CHAPTER 2380. ADULT TRAINING FACILITIES

§ 2380.1. Purpose.

 The purpose of this chapter is to protect the health, safety and well-being of individuals with disabilities, through the formulation, implementation and enforcement of minimum requirements for the operation of adult training facilities.

 (a)  This chapter applies to adult training facilities, except as provided in subsection (f).

 (b)  This chapter contains the minimum requirements that shall be met to obtain a certificate of compliance. Each adult training facility will be inspected by the Department each year and shall obtain a certificate of compliance to operate or continue to operate.

 (c)  This chapter applies to profit, nonprofit, publicly-funded and privately-funded facilities.

 (d)  This chapter applies to adult training facilities operated on the grounds of or in a community residential rehabilitation mental health facility or a community home for individuals with mental retardation if permitted in accordance with Chapter 6400 (relating to community homes for individuals with mental retardation).

 (e)  This chapter applies to adult training facilities operated on the grounds of or in a non-State operated intermediate care facility for the mentally retarded, unless it is medically necessary or in the individual’s best interest to remain at home.

 (f)  This chapter does not apply to the following:

   (1)  Older adult daily living centers as defined in the Older Adult Daily Living Centers Licensing Act (62 P. S. § §  1511.1—1511.22), serving four or more adults who are 60 years of age or older or adults who are 59 years of age or younger but have a dementia-related disease, such as Alzheimer’s disease, as a primary diagnosis, but serving no more than three adults with disabilities who are 59 years of age or younger and who do not have a dementia-related disease as a primary diagnosis.

   (2)  Vocational facilities as defined in Chapter 2390 (relating to vocational facilities).

   (3)  Partial hospitalization facilities as defined in Chapter 5210 (relating to partial hospitalization).

   (4)  Summer recreation programs, camping programs and socialization clubs.

   (5)  Adult day care facilities located in nursing homes that serve only individuals who live in the nursing home.

   (6)  Adult training facilities operated by the Department or the Department of Education.

   (7)  Community homes for individuals with mental retardation licensed in accordance with Chapter 6400 and intermediate care facilities for the mentally retarded licensed in accordance with Chapter 6600 (relating to intermediate care facilities for the mentally retarded) that provide day services in the same building in which the individuals live to individuals who remain at home because they are medically unable to attend a community day program or because it is in the individual’s best interest to remain at the home.

   (8)  Activities occurring at a location other than the facility and the facility grounds, during the time an individual is away from the facility.

 The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:

   Adult—A person 18 years of age or older.

   Adult training facility or facility—A building or portion of a building in which services are provided to four or more individuals, who are 59 years of age or younger and who do not have a dementia-related disease as a primary diagnosis, for part of a 24-hour day, excluding care provided by relatives. Services include the provision of functional activities, assistance in meeting personal needs and assistance in performing basic daily activities.

   Department—The Department of Public Welfare of the Commonwealth.

   Firesafety expert—A local fire department, fire protection engineer, State certified fire protection instructor, college instructor in fire science, county or State fire school, volunteer fire person trained by a county or State fire school or an insurance company loss control representative.

   IPP—Individual Program Plan.

   Individual—An adult with disabilities who receives care in an adult training facility and who has developmental needs which require assistance to meet personal needs and to perform basic daily activities. Examples of adults with disabilities include adults who exhibit one or more of the following:

     (i)   A physical disability such as blindness, visual impairment, deafness, hearing impairment, speech or language impairment or a physical handicap.

     (ii)   A mental illness.

     (iii)   A neurological disability such as cerebral palsy, autism or epilepsy.

     (iv)   Mental retardation.

     (v)   A traumatic brain injury.

   The provisions of this §  2380.3 adopted December 29, 1978, effective December 30, 1978, 8 Pa.B. 3820; reserved January 15, 1993, effective January 16, 1993, 23 Pa.B. 343. Immediately preceding text appears at serial page (131159).

   The provisions of this §  2380.4 adopted December 29, 1978, effective December 30, 1978, 8 Pa.B. 3820; reserved January 15, 1993, effective January 16, 1993, 23 Pa.B. 343. Immediately preceding text appears at serial pages (131159) to (131160).

GENERAL REQUIREMENTS

§ 2380.11. Licensure or approval of facilities.

 The requirements in Chapter 20 (relating to licensure or approval of facilities and agencies) shall be met.

 (a)  Appeals related to the Department’s approval or licensure shall be made in accordance with 2 Pa.C.S. § §  501—508 and 701—704 (relating to the Administrative Agency Law) and 1 Pa. Code Part II (relating to General Rules of Administrative Practice and Procedure).

 (b)  Appeals related to the Department’s approval or licensure shall be made by filing a petition within 30 days after service of notice of the action.

 (c)  Subsection (b) supersedes the appeal period of 1 Pa. Code §  35.20 (relating to appeals from actions of the staff).

 The maximum capacity specified on the certificate of compliance may not be exceeded.

 (a)  A facility shall have a valid firesafety occupancy permit listing the appropriate type of occupancy from the Department of Labor and Industry, the Department of Public Safety of the city of Pittsburgh, the Department of Licensing and Inspection of the city of Philadelphia or the Department of Community Development of the city of Scranton.

 (b)  If the firesafety occupancy permit is withdrawn, restricted or revised, the facility shall notify the Department orally within 1 working day and in writing within 2 working days.

 (c)  If a building is structurally renovated or altered after the initial firesafety occupancy permit is issued, the facility shall have a new occupancy permit or written approval from the Department of Labor and Industry, the Department of Public Safety of the city of Pittsburgh, the Department of Licensing and Inspection of the city of Philadelphia or the Department of Community Development of the city of Scranton.

 If an individual is paid below minimum wage for work performed, the facility shall have a valid Federal or State wage and hour certificate authorizing payment of subminimum wages.

 Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.

 (a)  An unusual incident is:

   (1)  Abuse or suspected abuse of an individual.

   (2)  Injury, trauma or illness requiring inpatient hospitalization, that occurs while the individual is at the facility or under the supervision of the facility.

   (3)  A suicide attempt by an individual.

   (4)  A violation or alleged violation of an individual’s rights.

   (5)  An individual whose absence is unaccounted for, and is therefore presumed to be at risk.

   (6)  The misuse or alleged misuse of an individual’s funds or property.

   (7)  An outbreak of a serious communicable disease, as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting.

   (8)  An incident requiring the services of a fire department or law enforcement agency.

   (9)  A condition, except for snow or ice conditions, that results in closure of the facility for more than 1 scheduled day of operation.

 (b)  Written policies and procedures on the prevention, reporting, investigation and management of unusual incidents shall be developed and kept at the facility.

 (c)  The facility shall orally notify, within 24 hours after abuse or suspected abuse of an individual or an incident requiring the services of a fire department or law enforcement agency occurs:

   (1)  The county mental health and mental retardation program of the county in which the facility is located if the individual involved in the unusual incident has mental illness or mental retardation.

   (2)  The funding agency.

   (3)  The appropriate regional office of mental retardation.

 (d)  The facility shall initiate an investigation of the unusual incident and complete and send copies of an unusual incident report on a form specified by the Department, within 72 hours after an unusual incident occurs, to:

   (1)  The county mental health and mental retardation program of the county in which the facility is located if the individual involved in the unusual incident has mental illness or mental retardation.

   (2)  The funding agency.

   (3)  The appropriate regional office of mental retardation.

 (e)  At the conclusion of the investigation the facility shall send a copy of the final unusual incident report to:

   (1)  The county mental health and mental retardation program of the county in which the facility is located if the individual involved in the unusual incident has mental illness or mental retardation.

   (2)  The funding agency.

   (3)  The appropriate regional office of mental retardation.

 (f)  A copy of unusual incident reports relating to an individual shall be kept in the individual’s record.

 (g)  A copy of unusual incident reports relating to the facility itself, such as those requiring the services of a fire department, shall be kept.

 (h)  The individual’s family, if appropriate, and the residential services provider, if applicable, shall be immediately notified in the event of an unusual incident relating to the individual.

   The provisions of this §  2380.17 adopted December 29, 1978, effective December 30, 1978, 8 Pa.B. 3820; amended January 15, 1993, effective January 16, 1993, 23 Pa.B. 343. Immediately preceding text appears at serial page (88775).

 (a)  The facility shall complete and send copies of a death report on a form specified by the Department, within 24 hours after a death of an individual that occurs at the facility or while under the supervision of the facility to:

   (1)  The county mental health and mental retardation program of the county in which the facility is located if the individual had mental illness or mental retardation.

   (2)  The funding agency.

   (3)  The regional office of mental retardation.

 (b)  The facility shall investigate and orally notify, within 24 hours after an unusual or unexpected death occurs:

   (1)  The county mental health and mental retardation program of the county in which the facility is located if the individual had mental illness or mental retardation.

   (2)  The funding agency.

   (3)  The regional office of mental retardation.

 (c)  A copy of death reports shall be kept in the individual’s record.

 (d)  The individual’s family, and the residential service provider, if applicable, shall be immediately notified in the event of a death of an individual.

 The facility shall maintain a record of an individual’s illnesses, traumas and injuries requiring medical treatment but not inpatient hospitalization, and seizures that occur at the facility or while under the supervision of the facility.

 (a)  An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the facility who will have direct contact with individuals, and for part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person’s date of hire.

 (b)  If a prospective employe who will have direct contact with individuals resides outside of this Commonwealth, an application for a Federal Bureau of Investigation (FBI) criminal history record check shall be submitted to the FBI in addition to the Pennsylvania criminal history record check, within 5 working days after the person’s date of hire.

 (c)  Pennsylvania and FBI criminal history record checks shall have been completed no more than 1 year prior to the person’s date of hire.

 (d)  A copy of the final reports received from the State Police, and the FBI, if applicable, shall be kept.

 (a)  An individual may not be discriminated against because of race, color, religious creed, disability, handicap, ancestry, national origin, age or sex.

 (b)  The facility shall develop and implement civil rights policies and procedures. Civil rights policies and procedures shall include the following:

   (1)  Nondiscrimination in the provision of services, admissions, placements, facility usage, referrals and communications with individuals who are nonverbal or non-English speaking.

   (2)  Physical accessibility and accommodation for individuals with physical disabilities.

   (3)  The opportunity to lodge civil rights complaints.

   (4)  Informing individuals on their right to register civil rights complaints.

 The facility shall have written grievance procedures for individuals and their families and advocates, that assure investigation and resolution of complaints.

   The provisions of this §  2380.25 adopted December 29, 1978, effective December 30, 1978, 8 Pa.B. 3820; reserved January 15, 1993, effective January 16, 1993, 23 Pa.B. 343. Immediately preceding text appears at serial page (131161).

STAFFING

§ 2380.31. Effective date of staff qualifications.

 The requirements in § §  2380.32(c) and 2380.33(c) (relating to chief executive officer; and program specialist) apply for staff persons hired or promoted on or after April 16, 1993.

 (a)  There shall be one chief executive officer responsible for the facility.

 (b)  The chief executive officer shall be responsible for the administration and general management of the facility, including the following:

   (1)  Implementation of policies and procedures.

   (2)  Admission and discharge of individuals.

   (3)  Safety and protection of individuals.

   (4)  Compliance with this chapter.

 (c)  A chief executive officer shall have one of the following groups of qualifications:

   (1)  A master’s degree or above from an accredited college or university and 2 years of work experience in administration or the human services field.

   (2)  A bachelor’s degree from an accredited college or university and 4 years of work experience in administration or the human services field.

   The provisions of this §  2380.32 adopted January 15, 1993, effective January 16, 1993, 23 Pa.B. 343.

 (a)  At least one program specialist shall be assigned for every 30 individuals, regardless of whether they meet the definition of individual in §  2380.3 (relating to definitions).

 (b)  A program specialist shall be responsible for the program at the facility, including the following:

   (1)  Coordination or completion of assessments.

   (2)  Coordination or development and review of IPPs.

   (3)  Coordination of training and development for individuals.

   (4)  Development of planned program activities.

   (5)  Participation in interdisciplinary team meetings.

   (6)  Ensurance of the implementation of IPPs and program activities.

 (c)  A program specialist shall have one of the following groups of qualifications:

   (1)  A master’s degree or above from an accredited college or university and 1 year of work experience working directly with persons with disabilities.

   (2)  A bachelor’s degree from an accredited college or university and 2 years of work experience working directly with persons with disabilities.

   (3)  An associate’s degree or 60 credit hours from an accredited college or university and 4 years of work experience working directly with persons with disabilities.

   The provisions of this §  2380.33 adopted January 15, 1993, effective January 16, 1993, 23 Pa.B. 343.

 A direct service worker shall be responsible for the daily care, training and supervision of individuals.

 (a)  A minimum of one direct service worker for every six individuals shall be physically present with the individuals at all times individuals are present at the facility, except while staff persons are attending meetings or training at the facility.

 (b)  While staff persons are attending meetings or training at the facility, a minimum of one staff person for every ten individuals shall be physically present with the individuals at all times individuals are present at the facility.

 (c)  A minimum of two staff persons shall be present with the individuals at all times.

 (d)  An individual may be left unsupervised for periods of time if the absence of direct supervision is consistent with the individual’s assessment and is part of an individual’s IPP aimed at achieving a higher level of independence.

 (e)  An individual may not be left unsupervised solely for the convenience of the facility or staff persons.

 (a)  The facility shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the facility and policies and procedures of the facility before working with individuals or in their appointed positions.

 (b)  The chief executive officer shall have at least 24 hours of training relevant to human services or administration annually.

 (c)  Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually.

 (d)  Program specialists and direct service workers shall have training in the areas of services for people with disabilities and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment.

 (e)  Program specialists and direct service workers shall be trained before working with individuals in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the facility, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.

 (f)  Program specialists and direct service workers shall be trained annually by a firesafety expert in the training areas specified in subsection (f).

 (g)  There shall be at least one staff person for every 18 individuals, with a minimum of two staff persons present at the facility at all times who have been trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation within the past year. If a staff person has formal certification from a hospital or other recognized health care organization that is valid for more than 1 year, the training is acceptable for the length of time on the certification.

 (h)  Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.

   The provisions of this §  2380.44 adopted December 29, 1978, effective December 30, 1978, 8 Pa.B. 3820; reserved January 15, 1993, effective January 16, 1993, 23 Pa.B. 343. Immediately preceding text appears at serial page (131162).

PHYSICAL SITE

§ 2380.51. Special accommodations.

 A facility serving one or more individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the facility based upon each individual’s needs.

 (a)  There shall be at least 50 square feet of indoor floor space for each individual. Indoor floor space shall be measured wall to wall, including space occupied by equipment, temporary storage and furnishings. Space occupied by lavatories, dining areas, loading docks, kitchens, offices and first aid rooms may not be included unless it is documented that the space is used for programming for at least 50% of each program day. Hallways and permanent storage space may not be included in the indoor floor space.

 (b)  The indoor floor space square footage requirements specified in subsection (a) apply to each separate program area and room within the facility.

 (a)  Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.

 (b)  Poisonous materials shall be stored in their original, labeled containers.

 (c)  Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.

 Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal burning stoves and fireplaces, exceeding 120°F that are accessible to an individual, shall be equipped with protective guards or insulation to prevent an individual from coming in contact with the heat source.

 (a)  Clean and sanitary conditions shall be maintained in the facility.

 (b)  There may not be evidence of infestation of insects or rodents in the facility.

 (c)  Trash shall be removed from the premises at least once per week.

 (d)  Trash in bathroom, dining, kitchen and first aid areas shall be kept in covered, cleanable receptacles that prevent the penetration of insects and rodents.

 (e)  Trash outside the facility shall be kept in closed receptacles that prevent the penetration of insects and rodents.

 (f)  A facility that is not connected to a public sewer system shall have a written sanitation approval for its sewage system by the sewage enforcement official for the municipality in which the facility is located.

 (g)  A facility that is not connected to a public sewer system shall have written documentation that the sewage system is checked for sludge, and pumped if necessary, at least every 4 years.

 Program areas, dining areas, kitchens, bathrooms and first aid rooms shall be ventilated by operable windows or mechanical ventilation such as fans or air conditioning.

 Rooms, hallways, interior stairways, outside steps, interior and outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.

 (a)  Floors, walls, ceilings and other surfaces shall be in good repair.

 (b)  Floors, walls, ceilings and other surfaces shall be free of hazards.

 (c)  If the facility serves an individual who injests paint or paint substances, the facility shall test all layers of paint in areas that are accessible to individuals, for lead content. If the testing shows lead content exceeding .06%, all paint shall be completely stripped and recovered with lead free paint or securely encased with other lead free material. Documentation of the lead paint testing and results shall be kept.

 (a)  The facility shall have hot and cold running water under pressure in bathrooms and kitchen areas.

 (b)  Hot water temperatures in areas accessible to individuals may not exceed 120°F.

 (c)  A facility that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept.

 (a)  Indoor temperature shall be at least 65°F when individuals are in the facility.

 (b)  Whenever indoor temperature exceeds 85°F, mechanical ventilation such as fans shall be used.

 The facility shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.

 Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted on or by each telephone in the facility with an outside line.

 (a)  Windows, including windows in doors, shall be screened when windows or interior doors are open.

 (b)  Screens, windows and doors shall be in good repair.

 (a)  Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail.

 (b)  Each porch that has over an 18-inch drop shall have a well-secured railing.

 Interior stairs and outside steps shall have a nonskid surface.

 (a)  A landing shall be provided beyond each interior and exterior door that opens directly into a stairway.

 (b)  A landing shall be at least as wide as the stairs leading to the landing.

 (c)  A landing shall be at least 3 feet in length.

 (a)  Furniture and equipment shall be nonhazardous, clean and sturdy.

 (b)  Furniture and equipment shall be appropriate for the age, size and disabilities of the individuals.

 Space shall be provided for hanging hats and coats and storing personal belongings.

 (a)  There shall be one toilet for every 18 individuals served at one time.

 (b)  There shall be one sink for every 24 individuals served at one time.

 (c)  For facilities with individuals who have a physical disability, at least one toilet and one sink shall be constructed so that individuals with physical handicaps have access and use. The toilet shall be large enough to allow for transfer from a wheelchair to the toilet and to accommodate the individual and a staff person.

 (d)  If the facility serves 18 or more individuals at one time, there shall be separate bathrooms for men and women.

 (e)  Each bathroom shall have a wall mirror, soap, toilet paper, covered trash receptacle and individual clean paper towels or air hand dryer.

 (f)  Privacy shall be provided for all toilets by partitions, doors or curtains.

 (a)  The facility shall have a first aid area that is separated by partition or privacy screen from program areas.

 (b)  The first aid area shall have a bed or cot, a blanket, a pillow and a first aid kit.

 (c)  Each floor of the facility shall have a first aid kit accessible to staff persons.

 (d)  First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer or other temperature gauging equipment, tweezers, tape and scissors.

 (e)  A first aid manual shall be kept with each first aid kit.

 If an elevator is present in the facility, there shall be a valid certificate of operation from the Department of Labor and Industry.

 (a)  Outside walkways shall be free from ice, snow, obstructions and other hazards.

 (b)  The outside of the building and the facility grounds shall be well maintained, in good repair and free from unsafe conditions.

   The provisions of this §  2380.72 adopted January 15, 1993, effective January 16, 1993, 23 Pa.B. 343.

FIRESAFETY

§ 2380.81. Exits.

 Each building in which the facility operates shall have a minimum of two exits leading directly to the outside.

 Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed.

 (a)  There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation, an emergency shelter location and an evacuation diagram specifying directions for egress in the event of an emergency.

 (b)  An evacuation diagram shall be posted in all areas of the facility.

 The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept.

 Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.

 Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including offices.

 (a)  There shall be an operable fire alarm system that is audible throughout the building.

 (b)  If one or more individuals or staff persons are not able to hear the fire alarm system, the fire alarm system shall be equipped so that each person who is not able to hear the alarm shall be alerted in the event of a fire.

 (c)  If the fire alarm is inoperative, arrangements for repair shall be made within 24 hours and the repairs completed within 4 working days of the time the fire alarm was found to be inoperative.

 (d)  There shall be a written procedure for firesafety monitoring in the event the fire alarm is inoperative.

 (a)  There shall be at least one fire extinguisher with a minimum 2-A rating for each floor including the basement.

 (b)  If the indoor floor area is more than 5,000 square feet on a floor including the basement, there shall be an additional fire extinguisher with a minimum 2-A rating for each additional 5,000 square feet of indoor floor space.

 (c)  A fire extinguisher with a minimum 10-B rating shall be located in each kitchen. This extinguisher is required in addition to the extinguishers with a minimum 2-A rating required for each floor in subsections (a) and (b).

 (d)  Fire extinguishers shall be listed by Underwriters Laboratories or approved by Factory Mutual Systems.

 (e)  Fire extinguishers shall be accessible to staff persons and individuals.

 (f)  Fire extinguishers shall be inspected and approved annually by a firesafety expert. The date of the inspection shall be on the extinguisher.

 (a)  An unannounced fire drill shall be held at least once a month.

 (b)  Fire drills shall be held during normal attendance and staffing conditions and not when additional staff persons are present or when attendance is below average.

 (c)  A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm was operative.

 (d)  Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility.

 (e)  Alternate exit routes shall be used during fire drills.

 (f)  Fire drills shall be held on different days of the week and at different times of the day.

 (g)  Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.

 (h)  A fire alarm shall be set off during each fire drill.

 (a)  Signs bearing the word ‘‘EXIT’’ in plain, legible letters shall be placed at exits.

 (b)  If the exit or way to reach the exit is not immediately visable to the individuals, access to exits shall be marked with visible signs indicating the direction of travel.

 (a)  An individual shall be instructed in the individual’s primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility.

 (b)  If an individual is medically or functionally unable to participate in the firesafety training, the facility shall keep documentation specifying why the individual could not participate.

 (c)  A written record of firesafety training, including the content of the training and individuals attending, shall be kept.

 (a)  If smoking is permitted at the facility, there shall be written smoking safety procedures.

 (b)  Written smoking safety procedures shall be followed.

   The provisions of this §  2380.93 adopted December 29, 1978, effective December 30, 1978, 8 Pa.B. 3820; reserved January 15, 1993, effective January 16, 1993, 23 Pa.B. 343. Immediately preceding text appears at serial page (131165).

PROGRAM

§ 2380.101. Program activities.

 (a)  Program activities shall include assistance, training and support for the acquisition of functional skills, personal needs, communication and personal adjustment.

 (b)  The facility shall provide opportunities and support for participation in community life, including work opportunities.

 (c)  Program activities shall be provided as specified in each IPP.

 (d)  Program activities shall be age and functionally appropriate.

 (a)  Each individual shall have a written assessment within 1 year prior to or 20 individual attendance days after admission and annually thereafter.

 (b)  The assessment shall be completed and updated, or coordinated, by the program specialist.

 (c)  The program specialist shall sign and date the assessment.

 (d)  The assessment shall be based on assessment instruments, interviews, progress notes and observations.

 (e)  The assessment shall include the following information:

   (1)  Functional strengths, needs and wants of the individual.

   (2)  The likes, dislikes and interests of the individual.

   (3)  The individual’s current level of performance and progress in the areas of the acquisition of functional skills, personal needs, communication and personal adjustment.

   (4)  The individual’s need for supervision.

   (5)  If the individual is not able to self-administer medications, the individual’s progress toward self-administration.

   (6)  Documentation of the individual’s disability, including functional and medical limitations.

   (7)  A lifetime medical history.

   (8)  Additional evaluations as necessary.

 (f)  A copy of the assessment shall be kept in the individual’s record.

 (g)  The individual, the individual’s parent, guardian, advocate or residential service provider, if appropriate, and the funding agency, if applicable, shall be informed of the results of the assessment. Documentation of transmittal of this information shall be kept.

 (a)  An IPP shall be developed for each individual based upon the individual assessment, within 30 individual attendance days after the individual’s admission date.

 (b)  The IPP shall be developed by the interdisciplinary team.

 (c)  Members of the interdisciplinary team shall include the individual, the program specialist, the individual’s parent, guardian or advocate, if appropriate, direct service staff persons who work with the individual, staff persons from the funding agency, staff persons from the individual’s residential program, if applicable, and other specialists, such as medical, nursing, behavior management, speech, occupational or physical therapy specialists if appropriate for the individual’s special needs.

 (d)  At least three members of the interdisciplinary team, in addition to the individual if the individual chooses to attend, shall be present at the interdisciplinary team meeting at which the IPP is developed.

 (e)  Members of the interdisciplinary team who attend the meeting to develop the IPP shall sign and date the IPP.

 (a)  A review of each individual’s progress on the IPP, and a revision of the IPP if necessary, shall be completed or coordinated by the program specialist at least every 65 individual attendance days.

 (b)  The IPP shall be revised in accordance with subsection (a) if there has been no progress on a goal, if a goal is no longer appropriate or if a goal needs to be added.

 (c)  The IPP shall be reviewed and rewritten by the interdisciplinary team at least annually.

 (d)  At least three members of the interdisciplinary team, in addition to the individual if the individual chooses to attend, shall be present at the annual interdisciplinary team meeting at which the IPP is reviewed and rewritten.

 (e)  Members of the interdisciplinary team who attend the meeting to rewrite the IPP shall sign and date the new IPP.

 (f)  The IPP shall be discussed with, dated by and signed by the individual, the individual’s parent, guardian or advocate if appropriate, and the program specialist after each 65-day review and annual rewrite of the IPP.

 The individual’s parent, guardian or advocate, if appropriate, and the funding agency shall be invited, in writing, to participate in the initial development and annual rewrite of the IPP. A copy of the written invitations shall be kept.

 Each IPP shall include:

   (1)  The goals for the individual in specific areas of growth and development.

   (2)  An evaluation of the individual’s skill level for each goal.

   (3)  Monthly documentation of the individual’s progress on each goal.

   (4)  Specific activities and services that meet the needs of the individual.

   (5)  A program and schedule for allowing the individual to be without direct staff supervision for specific periods of time, aimed at achieving a greater level of independence, if the individual’s assessment states the individual may be without direct supervision.

   (6)  A planned program to address the social, emotional and environmental needs of the individual, if a medication is prescribed to treat maladaptive behavior.

 Each IPP shall be implemented as written.

 (a)  A written copy of IPPs and adjustments made during reviews shall be kept in the individual’s record.

 (b)  The individual, the individual’s parent, guardian or advocate, if appropriate, the residential service provider, if applicable, and the funding agency shall be provided with a copy of all IPPs. Documentation of transmittal of each IPP shall be kept.

   The provisions of this §  2380.108 adopted January 15, 1993, effective January 16, 1993, 23 Pa.B. 343.

HEALTH

§ 2380.111. Individual physical examination.

 (a)  Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.

 (b)  The physical examination documentation shall be signed and dated by a licensed physician, certified nurse practitioner or certified physician’s assistant.

 (c)  The physical examination shall include:

   (1)  A review of previous medical history.

   (2)  A general physical examination.

   (3)  Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.

   (4)  Vision and hearing screening, as recommended by the physician.

   (5)  Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted.

   (6)  Specific precautions that shall be taken if the individual has a serious communicable disease as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, to prevent the spread of the disease to other individuals.

   (7)  An assessment of the individual’s health maintenance needs, medication regimen and the need for blood work at recommended intervals.

   (8)  Physical limitations of the individual.

   (9)  Allergies or contraindicated medication.

   (10)  Medical information pertinent to diagnosis and treatment in case of an emergency.

   (11)  Special instructions for an individual’s diet.

 (d)  Immunizations, vision and hearing screening and tuberculin skin testing may be completed, signed and dated by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician’s assistant.

 If an individual refuses a routine medical examination, the refusal shall be documented in the individual’s record.

 (a)  A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter.

 (b)  The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or certified physician’s assistant.

 (c)  The physical examination shall include:

   (1)  A general physical examination.

   (2)  Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician’s assistant.

   (3)  A signed statement that the person is free of serious communicable diseases as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or that the person has a serious communicable disease as defined in §  27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals.

   (4)  Information of medical problems which might interfere with the safety or health of the individuals.

 (a)  If a staff person or volunteer has a serious communicable disease as defined in 28 Pa. Code §  27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or a medical problem which might interfere with the health, safety or well-being of the individuals, written authorization from a licensed physician is required for the person to be present at the facility.

 (b)  Written authorization from a licensed physician shall include a statement that the person will not pose a serious threat to the health, safety or well-being of the individuals and specific instructions and precautions to be taken for the protection of the individuals at the facility.

 (c)  The physician’s written instructions and precautions shall be followed.

 The facility shall have a written emergency medical plan listing the following:

   (1)  The hospital or source of health care that will be used in an emergency.

   (2)  The method of transportation to be used.

   (3)  An emergency staffing plan.

   The provisions of this §  2380.115 adopted January 15, 1993, effective January 16, 1993, 23 Pa.B. 343.

MEDICATIONS

§ 2380.121. Storage of medications.

 (a)  Prescription and nonprescription medications shall be kept in their original containers, except for medications of individuals who self-administer medications and keep their medications in personal daily or weekly dispensing containers.

 (b)  Prescription and nonprescription medications shall be kept in an area or container that is locked.

 (c)  Prescription medications stored in a refrigerator shall be kept in a separate locked container.

 (d)  Prescription and nonprescription medications shall be stored under proper conditions of sanitation, temperature, moisture and light.

 (e)  Discontinued prescription medications shall be returned to the individual’s family or residential program for proper disposal.

 (a)  The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual’s name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician.

 (b)  Nonprescription medications, except for medications of individuals who self-administer medications, shall be labeled with the original label.

 (a)  Prescription medications shall only be used by the individual for whom the medication was prescribed.

 (b)  If a medication is prescribed to treat maladaptive behavior, there shall be a planned program as part of the IPP to address the social, emotional and environmental needs of the individual related to the maladaptive behavior.

 (a)  A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered, and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication.

 (b)  The information specified in subsection (a) shall be logged immediately after each individual’s dose of medication.

 (c)  A list of prescription medications, the prescribed dosage, special instructions and the name of the prescribing physician shall be kept for each individual who self-administers medication.

 Documentation of medication errors and follow-up action taken shall be kept.

 If an individual has a suspected adverse reaction to a medication, the facility shall notify the prescribing physician and the family or residential program immediately. Documentation of adverse reactions shall be kept.

 (a)  Prescription medications and injections of a substance not self-administered by individuals shall be administered by one of the following:

   (1)  A licensed physician, licensed dentist, certified physician’s assistant, registered nurse or licensed practical nurse.

   (2)  A graduate of an approved nursing program functioning under the direct supervision of a professional nurse who is present in the facility.

   (3)  A student nurse of an approved nursing program functioning under the direct supervision of a member of the nursing school faculty who is present in the facility.

   (4)  A staff person who meets the criteria in §  2380.128 (relating to medication administration training), for the administration of oral, topical and eye and ear drop prescription medications and insulin injections.

 (b)  Prescription medications and injections shall be administered according to the directions specified on the prescription.

 (a)  A staff person who has completed and passed the Department’s Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications.

 (b)  A staff person who has completed and passed the Department’s Medications Administration Course and who has completed and passed a diabetes patient education program within the past 12 months that meets the National Standards for Diabetes Patient Education Programs of the National Diabetes Advisory Board, 7550 Wisconsin Avenue, Bethesda, Maryland 20205, is permitted to administer insulin injections to an individual who is under the care of a licensed physician who is monitoring the diabetes.

 (c)  Medications administration training of staff persons shall be conducted by an instructor who has completed and passed the Medications Administration Course for trainers and is certified by the Department to train staff persons.

 (d)  A staff person who administers prescription medications or insulin injections to individuals shall complete the Medications Administration Course Practicum annually.

 (e)  Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept.

   The provisions of this §  2380.128 adopted January 15, 1993, effective January 16, 1993, 23 Pa.B. 343.

 (a)  To be considered capable of self-administration of medications, an individual shall:

   (1)  Be able to recognize and distinguish the individual’s own medication.

   (2)  Know how much medication is to be taken.

   (3)  Know when the medication is to be taken.

 (b)  Insulin that is self-administered by an individual shall be measured by the individual or by licensed or certified medical personnel.

   The provisions of this §  2380.129 adopted January 15, 1993, effective January 16, 1993, 23 Pa.B. 343.

NUTRITION

§ 2380.131. Dining area.

 (a)  The facility shall have a dining area for lunches and breaks. The dining area may be a program area as long as the area is not used for purposes of programming and dining at the same time.

 (b)  The dining area shall be clean and sanitary.

 (c)  The dining area shall have a sufficient number of tables and chairs to accommodate the maximum number of individuals scheduled for lunch or break at any one time.

 If the facility provides or arranges for meals for individuals, the following requirements apply:

   (1)  Written daily menus shall be prepared and posted in a location visable to the individuals.

   (2)  Menus shall be posted at least 1 program day prior to the menu date.

   (3)  Menus shall be followed.

   (4)  Written menus shall be retained for at least 2 months.

   (5)  At least one complete meal shall be provided if the individual is at the facility for 4 or more hours. If an individual is at the facility for more than 6 hours, a nutritional snack shall also be provided.

   (6)  Each meal served shall contain at least one item from the dairy, protein, fruits and vegetables and grain food groups, unless medically contraindicated for an individual.

   (7)  The quantity of food served at each meal shall contain at least one-third of the minimum daily requirements as recommended by the United States Department of Agriculture.

   (8)  A prescribed diet for an individual with a medically restricted diet shall be followed. A written record of the prescribed diet shall be kept.

   (9)  Cold food shall be kept at or below 45°F. Hot food shall be kept at or above 140°F. Frozen food shall be kept at or below 0°F.

   (10)  Food shall be protected from contamination while being stored, prepared, served and transported. Food shall be stored in sealed containers.

   (11)  Uneaten food from a person’s dish or from family style serving dishes may not be served again or used in the preparation of other meals.

   (12)  Utensils used for eating, drinking, preparation and serving of food or drink shall be washed after each use by a mechanical dishwasher or by a method approved by the Department of Environmental Resources.

   (13)  Mechanical dishwashers shall use hot water temperatures exceeding 140°F in the wash cycle and 180°F in the final rinse cycle or shall be of a chemical sanitizing type approved by the National Sanitation Foundation.

   (14)  Mechanical dishwashers shall be operated in accordance with the manufacturer’s instructions.

   The provisions of this §  2380.132 adopted January 15, 1993, effective January 16, 1993, 23 Pa.B. 343.

RESTRICTIVE PROCEDURES

§ 2380.151. Definition of restrictive procedures.

 A restrictive procedure is a practice that does one or more of the following:

   (1)  Limits an individual’s movement, activity or function.

   (2)  Interferes with an individual’s ability to acquire positive reinforcement.

   (3)  Results in the loss of objects or activities that an individual values.

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

 A written policy that defines the prohibition or use of specific types of restrictive procedures, describes the circumstances in which restrictive procedures may be used, the persons who may authorize the use of restrictive procedures, a mechanism to monitor and control the use of restrictive procedures and a process for the individual and family to review the use of restrictive procedures shall be kept at the facility.

 (a)  A restrictive procedure may not be used as retribution, for the convenience of staff persons, as a substitute for a program or in a way that interferes with the individual’s developmental program.

 (b)  For each incident requiring a restrictive procedure:

   (1)  Every attempt shall be made to anticipate and de-escalate the behavior using methods of intervention less intrusive than a restrictive procedure.

   (2)  A restrictive procedure may not be used unless less restrictive techniques and resources appropriate to the behavior have been tried but have failed.

 (a)  If a restrictive procedure is used, there shall be a restrictive procedure review committee.

 (b)  The restrictive procedure review committee shall include a majority of persons who do not provide direct services to the individual.

 (c)  The restrictive procedure review committee shall establish a time frame for review and revision of the restrictive procedure plan, not to exceed 6 months between reviews.

 (d)  A written record of the meetings and activities of the restrictive procedure review committee shall be kept.

   The provisions of this §  2380.154 adopted January 15, 1993, effective January 16, 1993, 23 Pa.B. 343.

 (a)  For each individual for whom restrictive procedures may be used, a restrictive procedure plan shall be written prior to the use of restrictive procedures.

 (b)  The restrictive procedure plan shall be developed and revised with the participation of the program specialist, the individual’s direct care staff, the interdisciplinary team, as appropriate, and other professionals, as appropriate.

 (c)  The restrictive procedure plan shall be reviewed, and revised if necessary, according to the time frame established by the restrictive procedure review committee, not to exceed 6 months.

 (d)  The restrictive procedure plan shall be reviewed, approved, signed and dated by the chairperson of the restrictive procedure review committee and the program specialist, prior to the use of a restrictive procedure, whenever the restrictive procedure plan is revised and at least every 6 months.

 (e)  The restrictive procedure plan shall include:

   (1)  The specific behavior to be addressed and the suspected antecedent or reason for the behavior.

   (2)  The single behavioral outcome desired, stated in measurable terms.

   (3)  Methods for modifying or eliminating the behavior, such as changes in the individual’s physical and social environment, changes in the individual’s routine, improving communications, teaching skills and reinforcing appropriate behavior.

   (4)  Types of restrictive procedures that may be used and the circumstances under which the procedures may be used.

   (5)  A target date for achieving the outcome.

   (6)  The amount of time the restrictive procedure may be applied, not to exceed the maximum time periods specified in this chapter.

   (7)  Physical problems that require special attention during the use of the restrictive procedure.

   (8)  The name of the staff person or staff position responsible for monitoring and documenting progress with the plan.

 (f)  The restrictive procedure plan shall be implemented as written.

 (g)  Copies of the restrictive procedure plan shall be kept in the individual’s record.

   The provisions of this §  2380.155 adopted January 15, 1993, effective January 16, 1993, 23 Pa.B. 343.

 (a)  If a restrictive procedure is used, at least one staff person shall be available when the restrictive procedure is used who has completed training within the past 12 months in the use of and ethics of using restrictive procedures including the use of alternate positive approaches.

 (b)  A staff person responsible for developing, implementing or managing a restrictive procedure plan shall be trained in the use of the specific techniques or procedures that are used.

 (c)  If manual restraint or exclusion is used, the staff person responsible for developing, implementing or managing a restrictive procedure plan shall have experienced the use of the specific techniques or procedures directly on themselves.

 (d)  Documentation of the training program provided, including the staff persons trained, dates of the training, description of the training and the training source, shall be kept.

 Seclusion, defined as placing an individual in a locked room, is prohibited. A locked room includes a room with any type of door locking device such as a key lock, spring lock, bolt lock, foot pressure lock or physically holding the door shut.

 The use of aversive conditioning, defined as the application, contingent upon the exhibition of maladaptive behavior, of startling, painful or noxious stimuli, is prohibited.

 (a)  A chemical restraint is a drug used to control acute, episodic behavior that restricts the movement or function of an individual.

 (b)  Administration of a chemical restraint is prohibited except for the administration of drugs ordered by a licensed physician on an emergency basis.

 (c)  If a chemical restraint is administered as specified in subsection (b), the following apply:

   (1)  Prior to each incidence of administering a drug on an emergency basis, a licensed physician shall examine the individual and give a written order to administer the drug.

   (2)  Prior to each readministration of a drug on an emergency basis, a licensed physician shall examine the individual and order readministration of the drug.

   (3)  The individual’s vital signs shall be monitored at least once each hour.

   (4)  Physical needs of the individual shall be met promptly.

 (d)  A Pro Re Nata (PRN) order for controlling acute, episodic behavior is prohibited.

 (e)  A drug ordered by a licensed physician as part of an ongoing program of medication is not a chemical restraint.

 (f)  A drug ordered by a licensed physician for a specific, time-limited stressful event or situation to assist the individual to control behavior, is not a chemical restraint.

 (g)  A drug ordered by a licensed physician as pretreatment prior to a medical or dental examination or treatment is not a chemical restraint.

 (h)  A drug self-administered by an individual is not a chemical restraint.

 (i)  If a drug is administered in accordance with subsection (b), (f), (g) or (h) to treat a behavior that occurs at the facility, there shall be training for the individual aimed at eliminating or reducing the need for the drug in the future.

 (j)  Documentation of compliance with subsections (b)—(i) shall be kept.

 (a)  A mechanical restraint is a device used to control acute, episodic behavior that restricts the movement or function of an individual or portion of an individual’s body. Examples of mechanical restraints include anklets, wristlets, camisoles, helmets with fasteners, muffs and mitts with fasteners, poseys, waist straps, head straps, restraining sheets and similar devices.

 (b)  The use of a mechanical restraint is prohibited except for the use of helmets, mitts and muffs to prevent self-injury on an interim basis but only for the first 3 months after admission.

 (c)  If a mechanical restraint is used as specified in subsection (b), the following apply:

   (1)  The use of a mechanical restraint may not exceed 2 hours, unless a licensed physician examines the individual and gives written orders to continue the use of the restraint. Reexamination and new orders by a licensed physician are required for each 2-hour period the restraint is continued. If a restraint is removed for a purpose other than for movement and reused within 24 hours after the initial use of the restraint, it is considered continuation of the initial restraint.

   (2)  A licensed physician shall be notified immediately after a mechanical restraint is used.

   (3)  The restraint shall be checked for proper fit by staff at least every 15 minutes.

   (4)  Physical needs of the individual shall be met promptly.

   (5)  The restraint shall be removed completely for at least 10 minutes during every 2 hours the restraint is used.

   (6)  There shall be training for the individual aimed at eliminating or reducing the need for the restraint in the future.

   (7)  Documentation of compliance with subsection (b) and paragraphs (1)—(6) shall be kept.

 (d)  A device used to provide support for functional body position or proper balance and a device used for medical treatment, such as sand bags to limit movement after medical treatment, a wheelchair belt that is used for body positioning and support or a helmet for prevention of injury during seizure activity, is not considered a mechanical restraint.

 (a)  A manual restraint is a physical hands-on technique that lasts more than 30 seconds, used to control acute, episodic behavior that restricts the movement or function of an individual or a portion of an individual’s body such as basket holds and prone or supine containment.

 (b)  A manual restraint shall be used only when necessary to protect the individual from injurying himself or others.

 (c)  A manual restraint shall be used only when it has been documented that other less restrictive methods have been unsuccessful in protecting the individual from injuring himself or others.

 (d)  An individual shall be released from the manual restraint within the time specified in the restrictive procedure plan not to exceed 30 minutes within a 2-hour period.

 (a)  Exclusion is removing an individual from his immediate environment and restricting him alone to a room or area. If a staff person remains with the individual, it is not exclusion.

 (b)  Exclusion shall be used only when necessary to protect the individual from self-injury or injury to others.

 (c)  Exclusion shall be used only when it has been documented that other less restrictive methods have been unsuccessful in protecting the individual from self-injury or injury to others.

 (d)  An individual shall be permitted to return to routine activity within the time specified in the restrictive procedure plan not to exceed 60 minutes within a 2-hour period.

 (e)  Exclusion may not be used for an individual more than two times in the same day.

 (f)  An individual in exclusion shall be monitored continually by a staff person.

 (g)  A room or area used for exclusion shall have at least 40 square feet of indoor floor space, with a minimum ceiling height of 7 feet.

 (h)  A room or area used for exclusion shall have an open door or a window for staff observation of the individual.

 (i)  A room or area used for exclusion shall be well lighted and ventilated.

 If exclusion or manual restraints are used on an unanticipated, emergency basis, § §  2380.154 and 2380.155 (relating to restrictive procedure review committee; and restrictive procedure plan) do not apply until after the exclusion or manual restraint is used for the same individual twice in a 6-month period.

 (a)  An individual’s personal funds or property may not be used as a reward or punishment.

 (b)  An individual’s personal funds or property may not be used as payment for damages unless the individual consents to make restitution for the damages.

 A record of each use of a restrictive procedure documenting the specific behavior addressed, methods of intervention used to address the behavior, the date and time the restrictive procedure was used, the specific procedures followed, the staff person who used the restrictive procedure, the duration of the restrictive procedure, the staff person who observed the individual if exclusion was used and the individual’s condition following the removal of the restrictive procedure shall be kept in the individual’s record.

   The provisions of this §  2380.165 adopted January 15, 1993, effective January 16, 1993, 23 Pa.B. 343.

RECORDS

§ 2380.171. Emergency information.

 (a)  Emergency information for individuals shall be easily accessible at the facility.

 (b)  Emergency information for each individual shall include:

   (1)  The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.

   (2)  The name, address and telephone number of the individual’s physician or source of health care.

   (3)  The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.

   (4)  A copy of the individual’s most recent annual physical examination.

 (a)  A separate record shall be kept for each individual.

 (b)  Entries in an individual’s record shall be legible, dated and signed by the person making the entry.

 Each individual’s record shall include:

   (1)  Personal information including:

     (i)   The name, sex, admission date, birthdate and social security number.

     (ii)   The race, height, weight, color of hair, color of eyes and identifying marks.

     (iii)   The language or means of communication spoken or understood by the individual and the primary language used in the individual’s natural home, if other than English.

     (iv)   Religious affiliation.

     (v)   A current, dated photograph.

   (2)  Unusual incident reports related to the individual.

   (3)  Physical examinations.

   (4)  Assessments.

   (5)  IPPs.

   (6)  Restrictive procedure plans.

   (7)  Restrictive procedure records relating to the individual.

   The provisions of this §  2380.173 adopted January 15, 1993, effective January 16, 1993, 23 Pa.B. 343.

 (a)  The record information required in §  2380.173(1) (relating to content of records) shall be kept at the facility.

 (b)  The most current copies of record information required in §  2380.173(3) and (5)—(7) shall be kept at the facility.

 (c)  The record information required in §  2380.173(3) and (5)—(7), that is not current shall be kept at the facility or at the facility’s administrative office.

 (d)  The record information required in §  2380.173(2) and (4) shall be kept at the facility or at the facility’s administrative office.

 (a)  Information in the individual’s record shall be kept for at least 4 years or until any audit or litigation is resolved.

 (b)  Individual records shall be kept for at least 4 years following the individual’s departure or until any audit or litigation is resolved.

 (a)  Individual records shall be kept locked when they are unattended.

 (b)  The individual, and the individual’s parent, guardian or advocate, shall have access to the records and to information in the records. If the interdisciplinary team documents, in writing, that disclosure of specific information constitutes a substantial detriment to the individual or that disclosure of specific information will reveal the identity of another individual or breach the confidentiality of persons who have provided information upon an agreement to maintain their confidentiality, that specific information identified may be withheld.