service operations for residents shall comply with current federal and state laws and rules concerning food service and shall include:
A. at least three nutritious meals per day shall be served;
B. no more than 14 hours may elapse between the end of an evening meal and the beginning of a morning meal;
C. therapeutic diets shall be provided when ordered by the physician;
D. under no circumstances may food be withheld for disciplinary reasons;
E. each CTC shall have seating capacity to reflect the licensed capacity, although clients may eat or be served in shifts during daily operations;
F. nutritional snacks shall be available to each client; and
G. weekly menus shall be posted in the dining area.
[188.8.131.52 NMAC - N, 10/30/2018]
184.108.40.206 PHARMACEUTICAL SERVICES:
A. Pharmacological services shall be provided only on order by a prescribing professional and in accordance with the terms and conditions of such professional’s license. These services may be administered or monitored, if self-administered, by nursing staff.
B. The CTC shall establish and implement policies, procedures and practices that guide the safe and effective use of medications and shall, at a minimum, address the following:
(1) Medications shall be administered upon direct order from a licensed prescriber, and the orders for medications and care shall be written and signed by the licensed prescriber;
(2) Medications shall be used solely for the purposes of providing effective treatment..
C. There shall be no standing orders for psychotropic medication.
(1) Every order given by telephone shall be received by an RN or LPN and shall be recorded immediately and read back to the ordering physician. The order shall include the ordering physician’s name and shall be signed by a physician within 24 hours. Such telephone orders shall include a note on the order that an order was made by telephone, and the content of, justification for, and the time and date of the order.
(2) Medication management policies and procedures shall follow federal and state laws, rules and regulations, and shall direct the management of medication ordering, procurement, prescribing, transcribing, dispensing, administration, documentation, wasting or disposal and security, to include the management of controlled substances, floor stock, and physician sample medications.
(3) The CTC shall develop a policy on informed consent on medication, including the right to refuse medication and the CTC’s plan for transfer of patients who lack capacity to consent to medications.
(4) The CTC shall develop and implement policies and procedures that describe actions to follow when adverse drug reactions and other emergencies related to the use of medications occur, and emergency medical care that may be initiated by a registered nurse in order to mitigate a life-threatening situation.
D. Medication distribution stations shall be in accordance with standards set forth by the New Mexico board of pharmacy.
E. Drugs and biologicals must be stored, prepared and administered in accordance to acceptable standards of practice and in compliance with the New Mexico state board of pharmacy.
F. Outdated drugs and biologicals must be disposed of in accordance with methods outlined by the New Mexico state board of pharmacy.
G. One individual shall be designated responsible for pharmaceutical services to include accountability and safeguarding.
H. Keys to the drug room or pharmacy must be made available only to personnel authorized by the individual having responsibility for pharmaceutical services.
I. Adverse reactions to medications must be reported to the physician responsible for the patient and must be documented in the patient's record.
[220.127.116.11 NMAC - N, 10/30/2018]
18.104.22.168 LABORATORY SERVICES:
A. Laboratory work and other diagnostic procedures deemed necessary shall be performed as ordered by the physician.
B. The CTC shall comply with clinical laboratory improvement amendments of 1988 (CLIA) requirements.
C. All lab test results performed either at the CTC or by contract or arrangement with another entity must be entered into the patient’s record.
[22.214.171.124 NMAC - N, 10/30/2018]
126.96.36.199 INFECTION CONTROL:
A. The CTC shall develop and implement policies and procedures for infection control and prevention. Policies shall include: educational course requirements; decontamination; disinfection and storage of sterile supplies; cleaning; and laundry requirements, and address the following:
(1) universal precautions when handling blood, body substances, excretions, secretions;
(2) proper disposal of biohazards;
(3) proper hand washing techniques;
(4) prevention and treatment of needle stick or sharp injuries; and
(5) the management of common illness likely to be emergent in the CTC service setting and specific procedures to manage infectious diseases.
B. The CTC's infection control risk assessment and plan is reviewed annually for effectiveness and revision, if necessary.
C. Staff shall be trained in and shall adhere to infection control practices, the release of confidential information and reporting requirements related to infectious diseases.
D. Where cleaning and decontamination of equipment and supplies are performed in the same room where clean or sterile supplies and equipment are stored, there shall be a physical separation of the clean or sterile supplies and equipment.
E. All special waste including blood, body fluids, sharps and biological indicators shall be disposed of in accordance with OSHA and the New Mexico environment department standards for biohazardous waste.
F. Each CTC shall have policies and procedures for the handling, processing, storing and transporting of clean and dirty laundry.
[188.8.131.52 NMAC - N, 10/30/2018]
A. If a CTC is conducting research activities, the CTC must have written policies and procedures for conducting research, documentation that the study has received institutional review board (IRB) approval, and a consent form for each client involved in the research in the client's record.
B. When research is conducted by the CTC or by the employees or by affiliates of the CTC or when the CTC is used as a research site, such that the CTC's clients and staff are involved in or the subjects of research; the research must be conducted:
(1) by qualified researchers, having evidence in formal training and experience in the conduct of clinical, epidemiologic or sociologic research;
(2) in accordance with the written, approved research policies and procedures;
(3) by staff trained to conduct such research; and
(4) in a manner that protects the client’s health, safety and right to privacy and the CTC and its clients from unsafe practices.
[184.108.40.206 NMAC - N, 10/30/2018]
220.127.116.11 CLIENT TRANSFERS:
A. The CTC shall have policies and procedures to stabilize and transfer clients in need of a higher level of care.
B. The CTC shall:
(1) discuss recommendations for transfer with the client or client’s legal guardian or agent and upon transfer, notify the client’s legal guardian or agent;
(2) make the determination as to the time and manner of transfer to ensure no further deterioration of the client during the transfer between facilities;
(3) specify the benefits expected from the transfer in the client’s record;
(4) coordinate care with receiving facility prior to transfer; and
(5) send a copy of the client’s record with the client upon transfer.
[18.104.22.168 NMAC - N, 10/30/2018]
22.214.171.124 BUSINESS HOURS: The CTC shall post hours of operation and admissions on signage exterior to the building.
[126.96.36.199 NMAC - N, 10/30/2018]
188.8.131.52 PHYSICAL ENVIRONMENT AND GENERAL BUILDING REQUIREMENTS:
A. When construction of new buildings, additions, or alterations to existing buildings are contemplated, plans and specifications covering all portions of the work must be submitted to the licensing authority for plan review and approval prior to beginning actual construction. When an addition or alteration is contemplated, plans for the entire CTC must be submitted.
B. CTCs licensed pursuant to these regulations must be accessible to and useable by disabled employees, staff, visitors, and clients and in compliance with the American’s with Disabilities Act (ADA), current edition.
C. All buildings of the premises providing client care and services will be considered part of the CTC and must meet all requirements of these regulations. Where a part of the CTC services is contained in another facility, separation and access shall be maintained as described in current building and fire codes.
D. A CTC applying for licensure pursuant to these regulations may have additional requirements not contained herein. The complexity of building and fire codes and requirements of city, county, or municipal governments may stipulate these additional requirements. Any additional requirements will be outlined by the appropriate building and fire authorities, and by the licensing authority through plan review, consultation and on-site surveys during the licensing process.
[184.108.40.206 NMAC - N, 10/30/2018]
220.127.116.11 COMMON ELEMENTS FOR FACILITIES:
A. Public services shall include:
(1) conveniently accessible wheelchair storage;
(2) an ADA compliant reception and information counter or desk;
(3) waiting areas;
(4) conveniently accessible public toilets; and
(5) drinking fountain (s) or water dispensers easily accessible to clients or other visitors.
B. Interview space(s) for private interviews related to mental health, medical information, etc., shall be provided.
C. General or individual office(s) for business transactions, records, administrative, and professional staff shall be provided. These areas shall be separated from public areas for confidentiality.
D. Special storage for staff personal effects with locking drawers or cabinets shall be provided.
E. General storage facilities for supplies and equipment shall be provided.
[18.104.22.168 NMAC - N, 10/30/2018]
22.214.171.124 PROVISIONS FOR EMERGENCY CALLS:
A. An easily accessible hard-wired telephone for summoning help, in case of emergency, must be available in the CTC.
B. A list of emergency numbers including, but not limited to, fire department, police department, ambulance services, local hospital, poison control center, and the department’s division of health improvement’s complaint hotline must be prominently posted by the telephone(s).
[126.96.36.199 NMAC - N, 10/30/2018]
Sufficient space for off-street parking for staff, clients and visitors shall be provided. A designated parking space(s) for one emergency, and one police vehicle shall be provided. Parking should be compliant with local zoning requirements and the 2009 New Mexico commercial building code, or current version.
[188.8.131.52 NMAC - N, 10/30/2018]
184.108.40.206 MAINTENANCE OF BUILDING AND GROUNDS: Facilities must maintain the building(s) in good repair at all times. Such maintenance shall include, but is not limited to, the following:
A. all electrical, mechanical, water supply, heating, fire protection, and sewage disposal systems must be maintained in a safe and functioning condition, including regular inspections of these systems;
B. all equipment and materials used for client care shall be maintained clean and in good repair;
C. all furniture and furnishings must be kept clean and in good repair; and
D. the grounds of the CTC must be maintained in a safe and sanitary condition at all times.
[220.127.116.11 NMAC - N, 10/30/2018]
A. The CTC must be kept free from offensive odors and accumulations of dirt, rubbish, dust, and safety hazards.
B. Treatment rooms, waiting areas and other areas of daily usage must be cleaned as needed to maintain a clean and safe environment for the clients.
C. Floors and walls must be constructed of a finish that can be easily cleaned. Floor polishes shall provide a slip resistant finish.
D. Deodorizers must not be used to mask odors caused by unsanitary conditions or poor housekeeping practices.
E. Storage areas must be kept free from accumulation of refuse, discarded equipment, furniture, paper, et cetera.
[18.104.22.168 NMAC - N, 10/30/2018]
22.214.171.124 CUSTODIAL CLOSET(S):
A. Each CTC shall have at least one custodial closet which must be locked and restricted from client access.
B. Each custodial closet shall contain:
(1) a service sink; and
(2) storage for housekeeping supplies and equipment.
C. Each custodial closet must be mechanically vented to the exterior.
D. Custodial closets are hazardous areas and must be provided with one-hour fire separation and one and three-quarter inch solid core doors which are rated at a 20-minute fire protection rating.
[126.96.36.199 NMAC - N, 10/30/2018]
188.8.131.52 HAZARDOUS AREAS:
A. Hazardous areas include the following:
(1) fuel fired equipment rooms;
(2) bulk laundries or laundry rooms with more than 100 sq. ft.;
(3) storage rooms with more than 50 sq. ft. but less than 100 sq. ft. not storing combustibles;
(4) storage rooms with more than 100 sq. ft. storing combustibles;
(5) chemical storage rooms with more than 50 sq. ft.; and
(6) garages, maintenance shops, or maintenance rooms.
B. Hazardous areas on the same floor or abutting a primary means of escape or a sleeping room shall be protected by either:
(1) an enclosure of at least one-hour fire rating with self-closing or automatic closing on smoke detection fire doors having a three-quarter hour rating; or
(2) an automatic fire protection (sprinkler) and separation of hazardous area with self-closing doors or doors with automatic-closing on smoke detection; or
(3) any other hazardous areas shall be enclosed with walls with at least a 20-minute fire rating and doors equivalent to one and three-quarter inch solid bonded wood core, operated by self-closures or automatic closing on smoke detection.
C. All boiler, furnace or fuel fired water heater rooms shall be protected from other parts of the building by construction having a fire resistance rating of not less than one hour. Doors to these rooms shall be one and three-quarter inch solid core.
[184.108.40.206 NMAC - N, 10/30/2018]
220.127.116.11 FLOORS AND WALLS:
A. Floor and wall areas penetrated by pipes, ducts, and conduits shall be tightly sealed to minimize entry of rodents and insects. Joints of structural elements shall be similarly sealed.
B. Threshold and expansion joint covers shall be flush with the floor surface to facilitate use of wheelchairs and carts.
[18.104.22.168 NMAC - N, 10/30/2018]
A. Each floor of a CTC shall have exits as required by the New Mexico commercial building code and applicable version of the National fire protection association 101.
B. Each exit must be marked by illuminated exit signs having letters at least six inches high whose principle strokes are at least three quarters inch wide.
C. Illuminated exit signs must be maintained in operable condition at all times.
D. Exit ways must be kept free from obstructions at all times.
[22.214.171.124 NMAC - N, 10/30/2018]
A. Minimum corridor width shall be five feet except work corridors less than six feet in length may be four feet in width.
B. For facilities contained within existing commercial or residential buildings, less stringent corridor widths may be allowed if not in conflict with building or fire codes. A waiver or variance may be requested but must be approved by the licensing authority prior to occupying the licensed part of the building.
[126.96.36.199 NMAC - N, 10/30/2018]
188.8.131.52 STAFF STATION:
A. Each client care area in the residential unit shall have a staff station located to provide visual or virtual monitoring of all resident room corridors and access to secured access to outdoor area, equipped with access to residential clients’ records, a desk or work counter, a cleaning area with a sink with hot and cold running water, operational telephone, and emergency call system.
B. Locked storage area for drugs or pharmacy grade, locked medication cart.
C. Access to a biohazard disposal unit for needles, and other “sharps,” and breakable items.
D. A reliable monitored emergency call system shall be provided for staff use in the event of an emergency.
E. If a kitchen is not open at all times to residents, a nourishment station with sink, hot and cold running water, refrigerator, and storage for serving residents between meal nourishment shall be provided.
F. View of fire alarm control panel, generator panel (if any), and any other life safety code components.
[184.108.40.206 NMAC - N, 10/30/2018]
220.127.116.11 SECURED ENVIRONMENT/OUTDOOR AREA:
A. The CTC shall provide a secure environment for client safety. A secured environment is a CTC and grounds that have secured or monitored exits. A secured environment for facilities that offer residential services may include but is not limited to: double alarm systems; gates connected to the fire alarm; or tab alarms for residents at risk for elopement. Locked areas shall have an access code or key which CTC employees shall have on their person or available at all times in accordance with the Life Safety Code, NPFA 101, 2012 or subsequent updates. For a CTC located within an existing licensed facility, a request for waiver may be submitted to the licensing authority containing an alternate plan for providing security for clients, provided that health, safety or welfare of the clients or staff would not be adversely affected.
B. In addition to the interior common areas required by this rule, a CTC providing residential services shall provide an outdoor secured environment independently accessible to residents for their year-round use.
(1) Fencing or other enclosures, not less than six feet high, shall protect the safety, security and privacy of the residents and have emergency egress gates that are connected to the emergency call system.
(2) Outdoor area shall not provide access to contact with the public.
[18.104.22.168 NMAC - N, 10/30/2018]
22.214.171.124 ASSESSMENT ROOMS:
A. general purpose assessment rooms shall meet the following requirements:
B. minimum floor area of 80 square feet, excluding vestibules, toilets, and closets;
C. room arrangement shall permit at least two feet - eight inch clearance around furniture items used for exam or assessment;
D. a lavatory or sink for hand washing.
[126.96.36.199 NMAC - N, 10/30/2018]
188.8.131.52 THERAPY/TREATMENT ROOMS:
A. Shall have a minimum floor area of 120 square feet, excluding vestibule, toilet, and closets.
B. All walls shall be constructed to a minimum length of 10 feet.
[184.108.40.206 NMAC - N, 10/30/2018]
220.127.116.11 ACTIVITY OR MULTIPURPOSE ROOM: The CTC shall provide a minimum of 250 square feet for common living area, dining and social spaces, or 40 square feet per resident, whichever is greater.
A. The CTC shall have a living or multipurpose room for the use of the residents. The furnishings shall be well constructed, comfortable and in good repair.
B. The activity or multi-purpose room may be used as a dining area.
C. The activity room or multipurpose rooms shall be provided with supplies to reasonably meet the interests and needs of the residents.
D. Each activity room shall have a window area of at least one tenth of the floor area with a minimum of at least 10 square feet.
E. A dining area shall be provided for meals. Facilities shall have tables and chairs in the dining area to accommodate the total number of residents in one sitting. All seating arrangements during meals shall allow clear access to the exits. Lunch times for adults and youth must be separate if there is only one lunch room.
[18.104.22.168 NMAC - N, 10/30/2018]
22.214.171.124 MEETING ROOM: The CTC shall have adequate meeting rooms and office space for use by staff, the interdisciplinary care team and client and family visits. Other rooms may serve as meeting rooms, provided resident confidentiality is maintained. Meeting and treatment rooms must not hold both adults and youth at the same time.
[126.96.36.199 NMAC - N, 10/30/2018]
188.8.131.52 RESIDENT ROOMS: The regulations in Section 184.108.40.206 NMAC apply to those facilities providing a residential treatment program.
A. A CTC providing residential treatment shall not exceed the bed capacity approved by the licensing authority.
B. Resident rooms may be private or semi-private or dormitory style depending on assessed, resident acuity and need Resident rooms must be separated by gender.
C. Facilities serving youth and adults must locate youth resident rooms and restrooms in a unit or wing that is physically separated from the adult facilities.
(1) Private rooms shall have a minimum of 100 square feet of floor area. The closet and locker area shall not be counted as part of the available floor space.
(2) Semi-private rooms shall have a minimum of 80 square feet of floor area for each resident and shall be furnished in such a manner that the room is not crowded and passage out of the room is not obstructed.
(3) A separate closet, bed (at least 36 inch wide), chair, towel bar, and non-metal trash receptacle, for each resident shall be provided.
(4) The beds shall be spaced at least three feet apart. Bunk beds, roll away beds, stacked beds, hide-a-beds, or beds with springs, cranks, rails or wheels, are not allowed.
D. Each resident room shall have a window to the outside. The area of the outdoor window shall be at least one tenth of the floor area of the room and allow for emergency egress. Windows may be textured or obscured glass to provide privacy without the use of any window coverings.
E. Resident rooms shall not be less than seven feet in any horizontal direction.
F. There must be no through traffic in resident rooms. Resident rooms must connect directly to hallway or other internal common areas of the facility.
[220.127.116.11 NMAC - N, 10/30/2018]
18.104.22.168 TOILETS, LAVATORIES AND BATHING FACILITIES:
A. General Requirements:
(1) All fixtures and plumbing must be installed in accordance with current state and local plumbing codes.
(2) All toilets must be enclosed and vented.
(3) All toilet rooms must be provided with a lavatory for hand washing.
(4) All toilets must be kept supplied with toilet paper.
(5) All lavatories for hand washing must be kept supplied with disposable towels for hand drying or provided with mechanical blower.
(6) The number of and location of toilets, lavatories and bathing facilities shall be in accordance with International Building Code (IBC) requirements. Toilets for public use shall be located adjacent to the waiting area. Such factors as extent of services provided and size of CTC will also dictate requirements.
(7) Facilities serving youth must provide separate toilet and shower facilities for adults and youth.
B. Residential component: Separate facilities shall be provided for male and female patients. Toilet and bathing facilities shall be located appropriately to meet the needs of residents.
(1) Facilities serving youth and adults must locate youth resident rooms and restrooms in a unit or wing that is physically separated from the adult facilities.
(2) A minimum of one toilet, one lavatory and one bathing unit (tub, shower, or combo unit) shall be provided for every eight residents or fraction thereof.
(3) Toilets to be flush meter type (no tank).
(4) Mirrors cannot be glass or polished metal. A polycarbonate mirror, fully secured and flat mounted to the wall is required.
(5) Individual shower stalls and dressing areas shall be provided. The shower head shall be recessed or have as smooth curve from which items cannot be hung.
(6) There shall not be any overhead rods, fixtures or privacy stall supports or protrusions capable of carrying more than a 30-pound load.
C. Staff restroom: The CTC shall provide a separate staff toilet including, lavatory and shower, near staff station.
[22.214.171.124 NMAC - N, 10/30/2018]
126.96.36.199 COLLECTION/DRAW/LAB AREA: Facilities shall be reward to support laboratory procedures, if provided. Minimum facilities provided on-site shall include space for the following:
A. A urine collection room equipped with a toilet and hand washing sink.
B. Blood collection facilities with space for a chair, work counter, and lavatory.
C. Each CTC shall have accommodations for storage and refrigeration of blood, urine and other specimens in a dedicated specimen refrigerator.
[188.8.131.52 NMAC - N, 10/30/2018]
184.108.40.206 NUTRITION: A CTC offering a residential treatment program shall provide planned and nutritionally balanced meals from the basic food groups in accordance with the “recommended daily dietary allowance” of the American dietetic association, the food and nutrition board of the national research council, or the national academy of sciences. Menus must be approved by a licensed nutritionist. Meals shall meet the nutritional needs of the residents in accordance with the current USDA dietary guidelines for Americans. Vending machines shall not be considered a source of snacks.
A. Dietary services. The CTC will develop and implement written policies and procedures that are maintained on the premises. All CTC food service operations for residents shall comply with current federal and state laws and rules concerning food service and shall include:
(1) at least three nutritious meals per day shall be served;
(2) no more than 14 hours may elapse between the end of an evening meal and the beginning of a morning meal;
(3) therapeutic diets shall be provided when ordered by the physician;
(4) under no circumstances may food be withheld for disciplinary reasons;
(5) each CTC shall have seating capacity to accommodate the licensed capacity and be able to feed adult and youth clients separately, although clients may eat or be served in shifts during daily operations;
(6) nutritional snacks shall be available to each client; and
(7) weekly menus shall be posted in the dining area.
[220.127.116.11 NMAC - N, 10/30/2018]
18.104.22.168 FOOD SERVICE: Requirements of Section 22.214.171.124 NMAC apply to facilities providing a residential treatment program.
A. The CTC shall have either contracted food preparation or prepare food on site.
B. A CTC that contracts food preparation shall have a dietary or a kitchen area adequate to meet food service needs and arranged and equipped for the refrigeration, storage, preparation, and serving of food, dish and utensil cleaning and refuse storage and removal.
C. Dietary areas consisting of a food warming and refrigeration area shall comply with the local health or food handling codes. Food preparation space shall be arranged for the separation of functions and shall be located to permit efficient services to residents and shall not be used for non-dietary functions.
D. A CTC that provides onsite food preparation shall comply with the New Mexico environment department food preparation regulations.
E. A CTC with a kitchen area, whether used for on-site food preparation or not, must adhere to the following requirements:
(1) limit traffic incidental to the receiving, preparation and serving of food and drink;
(2) toilet facilities may not open directly into the kitchen;
(3) food day-storage space shall be provided adjacent to the kitchen and shall be ventilated to the outside;
(4) a separate hand washing sink with soap dispenser, single service towel dispenser, or other approved hand drying facility shall be located in the kitchen;
(5) a separate dishwashing area, preferably a separate room, with mechanical ventilation shall be provided;
(6) at least a three-compartment sink shall be provided for washing, rinsing and sanitizing utensils, with adequate drain boards, at each end. In addition, a single-compartment sink located adjacent to the soiled utensil drain board shall be available for prewashing and liquid waste disposal. The size of each sink compartment shall be adequate to permit immersion of at least fifty percent of the largest utensil used. In lieu of the additional sink for prewashing, a well-type garbage disposal with overhead spray wash may be provided.
(7) mechanical dishwashers and utensil washers, where provided, shall meet the requirements of the current approved list from the national sanitation foundation or equivalent with approval of the department;
(8) temperature gauges shall be located in the wash compartment of all mechanical dishwashers and in the rinse water line at the machine of a spray-type mechanical dishwasher or in the rinse water tank of an immersion-type dishwasher. The temperature gauges shall be readily visible, fast-acting and accurate to plus or minus two degrees fahrenheit or one degree celsius;
(9) approved automatic fire extinguishing equipment shall be provided in hoods and attached ducts above all food cooking equipment;
(10) the walls shall be of plaster or equivalent material with smooth, light- colored, nonabsorbent, and washable surface;
(11) the ceiling shall be of plaster or equivalent material with smooth, light-colored, nonabsorbent, washable, and seamless surface;
(12) the floors of all rooms, except the eating areas of dining rooms, in which food or drink is stored, prepared, or served, or in which utensils are washed, shall be of such construction as to be non-absorbent and easily cleaned;
(13) an exterior door from a food preparation area shall be effectively screened. Screen doors shall be self-closing;
(14) all rooms in which food or drink is stored or prepared or in which utensils are washed shall be well lighted;
(15) rooms subject to sewage or wastewater backflow or to condensation or leakage from overhead water or waste lines shall not be used for storage of food preparation unless provided with acceptable protection from such contamination.
[126.96.36.199 NMAC - N, 10/30/2018]
188.8.131.52 LAUNDRY SERVICES:
A. General requirements. The CTC shall provide laundry services, either on the premises or through a commercial laundry and linen service.
(1) On-site laundry facilities shall be located in areas separate from the resident units and shall be provided with necessary washing and drying equipment.
(2) Soiled laundry shall be kept separate from clean laundry, unless the laundry facility is provided for resident use only.
(3) Staff shall handle, store, process and transport linens with care to prevent the spread of infectious and communicable disease.
(4) Soiled laundry shall not be stored in the kitchen or dining areas. The building design and layout shall ensure the separation of laundry room from kitchen and dining areas. An exterior route to the laundry room is not an acceptable alternative, unless it is completely enclosed.
(5) All linens shall be changed as needed and at least weekly or when a new resident is to occupy the bed.
(6) The mattress pad, blankets and bedspread shall be laundered as needed and when a new resident is to occupy the bed.
(7) Bath linens consisting of hand towel, bath towel and washcloth shall be changed as needed and at least weekly.
(8) There shall be a clean, dry, well-ventilated storage area provided for clean linen.
(9) CTC laundry supplies and cleaning supplies shall not be kept in the same storage areas used for the storage of foods and clean storage and shall be kept in a secured room or cabinet.
(10) CTC shall have a small washer and dryer for immediate unit needs and to wash clients’ clothes. These washing and drying units shall be equipped to sanitize clothes as a preventive measure of infection control.
(11) Residents may do their own laundry, if it is their preference and they are capable of doing so.
[184.108.40.206 NMAC - N, 10/30/2018]
A. A CTC licensed pursuant to these regulations must be provided with an adequate supply of water that is of a safe and sanitary quality suitable for domestic use.
B. If the water supply is not obtained from an approved public system, the private water system must be inspected, tested, and approved by the New Mexico environment department prior to licensure. It is the CTC's responsibility to ensure that subsequent periodic testing or inspection of such private water systems be made at intervals prescribed by the New Mexico environment department or recognized authority.
C. Hot and cold running water under pressure must be distributed at sufficient pressure to operate all fixtures and equipment during maximum demand periods.
D. Back flow preventers (vacuum breakers) must be installed on hose bibs, laboratory sinks, service sinks, and on all other water fixtures to which hoses or tubing can be attached.
E. Water distribution systems are arranged to provide hot water at each hot water outlet at all times.
F. Hot water to hand washing facilities must not exceed 120 degrees fahrenheit.
[220.127.116.11 NMAC - N, 10/30/2018]
18.104.22.168 SEWAGE AND WASTE DISPOSAL:
A. All sewage and liquid wastes must be disposed of into a municipal sewage system where such facilities are available.
B. Where a municipal sewage system is not available, the system used must be inspected and approved by the New Mexico environment department or recognized local authority.
C. Where municipal or community garbage collection and disposal service are not available, the method of collection and disposal of solid wastes generated by the CTC must be inspected and approved by the New Mexico environment department or recognized local authority.
D. All garbage and refuse receptacles must be durable, have tight fitting lids, must be insect and rodent proof, washable, leak proof and constructed of materials which will not absorb liquids. Receptacles must be kept closed and clean.
[22.214.171.124 NMAC - N, 10/30/2018]
126.96.36.199 ELECTRICAL STANDARDS:
A. All electrical installation and equipment must comply with all current state and local codes.
B. Circuit breakers or fused switches that provide electrical disconnection and over current protection shall be:
(1) enclosed or guarded to provide a dead front assembly;
(2) readily accessible for use and maintenance;
(3) set apart from traffic lanes;
(4) located in a dry, ventilated space, free of corrosive fumes or gases;
(5) able to operate properly in all temperature conditions;
(6) panel boards servicing lighting and appliance circuits shall be on the same floor and in the same facility area as the circuits they serve; and
(7) each panel board will be marked showing the services.
C. The use of jumpers or devices to bypass circuit breakers or fused switches is prohibited.
D. Light switches and electrical devices in the residential unit shall be secured with tamper resistant screws.
[188.8.131.52 NMAC - N, 10/30/2018]
A. All spaces occupied by people, machinery, or equipment within buildings, approaches to buildings, and parking lots shall have lighting.
B. Lighting will be sufficient to make all parts of the area clearly visible.
C. All lighting fixtures must be shielded.
D. Lighting fixtures must be selected and located with the comfort and convenience of the staff and clients in mind.
E. Lighting fixtures in the residential unit shall be recessed, tamperproof or protective translucent cover.
[184.108.40.206 NMAC - N, 10/30/2018]
220.127.116.11 ELECTRICAL CORDS AND RECEPTACLES:
A. Electrical cords and extension cords shall:
(1) be U/L approved;
(2) be replaced as soon as they show wear;
(3) be plugged into an electrical receptacle within the room where used;
(4) not be used as a general wiring method; and
(5) not be used in series.
B. Electrical receptacles shall:
(1) Be duplex-grounded type electrical receptacles (convenience outlets) and installed in all areas in sufficient quantities for tasks to be performed as needed.
(2) Be a ground fault circuit interrupter if located within six feet of a water source.
C. The use of multiple sockets (gang plugs) in electrical receptacles is strictly prohibited.
[18.104.22.168 NMAC - N, 10/30/2018]
22.214.171.124 EMERGENCY POWER & LIGHTING: Emergency electrical service with an independent power source which covers lighting at attendant stations, exit and corridor lights, boiler room, and fire alarm systems shall be provided.
A. The service may be battery operated if effective for at least four hours.
B. Facilities shall have emergency lighting with a minimum of two bulbs to light exit passageways.
C. Independent power source shall be in an exterior area near the exits and activate automatically upon disruption of electrical service.
[126.96.36.199 NMAC - N, 10/30/2018]
188.8.131.52 FIRE SAFETY COMPLIANCE: All current applicable requirements of state and local codes
for fire prevention and safety must be met by the CTC.
[184.108.40.206 NMAC - N, 10/30/2018]
220.127.116.11 FIRE CLEARANCE AND INSPECTIONS: Each CTC must request from the fire authority
having jurisdiction an annual fire inspection. If the policy of the fire authority having jurisdiction does not provide
for annual inspection of the CTC, the CTC must document the date the request was made and to whom. If the
fire authorities do make annual inspections; a copy of the latest inspection must be kept on file in the CTC.
[18.104.22.168 NMAC - N, 10/30/2018]
22.214.171.124 AUTOMATIC FIRE PROTECTION (SPRINKLER) SYSTEM: Facilities with residential services shall have an automatic fire protection (sprinkler) system. The system shall be in accordance with NFPA 13 or NFPA 13D or its subsequent replacement as applicable. Sprinkler heads in the residential unit shall be of the protective type, either vandal proof or tamper resistant. Sprinkler systems for facilities without residential services must be incompliance with current state building code requirements regarding a sprinkler system.
[126.96.36.199 NMAC - N, 10/30/2018]
188.8.131.52 FIRE ALARMS, SMOKE DETECTORS AND OTHER EQUIPMENT: The system shall be in accordance with NFPA 13 or NFPA 13D or its subsequent replacement as applicable.
A. Facilities shall have a manual fire alarm system. The manual fire alarm shall be inspected and approved in writing by the fire authority with jurisdiction.
B. Approved smoke detectors shall be installed on each floor that when activated provides an alarm which is audible in all sleeping areas. Areas of assembly, such as the dining, living or activity room(s) must also be provided with smoke detectors.
(1) Detectors shall be powered by the house electrical service and have battery backup.
(2) Construction of new facilities or facilities remodeling or replacing existing smoke detectors shall provide detectors in common living areas and in each sleeping room.
(3) Smoke detectors shall be installed in corridors at no more than 30 feet spacing.
(4) Heat detectors shall be installed in all kitchens and also powered by the house electrical service.
[184.108.40.206 NMAC - N, 10/30/2018]
220.127.116.11 FIRE EXTINGUISHERS: Fire extinguisher(s) must be located in the CTC, as approved by the state fire marshal or the fire prevention authority with jurisdiction.
A. Facilities must as a minimum have two 2A10BC fire extinguishers:
(1) one extinguisher located in the kitchen or food preparation area;
(2) one extinguisher centrally located in the CTC;
(3) all fire extinguishers shall be inspected yearly, recharged as needed and tagged noting the date of the inspection;
(4) The maximum distance between fire extinguishers shall be 50 feet.
B. Fire extinguishers, alarm systems, automatic detection equipment and other firefighting equipment shall be properly maintained and inspected as recommended by the manufacturer, state fire marshal, or the local fire authority.
[18.104.22.168 NMAC - N, 10/30/2018]
22.214.171.124 STAFF FIRE AND SAFETY TRAINING:
A. All staff of the CTC must know the location of and instructed in proper use of fire extinguishers and other procedures to be observed in case of fire or other emergencies. The CTC should request the fire authority having jurisdiction to give periodic instruction in fire prevention and techniques of evacuation.
B. CTC staff must be instructed as part of their duties to constantly strive to detect and eliminate potential safety hazards, such as loose handrails, frayed electrical cords, faulty equipment, blocked exits or exit ways, and any other condition which could cause burns, falls, or other personal injury to the patients or staff.
C. Fire and evacuation drills: The CTC must conduct at least one fire and evacuation drill for each work shift for each quarter. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted for use instead of audible alarms. A log must be maintained by the CTC showing the date, time, number of staff participating and outlining any problems noted in the conduct of the drill.
[126.96.36.199 NMAC - N, 10/30/2018]
188.8.131.52 EVACUATION PLAN: Each CTC must have a fire evacuation plan conspicuously posted in
each separate area of the building showing routes of evacuation in case of fire or other emergencies.
[184.108.40.206 NMAC - N, 10/30/2018]
220.127.116.11 HEATING, VENTILATION, AND AIR-CONDITIONING:
A. Heating, air-conditioning, piping, boilers, and ventilation equipment must be furnished, installed and maintained to meet all requirements of current state and local mechanical, electrical, and construction codes.
B. The heating, ventilation and air-conditioning system must be able to maintain interior temperatures in all rooms used by clients, staff or visitors with interior temperatures between 65 degrees fahrenheit and 78 degrees fahrenheit year-round.
C. The use of non-vented heaters, open flame heaters or portable heaters is prohibited.
D. An ample supply of outside air must be provided in all spaces where fuel fired boilers, furnaces, or heaters are located to assure proper combustion.
E. All fuel fired boilers, furnaces, or heaters must be connected to an approved venting system to take the products of combustion directly to the outside air.
F. A CTC must be adequately ventilated at all times to provide fresh air and the control of unpleasant odors.
G. All gas-fired heating equipment must be provided with a one hundred percent automatic cutoff control valve in event of pilot failure.
H. The CTC must be provided with a system for maintaining clients and staff's comfort during periods of hot weather, evaporative cooling is not allowed.
I. All boiler, furnace or heater rooms shall be protected from other parts of the building by construction having a fire resistance rating of not less than one hour. The door must be self-closing with three - quarter hour fire resistance.
J. Fireplace or wood burning stoves are prohibited.
K. The ceiling and air distribution devices (supply & return, etc.) in the residential component shall be a tamper resistant type.
[18.104.22.168 NMAC - N, 10/30/2018]
22.214.171.124 WATER HEATERS:
A. Must be able to supply hot water to all hot water taps within the CTC at full pressure during peak demand periods and maintain a maximum temperature of 120 degrees fahrenheit.
B. Fuel fired hot water heaters must be enclosed and separated from other parts of the building by construction as required by current state and local building codes.
C. All water heaters must be equipped with a pressure relief valve (pop-off valve).
[126.96.36.199 NMAC - N, 10/30/2018]
188.8.131.52 ADDITIONAL REQUIREMENTS FOR FACILITIES SERVING YOUTH: All requirements in the above rules apply to all facilities. For facilities serving youth, the additional requirements of this section must also be met.
A. Physical environment for general building requirements: Facilities serving adults and youth must locate youth resident rooms and restrooms in a unit or wing that is separated by sight and sound barriers from the adult facilities.
B. Enforcement involving suspension of license without prior hearing: Any CTC that allows any person, subject to all applicable statutes and regulations, to work at the CTC if that person is listed on the CYFD unreasonable risk background check and related regulations, as amended, may be subject to immediate suspension of its license without prior hearing.
C. Reporting of incidents: All facilities licensed under these regulations, must comply with all incident intake, processing, training and reporting requirements under all applicable NM Children’s Code, Section 32A-1-1 NMSA 1978, Children’s Mental Health and Developmental Disabilities Act, Section 32A-6A-1 NMSA 1978, Section 7.20.11 and Section 7.20.12 NMAC.
D. Policies And Procedures: The CTC shall establish written policies and procedures that are reviewed annually and approved by the governing body, which govern the CTC’s operation. The administrator shall ensure that these policies and procedures are adopted, administered and enforced to provide quality services in a safe environment. At a minimum, the CTC’s written policies and procedures shall include how the CTC intends to comply with all requirements of these regulations and address:
(1) immediate reporting of suspected child abuse, neglect or exploitation, pursuant to the NM Children’s Code and these licensing regulations;
(2) actions to be taken in case of accidents or emergencies involving a youth, including death;
(3) immediate personnel actions to be taken by the CTC if child abuse or neglect allegations are made involving a direct service staff;
(4) confidentiality of youth’ records;
(5) management of a youth who is a danger to him/herself or others or presents a likelihood of serious harm to him/herself or others. The CTC procedures must specify that immediate actions be taken to prevent such harm. At a minimum, the policies and procedures require that the following actions be taken and documented in the youth’s file:
(a) all appropriate actions to protect the health and safety of other youth, clients and staff who are endangered;
(b) all appropriate efforts to manage the youth’s behavior prior to proposing emergency discharge;
(6) Clinically appropriate and legally permissible methods of youth behavior management and discipline.
(7) The CTC shall prohibit in policy and practice the following:
(a) degrading punishment;
(b) corporal or other physical punishment;
(c) group punishment for one client’s behavior;
(d) deprivation of an client’s rights and needs (e.g., food, phone contacts, etc.) when not based on documented clinical rationale;
(e) aversive stimuli used in behavior modification;
(f) punitive work assignments;
(g) isolation or seclusion;
(h) harassment; and
(i) chemical or mechanical restraints.
(8) For those CTCs that serve mixed age occupants, the CTC shall establish policies and procedures to ensure the health and safety of all residents.
[184.108.40.206 NMAC - N, 10/30/2018]
220.127.116.11 RISK ASSESSMENT: Use of physical restraint must be consistent with federal and state laws and regulations and must include the following:
A. Physical restraints of youth are implemented only by staff who have been trained and certified by a state recognized body in the prevention and use of physical restraint. This training emphasizes de-escalation techniques and alternatives to physical contact with clients as a means of managing behavior. Clients and youth do not participate in the physical restraint of other clients and youth.
B. Youth treatment plans document the use of physical restraints and include: consideration of the client’s medical condition(s); the role of the client’s history of trauma in his/her behavioral patterns; the treatment team’s solicitation and consideration of specific suggestions from the client regarding prevention of future physical interventions.
C. Physical restraints orders for youth are issued by a restraint clinician within one hour of initiation of physical restraint and include documented clinical justification for the use of physical restraint.
D. If the youth has a treatment team physician or advanced practice registered nurse and he or she is available, only he or she can order physical restraint.
E. If physical restraint is ordered by someone other than the youth’s treatment team physician or advanced practice registered nurse, the restraint clinician will consult with the youth’s treatment team physician or advanced practice registered nurse as soon as possible and inform him or her of the situation requiring the youth to be restrained and document in the youth’s record the date and time the treatment team physician or advanced practice registered nurse was consulted and the information imparted.
F. The restraint clinician must order the least restrictive emergency safety intervention that is most likely to be effective in resolving the situation.
G. If the order for physical restraint is verbal, the verbal order must be received by a restraint clinician or a New Mexico licensed registered nurse (RN) or practical nurse (LPN). The restraint clinician must verify the verbal order in a signed, written form placed in the youth’s record within 24 hours after the order is issued.
H. A restraint clinician’s order must be obtained by a restraint clinician or New Mexico licensed RN or LPN prior to or while the physical restraint is being initiated by staff, or immediately after the situation ends.
I. Each order for physical restraint must be documented in the youth’s record and will include:
(1) the name of the restraint clinician ordering the physical restraint;
(2) the date and time the order was obtained;
(3) the emergency safety intervention ordered, including the length of time;
(4) the time the emergency safety intervention actually began and ended;
(5) the time and results of any one-hour assessment(s) required; and
(6) the emergency safety situation that required the client to be restrained; and
(7) the name, title, and credentials of staff involved in the emergency safety intervention.
J. The CTC will notify the parent(s) or legal guardian(s) that physical restraint has been ordered as soon as possible after the initiation of each emergency safety intervention. This will be documented in the client’s record, including the date and time of notification, the name of the staff person providing the notification, and who was notified.
K. After an incident of restraint, the professionals involved in the incident shall conduct a debriefing with the client to discuss the event with the intent of preventing future incidents. Within five days of a incident of restraint, the treatment team must meet to review the incident and revise plan of treatment if appropriate.
[18.104.22.168 NMAC - N, 10/30/2018]
22.214.171.124 CLIENT RIGHTS: All licensed facilities shall understand, protect and respect the rights of all youth demonstrating substantial compliance with all applicable New Mexico Children's Code, Section 32A-1-1 NMSA 1978, including the NM Children’s Mental Health and Developmental Disabilities Act, Section 32A-6A-1 NMSA 1978.
[126.96.36.199 NMAC - N, 10/30/2018]
188.8.131.52 CLIENT CLINICAL RECORD:
The client clinical records maintained by a crisis triage center in a paper-based or electronic system shall document the degree and intensity of the treatment provided to clients who are furnished services by the CTC. A client’s clinical record shall contain at a minimum all required NM Children’s Code documentation defined in Subsection A through Subsection O of Section 32A-6A-10 NMSA 1978 associated with the use of any emergency interventions such as physical restraint.
[184.108.40.206 NMAC - N, 10/30/2018]
220.127.116.11 STAFFING REQUIREMENTS: Other staff requirements:
A. All CYFD background check requirements governing criminal records clearances must remain in effect while a program is accredited.
B. When a prospective employee that will work with or have access to youth has not lived in the United States continuously for the five years prior to hire, the CTC must obtain the equivalent of a criminal records and background clearance from any country in which the prospective employee has lived within the last five years, for a period longer than one year.
C. If the CTC receives reliable evidence that indicates that an employee or prospective employee poses an unreasonable risk, as defined or pursuant to Subsection W of Section 18.104.22.168 NMAC, the CTC may not hire the prospective employee or retain the employee.
[22.214.171.124 NMAC - N, 10/30/2018]
126.96.36.199 PERSONNEL RECORDS: Each CTC licensed pursuant to these regulations intending to work with youth must maintain a complete record on file for each staff member or volunteer including:
A. Completed CYFD criminal records and background check, including the FBI-approved electronic fingerprint for each employee that serves as direct service staff working with youth including licensed and certified staff. (supervisors, physicians, nurses, therapists, client care workers, coordinators, or other agency personnel who work in immediate direct unsupervised contact with youth.) The agency must have received the background clearance from the CYFD background check unit prior to the employee’s direct, unsupervised contact with youth.
B. The date the employee was first employed and dates of transfers or changes in position.
C. Documentation that of a minimum of three references were checked.
D. A clearance letter from CYFD stating the applicant’s background check has been conducted with negative results or a signed statement by the administrator, director, or operator attesting to direct supervision of an uncleared employee by a cleared employee until official clearance is received.
E. Documentation that each uncleared employee is identified on the staff schedule.
[188.8.131.52 NMAC - N, 10/30/2018]
184.108.40.206 STAFF TRAINING: At least 12 hours of on-going training shall be provided to staff that provides direct care at least annually; the training and proof of competency shall include at a minimum: NM Children’s Mental Health and Developmental Disabilities Act Section 32A-6A-1 et. seq., NMSA 1978.
[220.127.116.11 NMAC - N, 18.104.22.168 10/30/2018]
HISTORY of 7.30.13 NMAC: [RESERVED]