§ 6000.1. Definitions.

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

   Act No. 1985-33—The act of July 1, 1985 (P. L. 124, No. 33), amending the Child Protective Services Law (11 P. S. § §  2201—2224).

   Act No. 1987-80—The act of November 6, 1987 (P. L. 391, No. 80).

   CWEP—The Community Work Experience Program.

   Child—A person 17 years of age or younger.

   Department—The Department of Public Welfare of the Commonwealth.

   Founded report—A report made under the Child Protective Services Law if there has been a judicial adjudication based on a finding that a child who is a subject of the report has been abused.

   Indicated report—A report made under the Child Protective Services Law if an investigation by the child protective service determines that substantial evidence of the alleged abuse exists based on one of the following:

     (i)   Available medical evidence.

     (ii)   The child protective service investigation.

 (a) Act Nos. 1985-33 and 1987-80 apply to facilities that are licensed, approved, certified or registered or provided by the Department and programs that are provided through a contract with the Department or a county social service agency. Act Nos. 1985-53 and 1987-80 apply to facilities which primarily serve children.

 (b)  For mental retardation facilities and services Act Nos. 1985-33 and 1987-80 apply to the following:

   (1)  Licensed community residential mental retardation facilities and agencies serving primarily children.

   (2)  Licensed non-State ICFs/MR serving primarily children.

   (3)  State-operated ICFs/MR serving primarily children.

   (4)  Early intervention facilities—licensed/approved as child day care centers.

   (5)  Nonlicensed mental retardation children’s programs, such as recreation programs, camps, transportation, family aid services, family support services and homebound instruction programs.

   (6)  County mental retardation program staff members who provide direct care, supervision, guidance or control of children.

 (c)  Act Nos. 1985-33 and 1987-80 do not apply to vocational facilities or adult day care centers that are licensed under Chapters 2380 and 2390 (relating to adult training facilities; and vocational facilities).

 The legal entity and administrator of the child care facilities and children’s programs listed under §  6000.2 (relating to applicability) are responsible for compliance with Act Nos. 1985-33 and 1987-80. The penalty for noncompliance with these acts is a civil penalty of up to $2,500.

REQUIREMENTS

§ 6000.21. Individuals requiring clearances.

 (a)  Act No. 1985-33 requires that certain staff members employed in the types of child care facilities and children’s programs listed under §  6000.2 (relating to applicability) have both child abuse and criminal history record clearances prior to employment. Only staff members who will be providing direct care, supervision, guidance or control of children are covered by Act No. 1985-33.

 (b)  The following is a description of which staff members require and do not require clearances:

   (1)  Staff members hired after January 1, 1986 require the clearances.

   (2)  Staff members providing only adult care do not require clearances.

   (3)  Only paid employes of the facility or agency require clearances; volunteers do not require clearances.

   (4)  Paid substitute and temporary staff members require clearances.

   (5)  CWEP workers require clearances.

   (6)  If a person meets the following criteria, clearances are not required:

     (i)   Is 20 years of age or younger.

     (ii)   Is employed for periods of 90 days or less.

     (iii)   Is part of a job development or job training program funded in whole or in part by public or private sources—other than CWEP.

   (7)  A new administrator or chief executive officer hired after January 1, 1986 requires clearance only if that person has direct contact with children. If the administrator or chief executive officer requires a clearance, the legal entity shall complete the clearances and keep documentation of the checks on file at the agency or facility.

 (a)  Two clearances are required: a criminal records check to investigate past criminal convictions and a child abuse check to determine if there have been founded or indicated reports of child abuse naming the applicant as perpetrator.

   (1)  Child Abuse Check.

     (i)   Departmental form CY113, titled ‘‘Application for Child Abuse History’’, shall be used to request child abuse checks. A copy of this form may be obtained by calling ChildLine at (717) 783-6211, or, by writing to ChildLine and Abuse Registry, Post Office Box 8170, Lanco Lodge, Second Floor, Harrisburg, Pennsylvania 17105-8170.

     (ii)   To request the child abuse check, form CY113 shall be submitted to ChildLine at the address in subparagraph (i) with a check or money order for $10 made payable to the ‘‘Pennsylvania Department of Public Welfare’’. If form CY113 is not used or if the $10 fee is not attached, the child abuse record check request will not be processed and ChildLine will return the request to the applicant. A CWEP applicant is exempt from payment of the $10 fee.

     (iii)   The Department is required to comply with certification requests within 14 days from the date of receipt at ChildLine.

   (2)  Criminal history records check.

     (i)   A separate request shall be made to the State Police to obtain a criminal history records check. The facility or agency may contact a State Police facility to request copies of the criminal records check forms.

     (ii)   The State Police charge $10 for the criminal history records check. A personal check, cashier’s check or certified check or money order shall accompany the request.

     (iii)   The estimated processing time from the date of receipt for the criminal history records check is 21 days.

     (iv)   If the prospective employe resides outside of this Commonwealth, a Federal FBI check is required in addition to the Pennsylvania criminal records check. For out-of-State prospective employes, contact ChildLine for a complete packet that will include an FBI check form. The charge for an FBI report is $14.

     (v)   The State Police do not maintain criminal information on persons 17 years of age or younger. However, Act No. 1985-33 requires that criminal history records checks be conducted on all prospective employes, which include prospective employes 17 years of age or younger. Therefore, a criminal records check shall be requested on individuals 17 years of age or younger, and a report of ‘‘no information available’’ will be considered compliance.

 (b)  Both the child abuse check and the criminal history records check shall be obtained by the applicant within 1 year prior to the application for employment of the prospective employe. If the date of a clearance exceeds 1 year prior to the application for employment, a new clearance shall be obtained.

 (c)  There is no requirement that specifies who is required to pay the fees for the criminal history records check and the child abuse records check.

 (d)  A prospective employe may not be hired in a child care position—direct care, supervision, guidance or control of children—if the results of either of the two clearances indicate that one of the following applies:

   (1)  The prospective employe is a perpetrator of a founded report of child abuse within 5 years prior to the report from the Department regarding the child abuse check, see 11 P. S. §  2223.1(d).

 (a)  Under Act No. 1987-80, child care administrators are permitted, but not required, to hire staff members in a child care position—direct care, supervision, guidance or control of children—for a single period not to exceed 30 calendar days for residents of this Commonwealth, or 90 calendar days for out-of-State residents, if the following conditions are met:

   (1)  The applicant has mailed the requests for the required clearances to ChildLine, the State Police and the FBI, if applicable.

   (2)  The applicant provides copies of the completed request forms for clearances to the administrator.

   (3)  The administrator has no knowledge of information which would disqualify the applicant from employment under section 23.1(d) or (e) of the Child Protective Services Law (11 P. S. §  2223.1(d) or (e)).

   (4)  The applicant swears or affirms in writing that he is not disqualified from employment under section 23.1(d) or (3) of the Child Protective Services Law.

 (b)  The applicant shall be immediately dismissed from employment if disqualified from employment under section 23.1(d) or (e) of the Child Protective Services Law.

 (c)  During the 30- or 90-day provisional period, the provisional employe is not permitted to work alone with children and shall work in the immediate vicinity of a permanent employe. As used in this subsection:

   (1)  ‘‘Immediate vicinity’’ means that the provisional employe shall work within eyesight of a permanent employe at all times.

   (2)  ‘‘Permanent employe’’ means one of the following:

     (i)   A child care worker who has been successfully cleared by ChildLine, State Police and FBI, if applicable.

 (a)  In addition to this chapter, Chapter 20 (relating to licensure or approval of facilities and agencies) also governs abuse and other circumstances which are considered as part of the Department’s issuance of certificates of compliance.

 The appropriate regional office of mental retardation may be contacted for a single copy of the following:

   (1)  Act No. 1985-33.

   (2)  Act No. 1987-80.

   (3)  Chapter 3490 (relating to protective services).

   (4)  A sample Criminal History Records Check Form.

   (5)  An application Form for Child Abuse History—Form CY113.

DETERMINATIONS

§ 6000.31. Child care service.

 (a)  To fall within this subchapter, the service shall be primarily for children. A vocational facility which occasionally serves a client 17 years of age or younger would not be covered. Residential programs for the mentally retarded are covered only if they primarily serve children, and not if they have a resident 17 years of age or younger from time to time. The reason for this distinction is that a facility which is primarily for adults has no special attraction for persons disposed toward child abuse, and that children who are present are likely to be in their mid to upper teens, and therefore somewhat less vulnerable than younger children.

 (b)  Regular child care employes are covered as well as employes who rotate into child care positions. An employe who predictably provides child care services as part of employment is covered, whether this is 5 days a week or 1 day a month.

 (c)  Act Nos. 1985-33 and 1987-80 do not apply to employes who provide child care coverage on only an unpredictable emergency basis. Because the attraction to persons disposed toward abuse is slight, the need for emergency care outweighs the small risk of an unscreened person providing it.

 (d)  Staff members employed prior to January 1, 1986, in a nonchild care position who are promoted or transferred to a child care position after January 1, 1986, with the present employer shall obtain clearances. The promoted or transferred individual would be deemed a prospective employe under Act Nos. 1985-33 and 1987-80. If an individual is already employed in a child care service in a position which involves direct contact with children and is promoted to a higher level, which still involves direct contact with children or which does not require direct contact with children, the individual is exempt from the screening requirements.

 (e)  Act No. 1985-33 does not apply to a person hired on or prior to December 31, 1985, but does not begin to work until after January 1, 1986, if a written commitment to hire an individual was made prior to January 1, 1986. The individual is not required to submit verifications prior to actual commencement of employment after January 1, 1986. Once the commitment to employ an individual is made, that individual has been hired for purposes of Act No. 1985-33, which provides that an administrator of a child care service may not hire an individual who possesses an adverse criminal record or child abuse history.

 (f)  An employe who works for an agency prior to January 1, 1986, and who resigns or is furloughed and later reapplies with the same agency after January 1, 1986 shall receive clearances as follows:

   (1)  If the employe is furloughed, clearances depend upon whether the furloughed employe retains a right to reemployment with the agency. Particularly in the case of a union contract, a furloughed employe may have a property interest in continued employment and is considered a current employe during the period of the furlough and is not required to submit the verifications. If the furloughed employe is not a union employe or if there is no contract with the employer regarding reemployment rights, the employe would require screening.

   (2)  The employe who resigns is treated differently. The employe retains no property right in reemployment and would be deemed a prospective employe and require the clearances.

 (g)  An administrator is subject to Act Nos. 1985-33 and 1987-80 if job duties involve direct contact with children.

   (1)  If an administrator’s job duties do not involve direct contact, he is outside the scope of Act No. 1985-33. In emergency situations, an administrator whose job duties do not involve direct contact with children is not required to be screened.

   (2)  An administrator may not be hired provisionally under Act No. 1987-80. Refer to §  6000.32(i) (relating to provisional hiring process).

 (h)  Janitors and food service workers who seek employment in a child care service are generally not required to seek criminal history and ChildLine clearances.

   (1)  Section 23.1(a) of the Child Protective Service Law (11 P. S. §  2223.1(a)) governing applicability, provides: ‘‘This section shall not apply to administrative or other support personnel unless their duties will involve direct contact with children.’’ Section 3490.121 (relating to definitions) defines ‘‘direct contact with children’’ as ‘‘care, control, supervision or guidance of a child.’’ In the ordinary course of employment, a janitor’s or food service worker’s job duties do not involve direct contact with children.

   (2)  If the janitor’s or food service worker’s job duties involve care, control, supervision or guidance of a child, the prospective janitor or food service worker who applies for a job in a child care service is required to submit the necessary verifications required by Act No. 1985-33. If, for example, a prospective food service worker’s job duties involve supervising a child in assisting in the preparation of meals at a juvenile detention facility when no other direct care staff person is present, the food service worker would have to be screened.

 (i)  Drivers of buses and vans who take children to and from child care services are within the scope of Act Nos. 1985-33 and 1987-80 if the drivers are employes of the child care agency or service, and there are no other child care services employes in the bus. The children would, in these circumstances, be under the supervision of the driver.

   (1)  If the driver is alone with the children, provisional hiring is not permitted.

   (2)  If there is another child care employe on the bus or van, and the driver is not in charge of the children, Act No. 1985-33 is not applicable to the driver.

   (3)  Drivers who are employes of general transportation companies which contract with child care services are not covered, because employment in a general transportation company is not especially attractive to persons with dispositions toward child abuse.

 (j)  In a family living community residential facility, only the family members applying to be family living providers are required to have clearances and are covered by Act Nos. 1985-33 and 1987-80. Other persons, including other adults living in the household, are not covered.

 (k)  The medical staff of mental retardation facilities for children who administers medications or other medical or health services to children, but who are not alone with the children, are covered under Act Nos. 1985-33 and 1987-80. They apply since the medical staff has direct contact, care, supervision, guidance or control of the children.

 (l)  Act Nos. 1985-33 and 1987-80 apply to consultants employed through contract by a child care service if the consultant will be providing direct care, supervision, guidance or control of children.

 (m)  Persons seeking employment as a substitute staff member are subject to Act Nos. 1985-33 and 1987-80. A person who seeks employment in a child care service whether on a full-time, part-time or substitute basis is a prospective employe for purposes of Act Nos. 1985-33 and 1987-80. No distinction is drawn among these types of employment.

 (n)  If a substitute is employed for Agency X and Agency Y, the substitute is required to be cleared only one time.

   (1)  A prospective substitute employe shall submit the required clearances with his application for employment to each child care service agency or facility to which he applies. Act No. 1985-33 permits prospective employes to submit copies of the verifications with the applications for employment. The original child abuse history clearance form and State Police criminal history clearance form shall be presented by the employe to the employer prior to employment.

   (2)  The prospective employe need only obtain one set of clearances, and may submit copies to each child care service where employment is sought. Verifications of child abuse and criminal record histories are valid for 1 year.

 (o)  Volunteers of child care services who are paid only expenses are not included within the scope of Act Nos. 1985-33 and 1987-80. They cover employes, not volunteers. An individual who volunteers to participate in a child care service who is paid, from whatever source, for expenses only, is outside the scope of Act Nos. 1985-33 and 1987-80; they remain volunteers. The individual is in no way receiving wages or salary or other compensation for services performed but is merely paid for expenses incurred for participation in the child care service activities. Act No. 1985-33 does permit an individual who is not otherwise subject to the act to seek voluntary certification as a child caretaker.

 (p)  Act Nos. 1985-33 and 1987-80 apply to a prospective employe of a Department licensed residential facility which has an onsite school licensed by the Department of Education depending upon whether the individual’s job duties will be strictly limited to teaching or whether the individual’s job duties include teaching in addition to other functions, such as a houseparent or counselor for children cared for in the facility.

   (1)  If the individual seeking employment in the facility will perform only educational services within the Department of Education-licensed school, the individual is outside the scope of Act Nos. 1985-33 and 1987-80. The individual would, however, be subject to section 111 of the Public School Code of 1949 (24 P. S. §  1-111), which governs prospective school employes and requires prospective employes to submit criminal history record information prior to employment.

   (2)  If the individual will perform functions other than teaching, the person would be subject to Act Nos. 1985-33 and 1987-80 and be required to submit both the criminal history record information and the ChildLine checks.

 (q)  If a facility changes ownership, but operates continuously after January 1, 1986, current employes at the center do not require screening. The fact that the current employes usually remain in spite of the change in ownership makes the employes more akin to current employes, rather than prospective employes seeking initial employment. Current child care service employes are not required to submit the record clearances as a condition of continued employment.

 (r)  An FBI check is required if a person lived in this Commonwealth at one time but now resides in another state. A person who currently resides outside of this Commonwealth is considered an out-of-State resident. Under Act No. 1985-33, a person who is not a resident of this Commonwealth shall submit an FBI report. There is no length of residency requirement. The fact that the prospective employe formerly resided in this Commonwealth is not relevant.

 (s)  If a prospective employe moved to this Commonwealth the week before application for employment, an FBI check is not required for the applicant. The person who moves to this Commonwealth is considered a Pennsylvania resident as soon as he takes residence in this Commonwealth. There is no length of residence requirement. A Pennsylvania resident, regardless of length of residency, is not required to seek FBI clearance.

 (t)  Private practitioners of licensed professions, such as child psychiatrists, are not covered by Act Nos. 1985-33 and 1987-80. Consideration of the statutes as a whole, especially the enforcement provisions, clearly indicate that the private practitioner was not intended to be covered. A psychiatrist who contracts with a psychiatric clinic for children is covered, however, because persons who contract with child care services whose duties involve direct contact with children are covered. The basis for this distinction is that the client of the private practitioner, or the parent, can choose the practitioner. This choice is usually not available in a clinic or other facility setting.

 (u)  Private practitioners are not covered by Act Nos. 1985-33 and 1987-80 if the practitioner is reimbursed by medical assistance.

 (v)  Summer camps are covered by Act Nos. 1985-33 and 1987-80 if the program offered is primarily for one of the groups of children specifically identified in the definition of ‘‘child care services’’: delinquent, dependent, mentally retarded, mentally ill, alcohol or drug dependent.

 (w)  If a county agency contracts with the YWCA for swimming lessons for mentally retarded children, the YWCA is not considered a child care service unless the swimming program is specifically identified as a service for mentally retarded children. The fact that a mentally retarded child is present either in a group of ‘‘regular’’ children who are receiving swimming lessons or a group composed entirely of mentally retarded is considered a child children receiving swimming lessons does not convert the YWCA into a child care service.

 (x)  A county mental retardation casemanager requires clearances depending upon the job duties of the casemanagers. If the case manager’s job duties involve direct contact with children, the individual who applies to be a casemanager is required to submit criminal history and child abuse history information. Section 3490.121 defines ‘‘direct contact’’ as ‘‘care, control, supervision or guidance’’ of a child.

 (y)  A child care service contractor with a pre-existing contract which is renewed on an annual basis is not required to submit clearances each year.

   (1)  Act Nos. 1985-33 and 1987-80 do not provide for annual checks of employes who were either hired before January 1, 1986, or those prospective employes hired after January 1, 1986.

   (2)  There is no rationale to treat current contractors who renew their contracts on an annual basis without interruption of service differently from current employes for purposes of Act Nos. 1985-33 and 1987-80.

 (z)  A new employe of a child care services contractor, who applies for employment after January 1, 1986 is subject to Act Nos. 1985-33 and 1987-80. The employe would be a prospective employe.

 (aa)  The project operator is responsible for the decision that a child care CWEP assignment involves direct contact with children and is in the best position to certify whether or not direct contact with children will be involved when the project position request is made to the employment office in the county assistance office.

 (bb)  Act Nos. 1985-33 and 1987-80 do not apply to all facilities/programs serving children.

   (1)  The acts apply only to facilities/programs primarily serving children. If more than 50% of the population served at a facility or unit within a facility are children, the facility or unit is considered a child care service. ‘‘Facility’’ means a building in which child care services are provided and ‘‘unit’’ means a separate and distinct portion or area of a building, such as an apartment unit, a wing of a building, or a floor of a building in which child care services are provided.

   (2)  The determination of whether a service is a child care service should be based upon the annual population of children cared for by the facility. The census of each facility should be examined on an annual basis to determine if more than 50% of the population is under 17 years of age or younger. If so, the facility is considered a child care service.

 (a)  A person may be hired in a child care position conditionally pending receipt of the clearances if the requirements specified in Act No. 1987-80 and Chapter 3490 (relating to protective services) are met.

 (b)  A person may be hired and placed in a training program prior to receipt of the clearances if the requirements specified in Act No. 1987-80 and Chapters 3480 and 3490 are met.

 (c)  If the applicant states that he has submitted the necessary requests for clearance, but did not make a copy of those requests for clearance, the administrators may not hire the applicant. The administrator shall retain a copy of those requests as a condition of provisional employment.

 (d)  An administrator as a matter of hiring policy may decide not to hire on a provisional basis.

 (e)  The administrator’s most prudent action to attempt to assure that the prospective employe would not be disqualified from employment under section 23.1(d) or (e) of the Child Protective Services Law (11 P. S. §  2223.1(d) or (e)) is to:

   (1)  Ask the applicant whether he will be disqualified under section 23.1(d) or (e) of the Child Protective Services Law and read those sections to the prospective employe.

   (2)  If the prospective employe answers that he would not be disqualified under section 23.1(d) or (e) of the Child Protective Services Law, he is required to affirm or swear to that in writing.

 (f)  Subsection (d) applies to an out-of-State person applying for employment in this Commonwealth. In addition, the applicant shall swear or affirm that he has not been convicted of an equivalent crime as listed in section 23.1(d) or (e) of the Child Protective Services Law in another state within 5 years preceding the application for employment.

 (g)  If the provisional employe does not submit the required clearances to the administrator within 30 calendar days of employment, the administrator has three options:

   (1)  Dismiss the employe until clearances are received.

   (2)  Retain and reassign the employe in a position that does not involve direct contact with children. As used in this subsection, ‘‘direct contact with children’’ means care, supervision, guidance or control of children.

   (3)  Furlough or lay off the employe until the clearances are received. This option is not applicable for Civil Service employes.

 (h)  A prospective operator or administrator of a new facility or agency may not acquire a license pending ChildLine and State Police clearances. Section 23.1(o) of the Child Protective Services Law does not apply to an operator or administrator seeking a license for a new facility or agency.

 (i)  The legal entity of a licensed/operating facility may not provisionally hire an administrator whose job duties involve direct contact with children. Section 23.1(o) of the Child Protective Services Law does not permit a legal entity to hire an administrator for the agency or facility pending clearances. Act No. 1987-80 was intended to allow administrators to hire child care staff to assure adequate supervision of children in care.

 (j)  Employment begins on the first day of work, rather than when the job is offered or accepted.

 (k)  The administrator may call ChildLine to confirm that the request has been received, processed or returned to the prospective employe. It is suggested that the administrator call between the 20th and 25th day after provisional hire. The number is (717) 783-6211. Staff members are on duty Monday through Friday between 8 a.m. and 4:30 p.m.

 (l)  The administrator needs to have the name, address and social security number of the employe and approximate date when the request was mailed when he calls ChildLine.

 (m)  When the administrator calls ChildLine, he shall confirm whether the request has been received and processed, and the date the response was mailed. ChildLine will not release the results of the clearance.

 (n)  If the applicant has not received the clearance within 7 days after the date ChildLine confirmed it was mailed, the applicant should call ChildLine at (717) 783-6211 for assistance in resolving the problems.

   This section cited in 55 Pa. Code §  6000.31 (relating to child care service).

MONITORING

§ 6000.41. Licensed community residential mental retardation facilities and agencies serving children and non-State operated intermediate care facilities for the mentally retarded serving children.

 (a)  The Department through the Office of Mental Retardation, will monitor licensed community residential mental retardation facilities and agencies for compliance with Act Nos. 1985-33 and 1987-80 routinely as part of the licensure process. The Department of Health will monitor licensed non-State operated intermediate care facilities for the mentally retarded for compliance with Act Nos. 1985-33 and 1987-80 routinely as part of their licensure process. The licensing procedures in this section will be followed by both the Office of Mental Retardation’s and the Department of Health’s licensing inspectors.

 (b)  During each annual licensing inspection, the licensing inspector will request access to the records of new child care employes hired or transferred to child care during the past 12 months—not to precede January 1, 1986. The licensing inspector will review a minimum of a 25% random sample of the records of new child care employes for each facility. The inspector will review the records for:

   (1)  A copy of Form CY113 showing no founded reports of child abuse within 5 years preceding clearance, or showing a founded report of child abuse not within 5 years preceding clearance or showing an indicated report of child abuse but giving justification for hiring person in child care position.

   (2)  A copy of State Police Criminal History Records form showing no criminal convictions listed in Act No. 1985-33 within 5 years preceding clearance.

   (3)  The dates of hire in child care position compared to the dates requests for clearances were mailed to ChildLine, the State Police, and the FBI, if applicable, and the dates clearances were received by the facility or program.

 (a)  Nonlicensed mental retardation children’s programs, such as recreation programs, camps, transportation, family aid services, family support services and homebound instruction programs that are specifically designed for children with mental retardation are covered by Act Nos. 1985-33 and 1987-80.

 (b)  The Department does not have responsibility for these programs for compliance with Act Nos. 1985-33 and 1987-80 since the programs do not require licensure/approval. Therefore, the Office of Mental Retardation will not routinely monitor the programs if the programs are not licensed/approved by the Department.

 County mental retardation programs staff members who provide direct care, supervision, guidance or control of children require child abuse and criminal records clearance. The Office of Mental Retardation will monitor county mental retardation programs to determine compliance with Act Nos. 1985-33 and 1987-80.

Subchapter B. [Reserved]

   The provisions of this Subchapter B adopted July 1, 1988, effective May 31, 1988, 18 Pa.B. 2910; reserved June 26, 2009, effective June 27, 2009, 39 Pa.B. 3174. Immediately preceding text appears at serial pages (213242) to (213244).

Subchapter C. LICENSING

TYPE OF CERTIFICATE OF COMPLIANCE

Sec.

§ 6000.301. Certificate of compliance determination.

 The type of certificate of compliance indicated is determined by the type of noncompliance areas, the total weighted score for vocational and community residential mental retardation facilities, the percentage of compliance with the licensing regulations for adult day care centers and the number of repeated areas of noncompliance.

COMMUNITY RESIDENTIAL MENTAL
RETARDATION FACILITIES AND AGENCIES

§ 6000.302. Computation of weighted score.

 (a)  The total weighted score for each facility shall be computed according to the instructions in the licensing inspection instrument. The individual weights for each licensing inspection instrument item are listed in Appendix A.

 (b)  The distribution of the weighted scores used to determine the type of license to be issued is as follows:

   (1)  Score of 100 through 65 = Regular license.

   (2)  Score of 64 through 43 = Provisional license.

 If there is noncompliance with either of the following two sections at the time the license is to be issued, no license will be issued:

   (1)  Section 6400.13 (relating to maximum capacity)—first sentence. This is a no license regulation for new facilities and for facilities with no occupancy permit.

 If there is noncompliance with any one of the following sections at the time the license is issued, a provisional license is indicated:

   (1)  Section 6400.13 (relating to maximum capacity)—first sentence. This is a provisional regulation for existing facilities that have an occupancy permit, but the occupancy classification is not correct.

   (2)  Section 6400.45 (relating to staff).

   (3)  Section 6400.46(a) and (b) (relating to staff training).

   (4)  Section 6400.103 (relating to evacuation procedures).

   (5)  Section 6400.105 (relating to flammable and combustible materials).

   (6)  Section 6400.133 (Reserved).

   (7)  Section 6400.136 (Reserved).

   (8)  Section 6400.156 (Reserved).

VOCATIONAL FACILITIES

§ 6000.311. Computation of weighted score.

 (a)  The total weighted score shall be computed according to the instructions in the licensing inspection instrument. The individual weights for each item are listed in Appendix B:

 (b)  The distribution of weighted scores used to determine the type of license to be issued is as follows:

   (1)  Score of 100 through 70 = Regular license.

   (2)  Score of 69 through 52 = Provisional license.

 (a)  Compliance with certain sections with a weight of 8 or above is so critical that if there is noncompliance with that section or subsection a regular license cannot be issued.

 (b)  If there is noncompliance with either of the following sections at the time the license is to be issued, no license will be issued:

   (1)  Section 2390.14(a) (relating to fire safety occupancy permit)—weight 8.33. This is a no license regulation for new facilities and facilities with no occupancy permit.

 If there is noncompliance with any of the following sections at the time the license is issued, a provisional license is indicated:

   (1)  Section 2390.14(a) (relating to fire safety occupancy permit)—weight 8.33. This is a provisional regulation for existing facilities that have an occupancy permit, but the occupancy classification is not correct.

   (2)  Section 2390.19 (relating to abuse).

     (i)   Subsection (b)—weight 8.64.

     (ii)   Subsection (c)—weight 8.60.

     (iii)   Subsection (d)—weight 8.76.

   (3)  Section 2390.53 (relating to outside walkways)—weight 8.17.

   (4)  Section 2390.54 (relating to combustible materials)—weight 8.59.

   (5)  Section 2390.63 (relating to lighting)—weight 8.06.

   (6)  Section 2390.64 (relating to handrails)—weight 8.06.

   (7)  Section 2390.68 (relating to hazardous equipment)—weight 8.64.

   (8)  Section 2390.69 (relating to personal protective equipment)—weight 8.65.

   (9)  Section 2390.70 (relating to special signals on equipment)—weight 8.13.

   (10)  Section 2390.71(b) (relating to ventilation)—weight 8.49.

   (11)  Section 2390.75 (relating to nutrition).

     (i)   Subsection (a)(1)—weight 8.37.

     (ii)   Subsection (a)(2)—weight 8.17.

   (12)  Section 2390.81 (relating to exits)—weight 8.42.

   (13)  Section 2390.83 (relating to fire alarms)—weight 8.56.

   (14)  Section 2390.84 (relating to fire extinguishers).

     (i)   Subsection (a)—weight 8.14.

     (ii)   Subsection (c)—weight 8.24.

     (iii)   Subsection (f)—weight 8.14.

     (iv)   Subsection (g)—weight 8.04.

   (15)  Section 2390.101 (relating to communicable disease)—weight 8.37.

   (16 )  Section 2390.102 (relating to first aid staff)—weight 8.15.

   (17)  Section 2390.104 (relating to emergency medical information)—weight 8.32.

ADULT DAY CARE CENTERS

§ 6000.321. Computation of percentage of compliance.

 (a)  If there is 95% compliance or above, a regular certificate is indicated.

 (b)  If there is greater than or equal to 85% but less than 95% compliance, a provisional certificate is indicated.

 If there is noncompliance with any of the following sections at the time the license is issued, a provisional license is indicated:

   (1)  Section 2380.25 (Reserved).

   (2)  Section 2380.41 (Reserved).

REQUIREMENTS FOR ALL TYPES
OF FACILITIES AND AGENCIES

§ 6000.331. Repeated noncompliance areas.

   (1)  Repeated noncompliance areas are determined based on the previous annual, provisional or interim—announced and unannounced—inspections.

   (2)  Repeated noncompliance areas are determined based on areas of noncompliance observed during the previous initial licensing inspection, and not at the time the previous license was issued.

   (3)  If there are one, two or three repeated noncompliance areas—regardless of weight—from the previous licensing inspection to the present licensing inspection, a provisional certificate is indicated.

   (4)  If there are four or more repeated noncompliance areas—regardless of weight—from the previous licensing inspection to the present licensing inspection, no certificate is indicated.

   (5)  If there are one or more repeated noncompliance areas—regardless of weight—in three or more consecutive annual, provisional or interim licensing inspections, no certificate is indicated.

   (6)  For community residential agencies, if the same noncompliance area at one facility is repeated at a different facility operated by the same community residential agency during the next inspection, this is considered a repeated noncompliance area.

 (a)  The weighting and percentage of compliance systems are guidelines used to determine the type of licensing to be issued. It is recognized that in special circumstances these standardized scoring systems may not be in the best interests of the clients and that professional discretion must be exercised.

 (b)  The policies and procedures for the type of certificate of compliance should be the basis for the licensure recommendation. If the Regional Mental Retardation Program Manager disagrees with the type of certificate to be issued based on this chapter, the Regional Mental Retardation Program Manager may make a recommendation that differs from these policies and procedures. If the Regional Mental Retardation Program Manager makes a recommendation for licensure that is inconsistent with the manual instructions, detailed written justification for the variance from the Regional Mental Retardation Program Manager will accompany the licensure packet.

LICENSED/APPROVED CAPACITY

§ 6000.341. Capacity.

 (a)  Licensed/approved capacity is defined as the maximum number of clients or residents who may be served at a facility at any one time. The licensed/approved capacity appears on a certificate of compliance. Capacity is based on the amount of available indoor floor space at the facility. Compliance with all other licensing regulations is measured by onsite observation, record review and interviews. Compliance with staffing ratios is measured by actual attendance on any given day.

 (b)  Licensed/approved capacity does not mean that the facility currently meets all the staffing requirements necessary for that number of clients. Licensed/approved capacity means only that the facility may serve up to the specified number of clients as determined by the application of minimum floor space requirements. The actual number of clients served depends on the facility meeting staffing and other regulations.

 (c)  The capacity of a facility will be increased or decreased only in the following instances:

   (1)  There is renovation or construction of the facility which changes the amount of indoor floor space.

   (2)  There is reallocation of the indoor space.

   (3)  There was an error in the previous calculation of the amount of indoor floor space.

 (d)  The licensed/approved capacity of a currently licensed/approved facility will be adjusted, if necessary, according to this statement of policy in either of the following instances:

   (1)  When the facility’s next renewal certificate of compliance is issued.

 The minimum amount of indoor floor space required for facilities is specified in the appropriate chapter of licensing regulations and further clarified in the corresponding licensing inspection instrument.

   (1)  Community Residential Mental Retardation Facilities—§ §  6400.85(b) and 6400.232 (relating to swimming pools; and awake staff persons) and corresponding sections of the Licensing Inspection Instrument. In addition to the amount of indoor floor space, the licensed/approved capacity for community residential facilities shall also be based upon the type of fire safety approval that the facility has. The licensed/approved capacity shall be based upon the amount of indoor floor space not to exceed the occupancy limit of the facility’s current fire safety approval. For example, if a facility has indoor floor space for 12 residents, but the facility has only a C-3 Certificate of Occupancy from the Department of Labor and Industry which limits occupancy to eight residents, the licensed/approved capacity will be eight.

   (2)  Adult Day Care Centers—§  2380.61 (relating to minimum amount of space) and corresponding section of the licensing inspection instrument. For the adult day care centers, indoor floor space is measured wall to wall, including space occupied by furniture. Hallways and offices are not counted when measuring indoor floor space. Dining areas, kitchens, bathrooms and first aid rooms are counted when measuring indoor floor space if it is clearly documented that the area is used for program purposes for at least 50% of each program day or if it is clearly documented in the facility’s training curriculum that the area is used as an integral part of their training program.

   (3)  Vocational Facilities—§  2390.52 (relating to indoor floor space) and corresponding sections of the licensing inspection instrument.

LICENSURE OF COMMUNITY RESIDENTIAL
MENTAL RETARDATION FACILITIES

§ 6000.351. Licensing criteria.

 (a)  The following criteria should be applied to determine if a facility should be licensed under Chapter 6400 (relating to community homes for individuals with mental retardation).

   (1)  If a facility meets either of the following criteria, the facility is considered a community residential facility and shall comply with Chapter 6400:

     (i)   The facility is leased or owned by the provider agency or County MH/MR Program. The resident does not sign his own lease or own his own home.

     (ii)   An average of more than 10 hours of direct staff contact per week is provided to the facility. Staff may or may not live within the same apartment building or complex.

   (2)  Direct staff contact includes person to person contact spent in training, programming and assisting the resident with daily living skills. It does not include telephone contact and time spent providing transportation to residents.

   (3)  Licensing staff should review written leases and staffing schedules to determine if the criteria in this section apply to a specific individual facility. Following is a matrix that may be helpful in determining applicability of the regulations for a specific facility.

LICENSURE OF ADULT DAY CARE CENTERS
LOCATED IN NURSING HOMES

§ 6000.361. Adult day care centers located in a nursing home.

 (a)  If an adult day care center located in a nursing home serves only nursing home clients, the Department should not license the adult day care center.

 (b)  If an adult day care center located in a nursing home serves one or more public clients (nonnursing home clients), with at least a total of four clients, the Department should license the adult day care center using the following procedures:

   (1)  The inspector asks the provider or inspects the facility to determine if the facility has a current License to Operate a Health Care Facility issued by the Department of Health. This license covers both skilled and intermediate nursing homes. This license should be posted in a conspicuous place in the facility.

   (2)  If the facility has a current Department of Health license, the provider shall acquire a letter from the Department of Health stating that specific space within the nursing home building may be utilized for adult day care.

   (3)  If the provider produces a letter from the Department of Health stating that specific space may be used for adult day care, standard procedures should be followed.

   (4)  If the provider cannot produce a letter from the Department of Health stating that space may be used for adult day care, the Department of Public Welfare cannot license the facility for adult day care and the facility may not provide adult day care to nonnursing home clients.

DUAL LICENSURE OF ADULT DAY CARE
CENTERS AND VOCATIONAL
REHABILITATION FACILITIES

§ 6000.371. Dual licensure.

 (a)  A facility should be licensed under both adult day care center and vocational facility regulations if the regulatory definitions of both sets of regulations are met. The main regulatory distinction between an adult day care center and a vocational facility is that an adult day care center, less than 20% of the client’s programming is comprised of remunerative work experience. In a vocational facility, 20% or more of the client’s programming is comprised of remunerative work experience. The average percentage of remunerative work experience provided to each client over a 12-month period will be considered in this determination.

 (b)  If both adult day care center and vocational facility definitions are met, the following dual licensure procedures apply.

   (1)  Adult day care clients and vocational clients must be served in separate and distinct program areas or groups within the facility. Nonprogram areas such as bathrooms and dining areas can be shared.

   (2)  Apply both sets of regulations, completing two separate licensing inspection instrument scoresheets and two licensing inspection instruments.

   (3)  Apply adult day care and vocational regulations separately. For example, apply 1:7 ratio adult day care clients and 1:15 or 1:20 ratio for vocational facility clients.

   (4)  Issue two separate certificates. It is possible that the adult day care center could receive a regular certificate and the vocational facility could receive a provisional certificate.

   (5)  The facility will appear on licensing printouts as both an adult day care center and a vocational facility.

Subchapter D. [Reserved]

Sec.

§ § 6000.401—6000.404. [Reserved].

   The provisions of these § §  6000.461—6000.474 adopted April 26, 2002, effective March 25, 2002, 32 Pa.B. 2117; reserved February 27, 2004, effective February 21, 2004, 34 Pa.B. 1234. Immediately preceeding text appears at serial pages (288022) to (288043).

Subchapter E. ZONING REQUIREMENTS FOR
LICENSURE OF INTERMEDIATE CARE FACILITIES
FOR THE MENTALLY RETARDED

Sec.

 (a)  Prior to October 3, 1988, a provider who intended to operate a four to eight bed ICF/MR was required to obtain written approval from the local zoning authorities to occupy a single family dwelling with more than three unrelated people. Various zoning officials were reluctant to provide this approval, thus delaying the opening of certain ICFs/MR. By removing the zoning requirement, ICF/MR providers may obtain licensure in a more timely manner.

 (b)  Current and future providers who apply for certificates of compliance from the Department of Public Welfare to operate ICFs/MR are no longer required to submit documentation with the Application for a Certificate of Compliance that zoning approval for the ICF/MR sites has been obtained.

 (c)  The Office of Mental Retardation has informed Department of Health staff from the Division of Long Term Care that ICF/MR providers need not produce, during survey site visits, documentation that zoning has been approved in order for survey staff to recommend that the Department of Public Welfare license and certify the facilities.

Subchapter F. ADMINISTRATION AND
MANAGEMENT OF CLIENT FUNDS

Sec.

§ 6000.521. Administration and management of client funds.

 (a)  The County Mental Health/Mental Retardation Administrator (Administrator) is responsible for compliance with the policies and procedures in this statement of policy.

 (b)  An Administrator should ensure that community residential facilities with which they contract establish policies and procedures on the administration and management of client funds consistent with this statement of policy. Administrators should review and approve the policies and procedures on client funds and monitor the implementation of these policies and procedures.

 (c)  Policies and procedures should include provision for a financial plan to be integrated into each client’s Individual Program Plan to insure the satisfaction of current and future needs. The financial plan should include, at a minimum:

   (1)  Documentation that a client has received assistance in applying for funds and benefits to which the client is entitled by establishing residential intake procedures that identify client eligibility for benefits from all resources and annually reviewing each client’s eligibility for programs—for example, rent rebate, food stamps and the like. A decision not to access benefits shall be approved by the Administrator.

   (2)  A forecast of cash flow, a budget plan and a review of proposed cash needs.

   (3)  A review and analysis of the client’s investments, insurance policies, burial accounts and conserved resources identified by family—for example, burial plots and the like.

   (4)  Development of a room and board contract, if applicable, in accordance with Chapter 6200 (relating to room and board charges).

   (5)  An assessment of the client’s need for supervision or training in money management, or both.

   (6)  Documentation of the client’s desire to receive oversight/training in the management of personal funds.

   (7)  An assessment of the individual client’s need for a representative payee based on the client’s ability to manage the client’s own monies.

 (d)  Policies and procedures should include provision for training clients in the management of personal funds. Training should include at a minimum:

   (1)  Assessing the client’s skills in the management of funds and the need for specific skill training.

   (2)  Specifying goals related to training in the management of personal funds. Goals should be included in the client’s Individual Program Plan, if appropriate.

   (3)  Monitoring of the training program via the client’s Individual Program Plan.

 (e)  Policies and procedures should include provision for the creation of irrevocable burial accounts. The policies and procedures should include:

   (1)  Review of individual client balances and spending patterns to determine if the client has adequate funds to meet present and projected financial needs.

   (2)  Consultation, if appropriate, with the client/the client’s family/interdisciplinary team about other available resources and whether a burial fund or other appropriate arrangements are in the client’s best interests.

   (3)  Review of the client’s insurance records to assure that the burial reserve plus cash surrender value of insurance policies would be adequate to meet anticipated client burial costs.

   (4)  Discussion of the nature of irrevocable burial funds—money can be withdrawn only for burial purposes.

   (5)  Establishment of a separate irrevocable burial reserve, interest-bearing account in the client’s name ensuring the following:

     (i)   Burial reserve funds are deposited either on a one-time basis or through periodic deposits.

     (ii)   Bank statements are received at least annually.

     (iii)   The bank is notified of client address changes.

     (iv)   Pertinent information on the existence of the burial reserve account is filed with the Case Management Unit and provider offices.

     (v)   The client’s family is notified about the existence of the burial reserve account, if appropriate.

     (vi)   For SSI beneficiaries:

       (A)   The Social Security field representative is notified of plans to establish an irrevocable burial account.

       (B)   A brief memorandum is sent to the Social Security Administration field representative stating the client’s name, referencing the initial discussion and attaching a copy of the irrevocable burial agreement.

       (C)   A standard agreement which meets the language requirements of the benefit-issuing agency is used.

 (f)  Policies and procedures should include provision for safeguarding client funds. The policies and procedures should include:

   (1)  A monitoring system to assure continuing eligibility of client benefits.

   (2)  The reporting of changes in client income or living situations to the appropriate benefit-issuing agency.

   (3)  The prompt deposit of client-funds in bank accounts. Client funds in excess of immediate financial obligations should be deposited in interest-bearing accounts where interest is allocated to individual client accounts on at least a quarterly basis.

   (4)  A monitoring system of the client’s checking account, savings account and cash on hand.

   (5)  Policies for client expenditures such as personal needs, movie tickets, vacations, newspaper, toll calls, cable TV and shared costs for fixed assets. A written rationale should be developed for client-shared costs.

   (6)  The establishment of procedures, including maintenance of an inventory, to safeguard client personal property.

   (7)  The maintenance of client funds in a secure manner.

   (8)  A procedure to meet client financial obligations and assure that client charges are made accurately and fairly.

   (9)  The documentation of—by receipt, invoice or expense record—client fund use.

   (10)  The maintenance, on an ongoing basis, of client financial records including, at a minimum, account balances, receipts, expenditures and reconciliations of client account balances.

     (i)   A client financial reconciliation should be completed monthly.

     (ii)   A periodic review of client funds should be conducted at least once a year.

   (11)  The establishment of criteria to determine and recommend payeeship responsibility and review individual assignment annually or as needed.

   (12)  The establishment of representative payee responsibility regarding documentation of money spent on client’s behalf.

   (13)  The prohibition of the commingling of client funds with agency operational funds, the borrowing of funds between clients and staff and the use of client’s money for rewards in behavior management programs.

   (14)  The establishment of procedures to be followed in the event of misappropriation or theft of clients funds or property as defined in Subchapter D (relating to unusual incidents and deaths).

 (g)  An Administrator should:

   (1)  Insure that Mental Retardation Bulletin # 99-87-18, issued November 23, 1987, titled ‘‘Case Management Services’’ is being followed in the area of safeguarding the use of client funds.

   (2)  Insure that policies and procedures specified in subsections (b)—(f) are in place and include reporting and auditing requirements.

   (3)  Monitor by random sampling at least 10% of client inventories against actual existence of the items.

   (4)  Ensure that, as part of the annual audit requirement for a provider, the system of internal control over client funds is evaluated and that a representative sample of individual client accounts are tested as part of the process.

Subchapter G. EARLY INTERVENTION

Sec.

§ 6000.601. Services—statement of policy.

 (a)  It is the policy of the Department as the lead agency, to plan, develop and implement a Statewide, comprehensive, coordinated, multidisciplinary, interagency system of early intervention services that incorporates the 14 components as specified under the Education of the Handicapped Act Amendments of 1986 (20 U.S.C.A. § §  1471—1485). It is further the intent of the Department to develop and implement policies pertaining to each of the 14 components. These policies will be in place by the beginning of the fourth year (Fiscal Year 1990-1991) of the Commonwealth’s involvement in the Education of the Handicapped Act Amendments of 1986, except for the delivery of services under the Individualized Family Service Plan (IFSP) which will be in place at the beginning of the fifth year (Fiscal Year 1991-1992).

 (b)  Components of a Statewide early intervention system shall include the following:

   (1)  A definition of developmentally delayed to be used in this Commonwealth to carry out programs.

   (2)  Timetables insuring availability of appropriate early intervention services for handicapped infants and toddlers before the beginning of the fifth year of the Commonwealth’s participation.

   (3)  A timely, comprehensive, multidisciplinary evaluation of the functioning of each handicapped infant and toddler and the needs of the family to assist the development of the infant and toddler.

   (4)  An individualized family service plan including case management services for each handicapped infant and toddler.

   (5)  A comprehensive childfind system that includes a system for making referrals to service providers that includes timelines and provides for participation by primary referral services.

   (6)  A public awareness program focusing on early identification of handicapped infants and toddlers.

   (7)  A central directory that includes early intervention services, resources and experts available in the State to research and demonstrate projects being conducted.

   (8)  A comprehensive system of personnel development.

   (9)  A single line of responsibility in a lead agency established by the Governor for carrying out the following:

     (i)   General administration, supervision and monitoring of programs and activities receiving assistance to ensure compliance.

     (ii)   The identification and coordination of available resources from Federal, State, local and private sources.

     (iii)   Assignment of financial responsibility to the appropriate agency.

     (iv)   The development of procedures to ensure that services are provided to handicapped infants and toddlers and their families in a timely manner pending resolution of disputes among public agencies or service providers.

     (v)   The resolution of intra- and interagency disputes.

     (vi)   The entry into formal interagency agreements that define financial responsibility of each agency for paying for early intervention services and procedures for resolving disputes and that include additional components necessary to ensure meaningful cooperation and coordination.

   (10)  A policy pertaining to contracting or making other arrangements with service providers to provide early intervention services, including contents of the application used and conditions of the contract or other arrangements.

   (11)  A procedure securing timely reimbursement of funds.

   (12)  Procedural safeguards with respect to programs.

   (13)  Policies and procedures relating to establishment and maintenance of standards to ensure that personnel are appropriately and adequately trained, including:

     (i)   Standards that are consistent with any State approved or recognized certification, licensing, registration or other comparable requirements which apply to the area in which the personnel are providing early intervention services.

     (ii)   The steps the Commonwealth is taking to require the retraining or hiring of personnel that meet appropriate professional requirements of the Commonwealth.

   (14)  A system for compiling data on the numbers of handicapped infants and toddlers and their families in need of early intervention services, the numbers of infants and toddlers and their families served, the types of services provided, and other information required by the Secretary of the United States Department of Education.

   The provisions of this §  6000.601 adopted August 25, 1989, effective August 10, 1989, 19 Pa.B. 3686.

Subchapter H. QUALITY ENHANCEMENT POLICY

Sec.

§ 6000.621. County policy.

 A county policy statement should contain the following elements:

   (1)  A statement of philosophy embracing the concept of quality in services for persons with mental retardation.

   (2)  A statement of methodology to be used by the county to conduct self-assessment. This methodology should support the consumer-oriented principles and practices and include involvement by family, friends, advocates and interested citizens.

   (3)  A description of the responsibility of providers, including staff and board, in enhancing quality in programs provided.

   (4)  A statement that the county and each of its providers will work cooperatively and within standards adopted by the county to develop the provider’s policy on assessment of quality.

   (5)  A statement addressing the incorporation of appropriate components of the definition of quality into the contracts drawn between the county and the providers of the service.

   (6)  A provision that orientation to the concept of quality enhancement be incorporated into staff development programs.

   (7)  A provision to update and refine both county and provider policy on quality enhancement and a mechanism as a result of ongoing feedback from the implementation.

 A county should formulate a separate procedures statement that utilizes its quality enhancement policy. Procedures should ensure that the process is consumer-centered. Procedures should address the methods the county will use to determine whether programs are having a positive effect on people’s lives. At a minimum, these methods should address consumer growth and development and consumer satisfaction. These procedures should contain the following:

   (1)  Methods for conducting annual self-assessments that measure individual consumer concern including growth, development and satisfaction.

   (2)  Methods for conducting an annual self-assessment that measures the availability of services in the county system as a whole. This includes addressing not only the availability of existing services but the need for additional services.

   (3)  Methods for contract monitoring to assure that quality enhancement provisions are being met.

 Elements in the county action plan should include:

   (1)  Identification of persons responsible for quality enhancement activities.

   (2)  Establishment of priorities for implementation and the respective roles identified for members of the partnership.

   (3)  A schedule for county and provider self-assessment, how that self-assessment is to be accomplished and the basis for the assessment. This assessment should include the County Mental Health and Mental Retardation Board and the members of the partnership, as well as provider staff and boards.

   (4)  Time frames for implementation which detail all levels of involvement.

   (5)  Strategy for utilizing the results of the self-assessment.

   (6)  Identification of ways to continually improve the quality of service delivery.

   (7)  Identification of the sources and recipients of technical assistance and training activities.

 (a)  Direct and independent review should include:

   (1)  A review of the county quality enhancement policy statement, county procedures to implement the policy and the county’s most recent action plan.

   (2)  A review of the most recent county self-assessment.

   (3)  Application of the county self-assessment methodology with a sample of consumers including record review and program observation.

   (4)  Verification of the contract provisions addressing quality and reports resulting from contract monitoring by the county.

 (b)  The Office of Mental Retardation will issue a written report in a timely manner as a result of the independent and direct review.

   The provisions of this §  6000.624 adopted November 11, 1989, effective July 1, 1990, 19 Pa.B. 4879.

Subchapter I. SUPPORT FOR INDEPENDENT LIVING

Sec.

§ 6000.641. Criteria for provision of support services.

 (a)  Support is provided in a residential setting in which there are 10 hours or less direct staff contact per week per facility, and residents sign their own lease without agency cosignature or own their own home.

 (b)  Support services are for persons who can live independently and who can generally be expected to pay their own room and board costs.

 (a)  Payment for support for people who live independently is made through the community mental retardation residential or nonresidential allocation and does not require a county match. Support services include the following:

   (1)  Reimbursement for up to an average of 10 hours a week of staff salaries.

   (2)  Minor physical adaptations of the resident’s home to accommodate a handicapping condition.

   (3)  Supplementation of room and board costs.

 (b)  Individuals receiving support to live independently are eligible for Federal funding participation through the Department’s approved 2176 Waiver Program based on the individual’s meeting applicable waiver eligibility requirements.

 In cases where room and board costs are supplemented, there should be documentation on file that the person has applied for and exhausted benefit payments under fuel assistance, food stamps and other public benefit programs that are available for payment of room and board costs.

 Support for people to live independently in the community may be provided in settings that were previously licensed as a community residential facility. Residents of prior licensed settings do not have to move from a community residential facility when they need an average of 10 hours or less of direct staff contact a week, although they are free to do so.

 Persons receiving support to live independently should be reported on the community residential services information system through use of the mental retardation community residential data input form MR 5.

 The person’s ability and willingness to live independently with supports should be verified by the county mental health/mental retardation program based on a recommendation of the person’s interdisciplinary team and assessment of the person’s need for staff support and supervision not to exceed an average of 10 hours per week.

   The provisions of this §  6000.646 adopted January 11, 1991, effective July 1, 1990, 21 Pa.B. 167.

Subchapter J. THERAPIES AND SPECIALIZED SERVICES

Sec.

§ 6000.661. Intent.

 (a)  Therapy and other specialized services are intended to:

   (1)  Provide necessary and appropriate services for individuals with mental retardation whose condition requires the services of a health care or human services professional.

   (2)  Focus on supporting the individual, together with the individual’s family and support staff, to address the individual’s needs to the greatest extent possible and to build upon the individual’s strengths and assets.

   (3)  Be time limited based upon measurable outcomes for the service.

 (b)  A distinguishing aspect of therapies and other specialized services is that they are focused on meeting a specific condition of an individual. Training for staff or family members which is not directly related to the condition does not constitute a therapy or specialized service, but is reimbursable as a training cost if it is relevant to the trainee’s general duties or responsibilities.

 (a)  Each therapy and other specialized service should be specified in the individual’s plan of care, individualized family service plan or habilitation plan and authorized by the county mental health/mental retardation administrator.

 (b)  To be included in the plan of care, each therapy and other specialized service should be based on a written assessment by a qualified professional and the recommendation of the individual’s interdisciplinary team.

 (c)  The plan of care should document the frequency, such as length and number of sessions a month, and duration of services—length of time the service is required—services methods to be employed, the name of the health care professional or agency responsible for the service and expected outcomes.

 (d)  The plan should be reviewed at regular intervals consistent with this title, accepted standards of professional practice and changes in the individual’s condition.

 The definitions in paragraphs (4) and (5) apply to all therapies and specialized services that are approved by the county mental health and mental retardation program:

   (1)  Under the 2176 Waiver Program, including visiting nurse services.

   (2)  Under the Family Resource Services Program—Chapter 6350 (relating to family resource services) and subsequent Family Support Services policy bulletins.

   (3)  Under other programs or services administered by the county mental health and mental retardation program, including community residential services, adult day services and early intervention services.

   (4)  Therapy—A therapy consists of one of the following services:

     (i)   Physical therapy provided by a licensed physical therapist based on either documentation or a prescription for a specific therapy program by a physician.

     (ii)   Occupational therapy by a registered occupational therapist based on either documentation or a prescription for a specific therapy program by a physician.

     (iii)   Speech/language therapy provided by a licensed speech therapist or certified audiologist upon examination and recommendation by a certified or certification-eligible audiologist or a licensed speech therapist.

     (iv)   Visual/mobility therapy provided by a trained visual or mobility specialist/instructor based on an evaluation by a trained mobility specialist/instructor who has recommended a specific therapy program.

     (v)   Behavior therapy provided by a licensed psychologist or psychiatrist based on an evaluation by a licensed psychologist or psychiatrist who has recommended a specific therapy program.

     (vi)   Visiting nurse services provided by a registered nurse or licensed practical nurse based on a prescription by a physician for a specific therapy program.

   (5)  Specialized services—Specialized services, some of which have taken on the name of a therapy, are recognized and reimbursable by the Department for individuals requiring the services, but are not considered therapies for the purpose of this subchapter. Specialized services include: nutrition services, disease prevention procedures, medications training, medical supplies and equipment, family planning, behavioral assessment and related program development, training, supervision and evaluation. A specialized service should be needed for the habilitation of the individual. Habilitation means ‘‘health, social, and other services needed to insure optimal functioning of persons with mental retardation in their home and community’’ (42 CFR 440.180 (relating to home or community-based services)). The same administrative controls which are applicable to specialized therapies also apply to specialized services.

 The county mental health and mental retardation administrator should ensure that the following administrative controls are in place for therapy and specialized services:

   (1)  That the need for service is documented by a written assessment and recommendation for the service by the individual’s interdisciplinary team.

   (2)  That the service incorporated in the individual’s plan is focused on supporting the recipient, family and staff to ameliorate the targeted condition to the greatest extent possible.

   (3)  That the service is provided at a duration and frequency which meets the needs of the recipient as indicated in the recipient’s individual plan.

   (4)  That the service is terminated or changed based on regular reviews by the qualified professional and the county case manager at intervals consistent with accepted standards of professional practice.

   (5)  That appropriate safeguards are implemented to protect the recipient’s rights to treatment and choice.

   (6)  That services meet applicable State, Federal and professional standards and requirements.

   (7)  That the provider is qualified to provide the services and documentation of the provider’s qualifications is maintained by the county mental health and mental retardation program, or its designee.

   (8)  That services are coordinated, reviewed and monitored through the county’s case management system.

 (a)  Some therapies and other specialized services may be available through funding streams apart from the county’s community mental retardation allocation. In keeping with the Mental Health and Mental Retardation Act of 1966 (50 P. S. § §  4101—4704) those sources of funding need to be explored and exhausted prior to funding by the county mental health and mental retardation program. An example of a potential funding source is the Medical Assistance Program, particularly home health services under the State’s Medical Assistance Plan, for individuals eligible for these benefits.

 (b)  Funding for therapies and specialized services authorized by the county mental health and mental retardation administrator is eligible for 100% State funding when the recipient receives services in a community residential facility or other service which qualifies as a new service under section 507 of the Mental Health and Mental Retardation Act of 1966 (50 P. S. §  4507). Funding for therapies and specialized services authorized by the county mental health/mental retardation administrator when criteria for 100% State funding participation are not met is eligible for 90% State funding.

 (c)  Therapy and other specialized services are eligible for Federal financial partcipation under the 2176 Waiver program in accordance with the conditions in the Department’s approved waiver proposal.

 (a)  As a general principle, costs for therapies and specialized services shall be applied to the cost center when costs may be readily classified.

 (b)  County mental health and mental retardation programs should report the cost and utilization of therapy and specialized services received by individuals receiving a community residential service under the community residential cost center on the Annual Income and Expenditure Report.

 (c)  County mental health and mental retardation programs should report the cost and utilization of all therapy and specialized services for all other recipients on the Annual Income and Expenditure Report under the family resource services cost center. If the service was included as part of a negotiated service rate it need not be separately identified as a therapy or specialized service and reported separately. For example, if the service was provided as part of an early intervention service, the costs would be reported under the early intervention cost center.

 (d)  County mental health and mental retardation programs should report annual specialized therapy costs as requested by the Health Care Financing Agency for the 2176 Waiver Program in accordance with reporting instructions issued by the Department.

   The provisions of this §  6000.666 adopted January 11, 1991, effective January 12, 1991, applies retroactively to January 2, 1991, 21 Pa.B. 167.

Subchapter K. EMPLOYMENT

Sec.

§ 6000.681. Employment.

 Persons with mental retardation who are of legal working age should have access to employment and the training necessary to sustain employment.

 (a)  Counties are encouraged to redirect existing resources from traditional adult day services, such as adult developmental training and sheltered workshops, to community-integrated employment opportunities for persons with mental retardation.

 (b)  If additional funding becomes available for adult day services in the future, the funding will be targeted specifically and exclusively for employment opportunities for persons with mental retardation.

 (c)  The Office of Mental Retardation will continue to support the projects sponsored by the Competitive Supported Employment of Pennsylvania (CSEPA) Task Force through local funding arrangements with the participating county mental retardation programs.

 The Office of Mental Retardation will work with other available resources to provide training and technical assistance to counties and private provider agencies in the provision of employment services for persons with mental retardation.

 The provision of employment services to recent graduates of public special education programs should be a high priority at the State and local levels.

 Counties should work cooperatively with the local special education and vocational rehabilitation systems to ensure that school-to-work transition planning occurs for students enrolled in public special education programs.

 Referral to the Office of Vocational Rehabilitation for employment services should be a high priority for counties when developing service plans for persons with mental retardation who are of legal working age.

 Follow-up services should be available on an ongoing basis to persons with mental retardation who need them to maintain employment.

 Contracts with providers of employment services should be negotiated to contain clear performance expectations in terms of client progress and outcomes, such as competitive employment, job/employment retention, and the like.

 (a)  Counties should initiate cooperative efforts with providers of adult day services to plan for the further development of community employment opportunities.

 (b)  Counties should initiate efforts, with assistance from providers, to ensure that consumers and their families, as well as case managers, are educated about the availability and benefits of employment. Individual consumer and family education about employment should be integral to the client intake and referral process, as well as to the development of the life management and service plans.

 (c)  Counties should strive to ensure that a variety of employment program models are available for persons with mental retardation to address individual and local needs.

   The provisions of this §  6000.689 adopted January 11, 1991, effective January 12, 1991, and apply retroactively to January 2, 1991, 21 Pa.B. 169.

Subchapter L. FAMILY-DRIVEN FAMILY SUPPORT SERVICES

Sec.

§ 6000.701. Definitions.

 (a)  Family support services include services defined in Chapter 6350 (relating to family resources services) and subsequent statements of policy such as Mental Retardation Bulletin No. 99-83-24, titled: DPW Policy on Support Services for Persons with Mental Retardation and Their Families and Mental Retardation Bulletin No. 99-84-21, titled: Supplement Agreement to the DPW Policy on Support Services for Persons with Mental Retardation and Their Families.

 (b)  Family-driven is a method of providing family support services whereby the family or the person with mental retardation, rather than the service system, are given the responsibility for deciding which services will best address the family’s specific needs. In a family-driven model, family members also have a primary responsibility for planning, implementing, evaluating and setting priorities on services to address their specific needs.

   Family-driven family support services (FD/FSS) pilot projects initiated in 1987/88 and 1989/90 are eligible for 100% State financial participation up to the level they were funded as pilot projects.They include only projects that were categorically funded as a result of their submission of a proposal in response to Mental Retardation Bulletin No. 00-87-15, issued October 6, 1987, and titled: Request for Proposals to Develop Family-Driven Family Support Services Pilot Projects, or Mental Retardation Bulletin No. 00-89-09, issued April 19, 1989, titled: Request for Proposals to Develop or Expand Family-Driven Family Support Services Pilot Projects. Funding for family support services which are not integrated into an approved family-driven project will continue to be reimbursed by the Department on a 90/10 matching basis.

 Counties sponsoring an approved 100% State-funded Family-Driven Family Support Services (FD/FSS) program should account for expenditures for that program separate from expenditures for family support services provided with 90/10 funding.

 The Office of Mental Retardation will monitor the progress of the projects on an ongoing basis to ensure that the family-driven nature of the projects is maintained.

   The provisions of this §  6000.704 adopted January 18, 1991, effective January 19, 1991, and apply retroactively to July 1, 1990, 21 Pa.B. 260.

Subchapter M. AGREEMENTS

SUPPLEMENTAL GRANT AGREEMENT

Sec.

§ 6000.761. Scope of the agreement.

 The Supplemental grant agreement covers the responsibilities of the county mental health/mental retardation program as the fiscal agent of the Department for the purposes of the waiver program, under 42 CFR 447.10(f) (relating to prohibition against reassignment of provider claims). The agreement consists of the responsibilities of the county and the Department with regard to county and provider fiscal, service, management and related administrative activities. Failure of the county mental health/mental retardation program to comply with its responsibilities under the grant agreement is subject to audit exception by the Department and the Federal Health Care Financing Administration.

   The provisions of this §  6000.761 adopted October 19, 1990, effective immediately but apply retroactively to July 1, 1990, 20 Pa.B. 5296.

 The term of the supplemental grant agreement is from July 1 through June 30 of each fiscal year of the 5-year renewal period subject to continuing Federal approval of the waiver and the availability of appropriated funds.

   The provisions of this §  6000.762 adopted October 19, 1990, effective immediately but apply retroactively to July 1, 1990, 20 Pa.B. 5296.

 (a)  Modifications which result from changes in Federal or State statutes, regulations or conditions of waiver approval will be issued by the Department to the county programs as binding revisions to the Supplemental Grant Conditions.

 (b)  At any time during the fiscal year, either party to the supplemental grant agreement may initiate discussions regarding modifications to Supplemental Grant Conditions. The currently existing agreement will remain in effect until superseded by agreed upon modifications. Modifications suggested by the county mental health/mental retardation program should be submitted to the regional office of mental retardation with appropriate rationales and documentation of need. Individual county modifications will normally be effective for up to 1 year, with extensions being subject to a change in conditions which warranted the initial modification.

   The provisions of this §  6000.763 adopted October 19, 1990, effective immediately but apply retroactively to July 1, 1990, 20 Pa.B. 5296.

 Compliance with the requirements of the grant agreement will be the basis of periodic reviews by the Office of Mental Retardation through its regional offices. Deficiencies noted by regional monitoring in terms of the county’s compliance with the conditions of the agreement will require a written plan of correction by the county mental health/mental retardation program within 30 days of notification by the regional office of mental retardation and correction of deficiencies within time frames agreed to by the regional office.

   The provisions of this §  6000.764 adopted October 19, 1990, effective immediately but apply retroactively to July 1, 1990, 20 Pa.B. 5296.

 (a)  Federal regulations at 42 CFR 447.10(h) (relating to prohibition against reassignment of provider claims) prohibit receipt of payment as a result of a factoring agreement.

 (b)  Factoring involves an individual or an organization that advances money to a provider for accounts receivable that the provider has assigned, sold or transferred to the factor for an added fee or a deduction of a portion of the accounts receivable. See 42 CFR 447.10(f).

 (c)  Factoring does not include a fiscal agent which furnishes services to a provider with respect to billing and collection. The Department’s allocation of discrete administration funding to the county program as the Department’s fiscal agent is intended to preclude factoring agreements between the county mental health/mental retardation program and providers of waiver service. The county program is prohibited under Federal law to charge a fee related on a percentage or other basis to the amount billed or collected for services rendered under the waiver, or to relate its costs for administrative services to the cost of waiver service provided. See 42 CFR 447.10(f).

   The provisions of this §  6000.765 adopted October 19, 1990, effective immediately but apply retroactively to July 1, 1990, 20 Pa.B. 5296.

   This section cited in 55 Pa. Code §  6000.784 (relating to county management responsibilities).

PROVIDER AGREEMENTS

§ 6000.771. Requirements for provider agreements.

 (a)  Under 42 CFR 431.107 (relating to required provider agreement), the Office of Mental Retardation will require a completed provider agreement for each provider of waiver services. This includes specialized therapists, providers of respite services, residential and adult day provider agencies, case management providers, county mental health/mental retardation programs and base service units providing waiver services to beneficiaries directly. Provider agreements are required for families contracting with the county programs to provide home-based habilitation services, as defined in the waiver renewal.

 (b)  Provider agreements are not required when habilitation services are provided by a parent of a minor child or a spouse since the services cannot be paid for with waiver funding. When families, such as providers of family living, render services under a subcontract arrangement with a provider agency, only the provider agency holding the contract with the county needs a provider number. Employes of a contracted agency, such as casemanagers, are excused from entering into provider agreements.

   The provisions of this §  6000.771 adopted October 5, 1990, effective immediately but apply retroactively to July 1, 1990, 20 Pa.B. 5054.

 Payment of waiver funding to a provider without a completed provider agreement is prohibited and is subject to audit exception by the Department. County programs may not enter into an agreement with or continue payment to a provider who has been terminated or suspended from participation in the Medical Assistance Program upon notification by the Department.

   The provisions of this §  6000.772 adopted October 5, 1990, effective immediately but apply retroactively to July 1, 1990, 20 Pa.B. 5054.

 The provider agreement is effective for the duration of waiver services being rendered by the provider and does not require renewal, subject to termination or suspension as provided by law.

   The provisions of this §  6000.773 adopted October 5, 1990, effective immediately but apply retroactively to July 1, 1990, 20 Pa.B. 5054.

 The following process shall be followed for provider agreement submissions:

   (1)  The county mental health/mental retardation program issues three provider agreement forms to the county’s providers of waiver services. Current providers who have rendered waiver services prior to July 1, 1990, should be sent the new provider agreement forms for completion as soon as possible. Provider agreements for providers who rendered waiver services prior to July 1, 1990, shall be effective on July 1, 1990. New providers should be sent provider agreements so that the agreement is signed by the provider prior to the rendering of waiver services.

   (2)  The provider completes the information on the three provider agreement forms and mails the agreements to the county mental health/mental retardation administrator, or a designee, for assignment of a provider number. The items to be completed consist of the provider name and address, the provider’s Social Security or Federal identification number, the provider’s signature, and the date of the provider’s signature.

   (3)  The county mental health/mental retardation administrator assigns a provider number in accordance with the instructions in §  6000.775 (relating to assignment of provider number) and enters the name of the county mental health/mental retardation program. Once a provider number is assigned and the county program name entered, the county forwards one agreement form to the Regional Office of Mental Retardation, Attention: Regional Waiver Coordinator, one to the provider and retains one agreement with the county’s current service purchase contract for waiver services with the provider.

   (4)  On receipt of its provider agreement from the county mental health/mental retardation administrator, the provider retains the agreement with its current service purchase contract for waiver services with the county mental health/mental retardation program.

   The provisions of this §  6000.774 adopted October 5, 1990, effective immediately but apply retroactively to July 1, 1990, 20 Pa.B. 5054.

 (a)  The county mental health/mental retardation administrator will assign a separate provider number for each provider of waiver services with which the county contracts. A separate waiver provider number shall be assigned to the county mental health/mental retardation program if the county provides services directly.

 (b)  The provider number consists of the county mental health/mental retardation program prefix, followed by the provider number.

 (c)  Provider numbers should be assigned in the order the signed provider agreement is processed by the county mental health/mental retardation program. Numbers are to be assigned consecutively, beginning with the number 1. Example: Bucks County uses the county prefix ‘‘09.’’ The first provider agreement processed for Bucks County would be assigned number 09-1. The second provider agreement processed would be 09-2, and so forth. A previously issued Medical Assistance or other provider number may be used for purposes of the waiver provider agreement with prior written approval of the regional mental retardation program manager.

 (d)  The same provider number cannot be assigned to more than one provider. A change in ownership or provider name requires a new provider agreement. A provider number that is terminated or suspended cannot be reassigned to another provider. A provider which renders more than one waiver service only requires one provider number. A provider of waiver services contracting with different county programs will have a separate provider number with each county program.

   The provisions of this §  6000.775 adopted October 5, 1990, effective immediately but apply retroactively to July 1, 1990, 20 Pa.B. 5054.

 The provider agreement number is used on waiver service invoices from the provider to the county mental health/mental retardation program. County programs should revise their invoice forms to accommodate the provider agreement number.

   The provisions of this §  6000.776 adopted October 5, 1990, effective immediately but apply retroactively to July 1, 1990, 20 Pa.B. 5054.

 The county mental health/mental retardation program is responsible to assure that providers have a completed provider agreement. Regional mental retardation program staff will review county records and procedures through the quarterly monitoring process.

   The provisions of this §  6000.777 adopted October 5, 1990, effective immediately but apply retroactively to July 1, 1990, 20 Pa.B. 5054.

 (a)  Provider agreements under the waiver are subject to termination and suspension due to violations of Chapter 1101 (relating to general provisions) under §  1101.77 (relating to enforcement actions by the Department); revocation, denial or nonrenewal of the provider’s license or certification to provide waiver services, and noncompliance with the conditions of the provider’s contract for waiver services with the county mental health/mental retardation program.

 (b)  A termination or discontinuance of the contract for waiver services which is not based on provider noncompliance has no bearing on termination of the provider agreement. The county should reserve a provider’s agreement number when a discontinued provider is likely to render waiver services for the county in the future.

 (c)  The county mental health/mental retardation program is responsible for notifying the regional office of mental retardation when a provider has not complied with the conditions of the provider agreement. The regional office of mental retardation will instruct the county to terminate or suspend the provider agreement based on the Department’s review of the county’s notification of provider agreement noncompliance or when noncompliance is determined by the Department based on licensing termination or a violation under §  1101.77.

 (d)  Termination of the provider agreement is subject to fair hearing, except in certain situations which warrant automatic termination, such as when the provider has been convicted of Medicaid/Medicare fraud, has otherwise been terminated by Federal authority or has lost its license/approval.

   The provisions of this §  6000.778 adopted October 5, 1990, effective immediately but apply retroactively to July 1, 1990, 20 Pa.B. 5054.

   This section cited in 55 Pa. Code §  6000.784 (relating to county management responsibilities).

Subchapter N. [Reserved]

   The provisions of this Subchapter N adopted August 23, 1991, effective immediately upon publication and apply retroactivity to July 1, 1991, 31 Pa.B. 3840; reserved June 25, 2009, effective June 26, 2009, 39 Pa.B. 3174. Immediately preceding text appears at serial pages (213284) to (213287).

Subchapter O. CRITERIA FOR APPROVAL OF NEW INTERMEDIATE CARE FACILITIES FOR PEOPLE WITH MENTAL RETARDATION

Sec.

 (a)  The Office of Mental Retardation will review proposals for intermediate care facilities for people with mental retardation (ICFs/MR), as part of the certificate of need process, through an interdepartmental cooperative agreement with the Department of Health. The Department of Public Welfare (Department) will only support and approve Medicaid funding for ICFs/MR which meet the following criteria:

   (1)  Projects to convert community homes to ICFs/MR shall be budget neutral and approved in writing by the county mental health/mental retardation program and the Office of Mental Retardation.

   (2)  In-State referrals of individuals to ICFs/MR shall be approved by the county MH/MR program in the individual’s county of residence in accordance with its responsibilities under Chapter 6201 (relating to county mental retardation services).

   (3)  The ICF/MR shall coordinate case management services with the appropriate county MH/MR program. Case management shall include cooperative planning to prevent prolonged institutional placement and to prepare the person for return to life at home in the community.

   (4)  Community-integrated day services shall be provided off the grounds of the ICF/MR, unless medically contraindicated by a physician.

   (5)  Non-State ICFs/MR shall be reimbursed in accordance with Chapter 6211 (relating to allowable cost reimbursement for non-State operated intermediate care facilities for people with mental retardation) and Medicare principals HIM-15.

 (b)  The Office of Mental Retardation does not currently support the development of new ICF/MR proposals. The Office will consider the following factors in determining whether to grant an exception to this policy:

   (1)  New residential settings shall be designed so that the building fits into the residential neighborhood and is limited to four people. Sites shall be dispersed within the community to foster social integration and participation with neighbors in the general population.

   (2)  Services in an ICF/MR shall be demonstrated to be the most programmatic and cost effective alternative for people with mental retardation who require an ICF/MR level of care.

Subchapter P. [Reserved]

   The provisions of this Subchapter P adopted April 19, 1996, effective April 20, 1996, 26 Pa.B. 1829; reserved June 26, 2009, effective June 27, 2009, 39 Pa.B. 3174. Immediately preceding text appears at serial pages (213288) and (302961).

Subchapter Q. INCIDENT MANAGEMENT

GENERAL PROVISIONS

Sec.

§ 6000.901. Scope.

 (a)  Individuals who are registered with a county mental retardation program or who receive supports and services from facilities licensed by the OMR are afforded the protections detailed in this subchapter.

 (b)  Providers who receive funds from the mental retardation system, either directly or indirectly, to provide or secure supports or services for individuals authorized to receive services from a county mental retardation program and providers licensed by the OMR are reporters and are to file incident reports as specified in this subchapter.

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

 Department—The Department of Public Welfare of the Commonwealth.

 HCSIS—The Home and Community Services Information System.

 OMR—The Office of Mental Retardation of the Department.

RESPONSIBILITY FOR REPORTING/INVESTIGATING

§ 6000.911. Providers.

 (a)  Employees, contracted agents and volunteers of providers covered within the scope of this subchapter are to respond to events that are defined as an incident in this subchapter. When an incident is recognized or discovered by a provider, prompt action is to be taken to protect the individual’s health, safety and rights. The responsibility for this protective action is assigned to the provider initial reporter and point person. The protection may include dialing 911, escorting to medical care, separating the perpetrator, calling ChildLine, arranging for counseling and referring to a victim assistance program. Unless otherwise indicated in the individual support plan, the provider point person or designee is to inform the individual’s family within 24 hours, or within 72 hours for medication error and restraint, of the occurrence of an incident and to also inform the family of the outcome of any investigation.

 (b)  After taking all appropriate actions following an incident to protect the individual, the provider is to report all categories of incidents and complete an investigation as necessary whenever services or supports are:

   (1)  Rendered at the provider’s site.

   (2)  Provided in a community environment, other than an individual’s home, while the individual is the responsibility of an employee, contracted agent or volunteer.

   (3)  Provided in an individual’s own home or the home of his family, while an employee, contracted agent or volunteer is providing services in the home.

 (c)  In situations when multiple providers learn of an incident, the provider responsible for the individual at the time the incident occurred is to report the incident and conduct any required investigation. If it cannot reasonably be determined which provider had responsibility at the time of the incident, all providers who are aware of the incident are to report the incident and investigate.

 (d)  If, during an investigation, the certified investigator assigned by the provider determines that an alleged perpetrator is not an employee, a volunteer or an individual receiving services from the provider, the certified investigator is to complete the investigation summary in the HCSIS incident management application stating the reason why the investigation could not be concluded. The certified investigator is to review the protective action taken by the agency and ensure communication with county staff occurs, outside HCSIS, to alert the county that appropriate interventions may be needed to protect the individual.

 (e)  In addition, employees, contracted agents or volunteers of provider agencies are to report deaths, alleged abuse or neglect when they become aware of such incidents regardless of where or when these incidents occur. If the death, alleged abuse or neglect occurred beyond the provider’s responsibility as specified in subsection (b)(1)—(3), the provider is not to report the incident in HCSIS, but instead should give notice of the incident, outside of HCSIS, to the individual’s supports coordinator.

 (f)  Any person, including the victim, shall be free from intimidation, discriminatory, retaliatory or disciplinary actions exclusively for the reporting or cooperating with a certified investigation. These individuals have specific rights as defined by the Whistleblower Law (43 P. S. § §  1421—1428) and the Older Adults Protective Services Act (35 P. S. §  10225.101—10225.5102). See Appendix F (relating to related laws, regulations and policies).

 (a)  Individuals and families are to notify the provider, when they feel it is appropriate, or their supports coordinator regarding any health and safety concerns they may have related to a service or support that they are receiving. If an individual or family member observes or suspects abuse, neglect or any inappropriate conduct, whether occurring in the home or out of the home, they should contact the provider or their supports coordinator, or both, and they may also contact the Office of Mental Retardation directly at 1 (888) 565-9435. As specified in this subchapter, the supports coordinator will either inform the involved provider of the incident or file an incident report. Once informed by the supports coordinator, the provider is subsequently responsible to take prompt action to protect the individual, complete an investigation as necessary and file an incident report. In the event of the death of an individual, the family is requested to notify the supports coordinator.

 (a)  When an individual or family informs his supports coordinator that an event has occurred that can be defined as an incident and there is a relationship as specified in §  6000.911(b)(1)—(3) (relating to providers) the supports coordinator is to immediately notify the provider rendering the support or service. The provider is responsible for taking prompt action to protect the individual, completing an investigation as necessary and filing an incident report in HCSIS.

 (b)  When an individual or a family member informs the supports coordinator of an event that can be categorized as abuse or neglect as defined in this subchapter and there is no relationship as specified in §  6000.911(b)(1)—(3), the supports coordinator will take prompt action to protect the individual. Once the individual’s health and safety are assured, the supports coordinator will ensure a certified investigator is assigned as necessary and file an incident report in HCSIS.

 (c)  When a family member of an individual informs the individual’s supports coordinator of the death of the individual, the supports coordinator will determine if a report has been filed by a provider. If a provider is not required to file the report, the supports coordinator will file an incident report in HCSIS.

 (d)  In some circumstances, county mental retardation program staff may be required to report incidents. County staff are to report deaths and incidents of alleged abuse or neglect when a provider or supports coordinator relationship does not currently exist, or in circumstances when the process for reporting or investigating incidents, described in this subchapter, for providers or support coordination entities compromises objectivity.

 (e)  If a county incident manager or designee is informed that a provider’s certified investigator suspects that abuse or neglect is occurring beyond the authority of the provider to investigate, the county is to take all available action to protect the health and safety of the individual. The county may need to employ the resources of law enforcement, ChildLine, area agency on aging, counselors or other protective service agencies to protect the individual.

REPORTABLE INCIDENTS

§ 6000.921. Categories of incidents.

 (a)  The following are the categories of incidents to be responded to by staff who are knowledgeable about incident management processes and protecting individuals. After the immediate health and safety assurances have been met, these incidents are to be reported in HCSIS. The categories are divided into those that must be reported within 24 hours of discovery or recognition and those that are to be reported within 72 hours.

 (b)  For the incidents that require reporting within 24 hours, the first section of the incident report must be completed in HCSIS within 24 hours. The first section includes a minimum data set (individual and provider demographics, action taken to protect the individual and description of the incident and the category of incident). The final section of the incident report includes additional information about the incident, any required investigation and corrective actions. The final section is to be completed within 30 days of recognition or discovery of the incident.

 (c)  The second set of incidents requires reporting within 72 hours of recognition or discovery. These incidents are reported using abbreviated data entry screens in HCSIS.

 (d)  When multiple individuals associated with a provider/entity are involved in certain primary categories or secondary categories, or both, of incidents, the incident can be reported using a site report. Only those events designated in the list of reportable incidents as a site report may be filed in this manner. An individual who is part of a group involved in a site report and is injured must have a separate individual report completed using the proper classification.

 (a)  The following are categories of incidents to be reported within 24 hours after the occurrence of the incident:

   (1)  Abuse. The allegation or actual occurrence of the infliction of injury, unreasonable confinement, intimidation, punishment, mental anguish, sexual abuse or exploitation. Abuse is reported on from the victim’s perspective, not on the person committing the abuse.

     (i)   Physical abuse. An intentional physical act by staff or other person which causes or may cause physical injury to an individual, such as striking or kicking, applying noxious or potentially harmful substances or conditions to an individual.

     (ii)   Psychological abuse. An act, other than verbal, which may inflict emotional harm, invoke fear or humiliate, intimidate, degrade or demean an individual.

     (iii)   Sexual abuse. An act or attempted acts such as rape, incest, sexual molestation, sexual exploitation or sexual harassment and inappropriate or unwanted touching of an individual by another. Any sexual contact between a staff person and an individual is abuse.

     (iv)   Verbal abuse. A verbalization that inflicts or may inflict emotional harm, invoke fear or humiliate, intimidate, degrade or demean an individual.

     (v)   Improper or unauthorized use of restraint. A restraint not approved in the individual support plan or one that is not a part of an agency’s emergency restraint procedure is considered unauthorized. A restraint that is intentionally applied incorrectly is considered an improper use of restraint.

   (2)  Death. All deaths are reportable.

   (3)  Disease reportable to the Department of Health. An occurrence of a disease on the Pennsylvania Department of Health List of Reportable Diseases. The current list can be found at the Department of Health’s website, www.health.state.pa.us. An incident report is required only when the reportable disease is initially diagnosed.

   (4)  Emergency closure. An unplanned situation that results in the closure of a home or program facility for 1 or more days. This category does not apply to individuals who reside in their own home or the home of a family member. This may be reported as a site report.

   (5)  Emergency room visit. The use of a hospital emergency room. This includes situations that are clearly ‘‘emergencies’’ as well as those when an individual is directed to an emergency room in lieu of a visit to the Primary Care Physician (PCP) or as the result of a visit to the PCP. The use of an emergency room by an individual’s PCP, in place of the physician’s office, is not reportable.

   (6)  Fire. A situation that requires the active involvement of fire personnel, that is, extinguishing a fire, clearing smoke from the premises, responding to a false alarm, and the like. Situations which require the evacuation of a facility in response to suspected or actual gas leaks or carbon monoxide alarms, or both, are reportable. Situations in which staff extinguish small fires without the involvement of fire personnel are reportable. This may be reported as a site report.

   (7)  Hospitalization. An inpatient admission to an acute care facility for purposes of treatment. Scheduled treatment of medical conditions on an outpatient basis is not reportable.

   (8)  Individual-to-individual abuse. An interaction between one individual receiving services and another individual receiving services resulting in an allegation or actual occurrence of the infliction of injury, unreasonable confinement, intimidation, punishment, mental anguish, sexual abuse or exploitation. Individual-to-individual abuse is reported on from the victim’s perspective, not on the person committing the abuse.

     (i)   Physical abuse. An intentional physical act that causes or may cause physical injury to an individual, such as striking or kicking, or applying noxious or potentially harmful substances or conditions to an individual.

     (ii)   Psychological abuse. An act, other than verbal, which may inflict emotional harm, invoke fear or humiliate, intimidate, degrade or demean an individual.

     (iii)   Sexual abuse. An act or attempted act such as rape, incest, sexual molestation, sexual exploitation or sexual harassment and inappropriate or unwanted touching of an individual by another. Nonconsensual sex between individuals receiving services is abuse.

     (iv)   Verbal abuse. A verbalization that inflicts or may inflict emotional harm, invoke fear or humiliate, intimidate, degrade or demean an individual.

   (9)  Injury requiring treatment beyond first aid. Any injury that requires the provision of medical treatment beyond that traditionally considered first aid. First aid includes assessing a condition, cleaning an injury, applying topical medications, applying a Band-Aid, and the like. Treatment beyond first aid includes lifesaving interventions such as CPR or use of the Heimlich maneuver, wound closure by a medical professional, casting or otherwise immobilizing a limb. Evaluation/assessment of an injury by emergency personnel in response to a ‘‘911’’ call is reportable even if the individual is not transported to an emergency room.

   (10)  Law enforcement activity. The involvement of law enforcement personnel is reportable in the following situations:

     (i)   An individual is charged with a crime or is the subject of a police investigation that may lead to criminal charges.

     (ii)   An individual is the victim of a crime, including crimes against the person or his property.

     (iii)   A crime such as vandalism or break-in that occurs at a provider site. This may be reported as a site report.

     (iv)   An on-duty employee or an employee who is volunteering during off duty time, who is charged with an offense, a crime or is the subject of an investigation while on duty or volunteering. This is reported as a site report.

     (v)   A volunteer who is charged with an offense, a crime or is the subject of an investigation resulting from actions or behaviors that occurred while volunteering. This is reported as a site report.

     (vi)   A crisis intervention involving police/law enforcement personnel.

     (vii)   A citation given to an agency staff person for a moving violation while operating an agency vehicle, or while transporting individuals in a private vehicle, is reported as a site report.

   (11)  Missing person. A person is considered missing when they are out of contact with staff for more than 24 hours without prior arrangement or if they are in immediate jeopardy when missing for any period of time. A person may be considered in ‘‘immediate jeopardy’’ based on the person’s personal history and may be considered ‘‘missing’’ before 24 hours elapse. Additionally, it is considered a reportable incident whenever the police are contacted about an individual or the police independently find and return the individual, or both, regardless of the amount of time the person was missing.

   (12)  Misuse of funds. An intentional act or course of conduct, which results in the loss or misuse of an individual’s money or personal property. Requiring an individual to pay for an item or service that is normally provided as part of the individual support plan is considered financial exploitation and is reportable as a misuse of funds. Requiring an individual to pay for items that are intended for use by several individuals is also considered financial exploitation. Individuals may voluntarily make joint purchases with other individuals of items that benefit the household.

   (13)  Neglect. The failure to obtain or provide the needed services and supports defined as necessary or otherwise required by law or regulation. This includes the failure to provide needed care such as shelter, food, clothing, personal hygiene, medical care, protection from health and safety hazards, attention and supervision, including leaving individuals unattended and other basic treatment and necessities needed for development of physical, intellectual and emotional capacity and well being. This includes acts that are intentional or unintentional regardless of the obvious occurrence of harm.

   (14)  Psychiatric hospitalization. An inpatient admission to a psychiatric facility, including crisis facilities and the psychiatric departments of acute care hospitals, for the purpose of evaluation or treatment, or both, whether voluntary or involuntary. This includes admissions for ‘‘23 hour’’ observation and those for the review or adjustment, or both, of medications prescribed for the treatment of psychiatric symptoms or for the control of challenging behaviors.

   (15)  Rights violation. An act which is intended to improperly restrict or deny the human or civil rights of an individual including those rights which are specifically mandated under applicable regulations. Examples include the unauthorized removal of personal property, refusal of access to the telephone, privacy violations and breach of confidentiality. This does not include restrictions that are imposed by court order or consistent with a waiver of licensing regulations.

 (a)  The following are categories of incidents to be reported within 72 hours after the occurrence of the incident:

   (1)  Medication error. Any nonconforming practice with the ‘‘Rights of Medication Administration’’ as described in the OMR Medication Administration Training Course. This includes omission, wrong dose, wrong time, wrong person, wrong medication, wrong route, wrong position, wrong technique/method and wrong form. Over the counter medication is excluded. Treatment procedures (for example, skin creams, shampoo, eye drops, and the like) that do not contain a prescription medication are excluded. A medication error occurring during a home visit, when the family is responsible for the administration, is not reportable. An individual’s refusal to take medication is not reportable. See Appendix H (relating to abbreviated incident report, medication error).

   (2)  Restraints. Any physical, chemical or mechanical intervention used to control acute, episodic behavior that restricts the movement or function of the individual or portion of the individual’s body, including those that are approved as part of an individual support plan or those used on an emergency basis. Improper or unauthorized use of restraint is considered abuse and is to be reported under the abuse category. See Appendix I (relating to abbreviated incident report, restraint).

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

     (ii)   Mechanical. 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. A device used to provide support for functional body position or proper balance and a device used for medical treatment, such as a wheelchair belt or helmet for prevention of injury during seizure activity, are not considered mechanical restraints.

 The following chart indicates those incidents to be investigated by the provider, the county and OMR. The investigation process does not preclude investigations by law enforcement or other agencies responsible to investigate.

SEQUENCE OF REPORTING

§ 6000.931. Multiple categories and sequences.

 (a)  Many real life occurrences may result in events that may be classified under multiple categories of incidents. In an attempt to assist the point person in identifying an appropriate order for reporting incidents that may be classified under multiple categories, the following sequence is suggested. This sequence may not be appropriate in all situations, but should be used as a guide in selecting the most appropriate category.

   (1)  24-Hour Reporting Primary Incident Category.

     (i)   Death.

     (ii)   Suicide attempt.

     (iii)   Hospitalization.

     (iv)   Psychiatric hospitalization.

     (v)   Emergency room visit.

     (vi)   Abuse.

     (vii)   Individual to individual abuse.

     (viii)   Neglect.

     (ix)   Missing person.

     (x)   Injury requiring treatment beyond first aid.

     (xi)   Disease reportable to the Department of Health.

     (xii)   Fire.

     (xiii)   Misuse of funds.

     (xiv)   Rights violation.

     (xv)   Law enforcement activity.

     (xvi)   Emergency closure.

   (2)  72-Hour Reporting Primary Incident Category.

     (i)   Medication error.

     (ii)   Restraint.

 (b)  If a death, hospitalization, psychiatric hospitalization, emergency room visit or injury requiring treatment beyond first aid is the result of a medication error or the use of a restraint, a report is to be initiated within 24 hours using the corresponding primary category. Data about the medication error or the restraint is also to be recorded within 72 hours in the abbreviated HCSIS data entry screens for medication error or restraint.

INCIDENT MANAGEMENT PROCESS

§ 6000.941. Administrative structure.

 Providers, supports coordination entities and counties are to create an administrative structure that is sufficient to implement the requirements of this subchapter. Specifically, they shall:

   (1)  Assign an individual with overall responsibility for incident management.

   (2)  Develop a policy for incident management.

   (3)  Ensure that staff, individuals and families are trained on incident management policies and procedures.

   (4)  Assign roles within their organization for reporting and investigation of incidents.

   (5)  Assure corrective action to individual incidents.

   (6)  Conduct analysis of data on incidents and the quality of investigations.

   (7)  Identify and implement individual and systemic changes based on risk management analysis.

ROLES

§ 6000.951. Initial reporter.

 A point person is assigned and authorized to perform specific duties as described in provider/entity or county policy. In general, a point person is to receive verbal or other reports or allegations of incidents from individuals, families and initial reporters. They are to safeguard the individual, ensure that HCSIS Incident Reports are submitted, communicate with others involved in investigations, follow-up and review of incidents. This role is pivotal in the incident management process. When an incident is reported, the point person, as a representative of the agency, is to:

   (1)  First confirm that appropriate actions have been taken or order additional actions to secure the safety of the individual involved in the incident.

   (2)  Separate the individual from the target when the individual’s health and safety may be jeopardized.

   (3)  Ensure notification requirements of the Older Adults Protective Services Act (35 P. S. § §  10225.101—10225.5102) and 23 Pa.C.S. § §  6301—6384 (relating to Child Protective Services Law) are met.

   (4)  Determine whether an investigation or other follow-up is needed.

   (5)  Secure the scene of an incident when an investigation may be required.

   (6)  Ensure that, when needed, a certified investigator is promptly assigned.

   (7)  Notify appropriate supervisory/management personnel within 24 hours of the incident, as specified in provider/entity or county policies.

   (8)  Initiate a HCSIS Incident Report within 24 or 72 hours as described in the Reportable Incident section of this bulletin.

 (a)  A support coordinator is a person who is responsible for the coordination of services for an individual and who receives reports from an individual or family. When an individual or a family member informs the supports coordinator of an event that can be categorized as abuse or neglect as defined in this subchapter and there is no relationship as specified in §  6000.911(b)(1)—(3) (relating to providers), the supports coordinator functioning in the point person role is to take prompt action to protect the individual. Once the individual’s health and safety are assured, the supports coordinator will ensure a certified investigator is assigned, as necessary, and file a HCSIS Incident Report.

 The BSOF incident manager is the person designated by OMR with overall responsibility for incident management for incidents filed by State-operated facilities. This responsibility includes a review to ensure that incidents are managed and reported in accordance with the process described in this subchapter and to approve or not approve HCSIS Incident Reports.

TYPES OF INCIDENT REPORTS

§ 6000.961. Standardized incident report.

 The following process applies to the primary incident category to be reported within 24 hours.

   (1)  The first section of the incident report is to include individual and provider demographics, incident categorization, actions taken to protect the health and safety of the individual, and a description of the incident. See Appendix K (relating to standardized incident report). The first section is to be submitted through HCSIS within 24 hours of the incident being recognized or discovered.

   (2)  The certified investigator is responsible for conducting certified investigations, completing investigation records and for entering the summary of the investigator’s findings into HCSIS. The summary is the compilation of the analysis and findings section of the investigation report. For more information on the analysis and findings section, see the Pennsylvania Certified Investigation Manual. The final section of the incident report will retain all of the information

   (3)  The final section of the incident report will retain all of the information from the first section and will add additional information relevant to the incident. See Appendix K. The final section is to be submitted through HCSIS within 30 days of the incident being recognized or discovered. If the provider agency determines it will not be able to meet the 30-day reporting timeframes for completion of the final section, notification of an extension is to be made to the county and the regional office of OMR by means of HCSIS prior to the expiration of the 30-day period.

 (a)  The following process applies to the primary incident categories requiring reporting within 72 hours. These incidents are not individually approved by the county, OMR regional office or Bureau of State Operated Facilities, but are to have a 30-day analysis completed and maintained by the provider/entity. Analysis of these incidents is to be included in the quarterly report.

 (b)  Medication errors and the use of restraints are to be reported using the abbreviated HCSIS incident management data entry screens, designed to gather relevant data about these incidents. Data is to be input within 72 hours of the recognition or discovery of the event.

REVIEW PROCESS

§ 6000.971. County review process.

 (a)  Within 24 hours of the submission of the first section of the incident report, designated county staff are to review the incident to determine that appropriate actions to protect the individual’s health, safety and rights occurred. If the appropriate actions have not taken place, the county staff should immediately communicate their concerns to the appropriate provider/entity staff.

 (b)  After the provider or entity submits the final section of the HCSIS Incident Report, county staff are to perform a management review within 30 days. Counties will conduct the management review process so that at least 90% of the submitted incident reports are approved or not approved within 30 days of finalization by the provider or supports coordination entity. The management review process is to review the full report and approve or not approve the incident report. This process will include a determination that:

   (1)  The appropriate action to protect the individual’s health, safety and rights occurred.

   (2)  The incident categorization is correct.

   (3)  A certified investigation occurred when needed.

   (4)  Proper safeguards are in place.

 (a)  Within 24 hours of the submission of the first section of the incident report, designated OMR regional office staff are to review the incident to determine that appropriate action to protect the individual’s health, safety and rights occurred. If the appropriate actions have not taken place the OMR regional office staff should immediately communicate their concerns to the appropriate provider/entity and county staff.

 (b)  After the county approves the incident report, regional OMR staff are to perform a management review within 30 days. The OMR regional office will conduct the management review process so that at least 90% of the county approved incident reports are approved or not approved within 30 days. The management review process is to review the full report, including the county’s response, and approve or not approve the incident report. This process will include a determination that:

   (1)  The appropriate action to protect the individual’s health, safety and rights occurred.

   (2)  The incident categorization is correct.

   (3)  A certified investigation occurred when needed.

   (4)  Proper safeguards are in place.

   (5)  Corrective action in response to the incident has, or will, take place.

QUALITY MANAGEMENT

§ 6000.981. Support to quality management.

 (a)  HCSIS produces a set of standardized online reports that are available to providers/entities, counties and OMR. In addition to the online reports, providers and counties may request an electronic extract of incident management data through HCSIS.

 (a)  Within 60 days following the end of a calendar quarter, a provider/entity is to submit to each county with whom the provider contracts, a qualitative report that describes the analysis of incidents and the systemic interventions implemented to improve the health and safety protections afforded to the individuals served. Supporting data is to be included with the report.

 (a)  The county MH/MR program is to submit to his respective regional office a semiannual qualitative report on June 1 and December 1 of each year. A general template will be disseminated by OMR which will give structure to the design of the county’s qualitative semi-annual report. The report is to describe the analysis of all incidents for individuals registered with the county mental retardation program. The county is to explain the systemic interventions implemented and document instructions to providers that will improve the health and safety protections afforded to the individuals served. Supporting data is to be included with the report. Training on this template will occur prior to the first semi-annual report due date.

 (b)  OMR will review data on all reported incidents at least semiannually to determine what trends may be developing Statewide, or by county, and take appropriate administrative steps to intervene. OMR will issue an annual report reviewing statewide incident trends.

 (c)  The following is a review schedule for quality incident management reporting:

APPENDIX A. [Reserved]

   The provisions of this Appendix A adopted August 19, 1988, effective October 1, 1988, 18 Pa.B. 3703; reserved August 9, 1991, effective November 8, 1991, 21 Pa.B. 3595. Immediately preceding text appears at serial pages (131329) to (131333).

APPENDIX B
LICENSING WEIGHTING SYSTEM FOR VOCATIONAL FACILITIES
WEIGHTS OF REGULATIONS

General Requirements	Subject	Weight	Rounded Weight
2390.11	Application	5.12	5
2390.14(a)	Labor & Industry—Fire Safety Approval	8.33	8
2390.14(b)	Written Annual Verification	6.61	7
2390.15(a)	Interstate Commerce—Fed. Wage & Hour Certificate	5.58	6
2390.15(b)	Intrastate Commerce—State Certificate	5.30	5
2390.15(c)	Interstate & Intrastate Commerce—Fed./State Certificate	5.01	5
2390.16	Public Eating & Drinking Certificate	7.38	7
2390.17	Written Statement of Purpose	4.49	4
2390.18(a)	Unusual Incident Report	6.87	7
2390.18(a)	Unusual Incident Report—24 hours	5.78	6
2390.18(b)	Unusual Incident Report—weekend	5.71	6
2390.19(a)	Abuse—Past 12 months	8.81	9
2390.19(b)	Abuse Reported—24 hours	8.64	9
2390.19(c)	Investigated Abuse—24 hours	7.86	8
2390.19(c)	Abuse Report—Support or Deny Allocation	7.55	8
2390.19(c)	Implement Change—Prevent Abuse	8.60	9
2390.19(d)	Criminal Abuse Reported Immediately	8.76	9
2390.20	Written Accident Prevention Policy	7.87	8
2390.21(a)	Discrimination	7.28	7
2390.21(a)	Civil & Legal Rights	7.68	8
2390.21(b)	Civil Rights Policy & Procedure	6.92	7
2390.22(a)	Governing Body	4.87	5
2390.22(b)	Governing Body—Financial Benefit	4.08	4
2390.22(c)	Conflict of Interest	4.21	4
2390.22(d)	Governing Body—Quarterly Meeting	3.49	3
2390.22(e)	Financial Reports—Review/Approval	3.82	4
2390.22(f)	Annual Program Report—Review/Approval	4.12	4
2390.23	Sound & Ethical Pract.	4.90	5
Staffing	Subject	Weight	Rounded Weight
2390.32(a)	Chief Executive Officer/Employed	5.49	5
2390.32(a)	Chief Executive Officer/Designee	5.33	5
2390.32(b)	Chief Executive Officer/Responsibilities	6.34	6
2390.32(c)	Chief Executive Officer/Qualifications	4.60	5
2390.33(a)	1:45 Program Specialist/Client Ratio	6.12	6
2390.33(b)	Program Specialist Responsibility	5.91	6
2390.33(c)	Program Specialist Qualification	5.21	5
2390.34(a)	One Production Manager	5.58	6
2390.34(b)	Production Manager Responsibility	5.26	5
2390.34(c)	Production Manager Qualifications	4.67	5
2390.35(a)	1:15 Floor Supervisor Ratio	6.60	7
2390.35(b)	Floor Supervisor Physically Present	6.56	7
2390.35(c)	Floor Supervisor Responsibility	6.95	7
2390.35(d)	Floor Supervisor Qualifications	5.11	5
2390.36(a)	1:10 Trainer Ratio	6.29	6
2390.36(b)	Trainer Responsibilities	6.00	6
2390.36(c)	Trainer Qualifications	5.06	5
2390.37(a)	Vocational Evaluator Employed	5.53	6
2390.37(b)	Vocational Evaluator Responsibilities	5.40	5
2390.37(c)	Vocational Evaluator Qualifications	5.09	5
2390.38(a)	Program Specialist & Floor Supervisor (ten or more clients)	5.67	6
2390.38(b)	Qualifications—2 Staff Positions	5.40	5
2390.39(a)	2 Staff Present—10 or More Clients	6.97	7
2390.39(b)	1 Staff Present—Fewer than 10 Clients	7.74	8
2390.39(c)	1 Qualified Program Specialist—20 or more clients	5.94	6
2390.40(a)	Orientation for Staff	6.54	7
2390.40(b)	24 Hrs Staff Training	5.42	5
2390.40(c)	Records of Training on file	4.15	4

Physical Site	Subject	Weight	Rounded Weight
2390.51	Accommodations for Physically Handicapped	7.91	8
2390.52(a)	80 Sq. Ft. Indoor Floor Space	5.69	6
2390.52(b)	60 Sq. Ft. Indoor Floor Space	5.64	6
2390.53	Outside Walks—Free of Hazards	8.17	8
2390.54	Combustible Supplies	8.59	9
2390.55(a)	Trash Removed—Once/Week	6.97	7
2390.55(b)	Insects/Rodents	7.64	8
2390.56	Hot & Cold Water—Bathroom & Kitchen	7.87	8
2390.57	Indoor Temperature—65° F-90° F	7.22	7
2390.58	Operable, Non-Coin Telephone	6.64	7
2390.59	Emergency Numbers Posted	7.72	8
2390.60(a)	First Aid Area	6.50	7
2390.60(b)	First Aid Area/Equipment	7.12	7
2390.60(c)	First Aid Accessible to Staff	7.33	7
2390.60(d)	First Aid Kit Contents	7.32	7
2390.61	Surfaces—Free of Hazards	7.36	7
2390.62	Sanitary Conditions Maintained	7.79	8
2390.63	Adequate Lighting	8.08	8
2390.64	Well-Secured Handrails	8.06	8
2390.65	Interior Stairs—Nonskid Surfaces	7.65	8
General Requirements	Subject	Weight	Rounded Weight
2390.66	Landings Provided	7.33	7
2390.67	Conditions—Safe & Sanitary	7.32	7
2390.68	Hazardous Equipment—Guard & Safety Devices	8.64	9
2390.69	Protective Equipment Worn	8.65	9
2390.70	Equipment—Visual, Auditory & Tactile Signals	8.13	8
2390.71(a)	Ventilation	7.32	7
2390.71(b)	Mechanical Exhaust—Toxic, Dust & Odor	8.49	8
2390.72(a)	Passages & Work Aisles—& Unobstructed	7.76	8
2390.72(b)	Work aisles—36 inches wide	6.45	6
2390.72(c)	Work aisles—marked—2" wide	5.62	6
2390.72(c)	Visually Handicapped—Tactile Guides	6.24	6
2390.73	Elevator—labor & industry approval	7.88	8
2390.74(a)	Lavatories—physically handicapped	7.36	7
2390.74(b)	1:30 Toilet Ratio	6.44	6
2390.74(c)	Separate Lavatories for Men & Women	5.92	6
2390.74(d)	Lavatory—Required Equip.	6.37	6
2390.75(a)(1)	Food Protection & Storage	8.37	8
2390.75(a)(2)	Food—Proper Temperatures	8.l7	8
2390.75(a)(3)	Utensils—washed with mechanical dishwasher	7.24	7
2390.75(a)(4)	Mechanical dishwasher—required temperatures	7.67	8
2390.75(a)(5)	Mechanical dishwasher—manufacturers instructions	6.92	7
2390.75(b)	Dining Area	5.33	5
2390.75(b)(1)	Dining Area Clear	6.88	7
2390.75(b)(2)	Dining Area—Table & Chairs	5.82	6

Fire Safety	Subject	Weight	Rounded Weight
2390.81	Corridors & Exits Unobstructed	8.42	8
2390.82(a)	Emergency Evacuation Procedures	7.88	8
2390.82(b)	Fire Safety Inspection or Notification	7.92	8
2390.83(a)	Operable Fire Alarm	8.56	9
2390.83(b)	Fire Alarm Checked	7.94	8
2390.83(b)	Written Record of Fire Alarm Check	7.01	7
2390.83(c)	Notification for Repair 24 Hours	7.85	8
2390.83(c)	Written Procedure—Fire Safety	7.58	8
2390.84(a)	10 ABC Fire Extinguishers	8.14	8
2390.84(b)	Fire Extinguishers—100 Feet	7.86	8
2390.84(c)	10B Fire Extinguishers—Kitchen	8.24	8
2390.84(d)	Fire Extinguisher Under 45 Pounds—Mounted	7.59	8
2390.84(e)	Fire Extinguisher Over 45 Pounds—Wheeled Unit	7.42	7
2390.84(f)	Fire Extinguisher—Accessible	8.14	8
2390.84(g)	Fire Extinguisher—Inspection & Approval	8.04	8
2390.85(a)	Fire Drill—Every 90 Days	7.73	8
2390.85(a)	Written Fire Drill Record	6.45	7
2390.85(b)	Fire Drills—Different Times	6.31	6
2390.85(b)	Hypothetical Location—Different	6.44	6
2390.85(c)	Clients Evacuation—Fire Drill	7.40	7
2390.85(d)	Fire Alarms Tested	7.56	8
2390.86	Signs—EXIT—Plain and Legible	7.90	8
2390.86	Exits Marked	7.83	8
2390.86	Exits Sign Letters—3/4 Inches Wide	6.76	7
2390.86	Tactile Exit Markings	7.18	7
2390.87	Instructed in General Fire Safety	7.40	7
Program	Subject	Weight	Rounded Weight
2390.91	Activities for Clients	5.99	6
2390.91	Individual Written Program Plan Provided	5.94	6
2390.92	20% Remunerative Work	5.29	5
2390.93	Work Training—Development Program	5.54	6
2390.94(a)	Written Assessment—20 Days	5.24	5
2390.94(b)	Initial Assessment by Program Specialist or Vocational Evaluator	5.10	5
2390.94(c)	Copy of Initial Assessment	4.92	5
2390.94(d)(1)	Document of Client’s Disability	6.40	6
2390.94(d)(2)	Level of Vocational Functioning	5.55	6
2390.94(d)(3)	Vocational Interests	5.17	5
2390.94(d)(4)	Ability for Instructions	5.95	6
2390.94(d)(5)	Recommendations for Specific Areas of Training	5.76	6

General Requirements	Subject	Weight	Weight
2390.94(e)	Written Statement Signed	5.14	5
2390.95(a)	Individual Written Program Plan (IWPP) Developed— 30 Days	5.62	6
2390.95(b)	IWPP Developed—Interdisciplinary Team	5.44	5
2390.95(b)	IWPP—Signature and Dated—Interdisciplinary Team	4.44	4
2390.96(1)	IWPP—Short Term Objectives	5.60	6
2390.96(2)	IWPP—Current Skill Level	5.63	6
2390.96(3)	IWPP—Time Frames	5.13	5
2390.96(4)	IWPP—Method of Evaluation	5.21	5
2390.96(5)	IWPP—Service Areas	5.27	5
2390.96(6)	IWPP—Staff Responsible	5.42	5
2390.96(7)	IWPP—Placement Potential	5.23	5
2390.97(a)	IWPP—Reviewed and Updated—65 days	5.24	5
2390.97(b)	IWPP—Reviewed and Updated—20 days	4.95	5
2390.97(c)	IWPP—Signed by Program Specialist & Client	5.40	5
2390.97(d)	IWPP—Reviewed and Rewritten Annually	5.77	6
2390.97(d)	IWPP—Signed and Dated Revised IWPP	4.65	5
2390.98(a)	IWPP—Copy in Client’s File	5.18	5
2390.98(b)	IWPP—Invitation to Client or Parent	4.96	5
2390.98(c)	IWPP—Provided Copy	4.81	5
2390.99	IWPP—Client Needs Met	5.73	6
2390.100(1)	Vocational Evaluation by Vocational Evaluator	5.24	5
2390.100(2)	Vocational Evaluation in Client’s File	5.19	5
2390.100(3)(i)	Vocational Evaluation of Client’s Vocational Level	5.44	5
2390.100(3)(ii)	Vocational Evaluation—Include Employers Objectives	5.23	5
2390.100(3)(iii)	Vocational Evaluation—Include Vocational Interests	5.15	5
2390.100(3)(iv)	Vocational Evaluation—Include Client’s Personal & Social Adjustment Level	5.40	5
2390.100(3)(v)	Vocational Evaluation—Work Attitude	5.31	5
2390.100(3)(vi)	Vocational Evaluation—Include Fatigue Level	5.88	6
2390.100(3)(vii)	Vocational Evaluation—Include Client’s Ability to Follow Instructions	6.08	6
2390.100(3)(viii)	Vocational Evaluation—Recommendation for Specific Areas	5.72	6
2390.100(4)	Vocational Evaluation—Signed Statement	5.37	5
Health	Subject	Weight	Rounded Weight
2390.101	Communicable Disease	8.37	8
2390.102	First Aid Technique—1 Certified Staff Member	8.15	8
2390.103	Written Emergency Medical Plan	7.92	8
2390.104	Emergency Information Accessible	8.27	8
2390.104	Emergency Medical Information	8.32	8
Admission and Placement	Subject	Weight	Rounded Weight
2390.111(a)	Client—Preadmission Interview	5.24	5
2390.111(b)	Notification—30 Days	4.41	4
2390.111(b)	Notification—Specify Service and Reason for Decision	4.62	5
2390.111(c)	Kept on File for 3 Years	3.36	3
2390.112(a)	Clients Oriented to Facility	6.27	6
2390.112(a)	Orientation Date—Client’s Record	4.21	4
2390.112(b)	Written Information Upon Admission	5.81	6
2390.112(b)	Written Statement in Client’s Record	5.17	5
2390.113(b)	Arrangements for Placement Services	5.94	6
2390.113(b)	Placement Services—Staff Responsibility	5.46	5
2390.113(c)(1)	Placement Services—Employer Information	5.54	6
2390.113(c)(2)	Placement Services—Notification	5.56	6
2390.113(c)(3)	Placement Services—Client Participation	5.95	6
2390.113(c)(4)	Placement Services—Clients Abilities	6.29	6
2390.113(c)(5)	Placement Services—Follow-Up Activities	6.47	6
2390.113(d)	Documents of Competitive Employment	5.08	5
2390.113(e)	Placement Services Component Written	4.67	5

Client Records	Subject	Weight	Rounded Weight
2390.121	Individual Record	6.44	6
2390.121	Legible, Dated and Signed	5.81	6
2390.122	Records Kept at Facility	6.01	6
2390.122	Records Kept 3 Years	4.23	4
2390.123	Confidential & Locked	6.87	7
2390.124	Information—Records	6.60	7
2390.125	Policy on Access to Records	5.89	6
2390.126(a)	Client/Parent/Guardian Access	6.01	6
2390.126(b)	Facility Responsible	6.32	6
2390.127	Written Consent—Release of Information	6.46	6
Handicapped Employment	Subject	Weight	Rounded Weight
2390.141	Written Documentation—Individual Client	5.16	5
2390.143(a)	Completed Work Performance Review	5.30	5
2390.143(b)(1)	Work Performance Review Quantity and Quality	5.30	5
2390.143(b)(2)	Work Performance Review Changes in Production	5.07	5
2390.143(b)(3)	Upward Movement to Competitive Employment	5.41	5
2390.143(b)(4)	Work Related Problems	5.53	6
2390.143(c)	Copy Provided	4.93	5
2390.144	1:20 Floor Supervisor Ratio	6.41	6

   The provisions of this Appendix B adopted August 19, 1988, effective October 1, 1988, 18 Pa.B. 3703.

   This appendix cited in 55 Pa. Code §  6000.311 (relating to computation of weighted score).

   The provisions of this Appendix C adopted August 19, 1988, effective October 1, 1988, 18 Pa.B. 3715.

   The provisions of this Appendix D adopted August 19, 1988, effective October 1, 1988, 18 Pa.B. 3715.

APPENDIX E
INCIDENT MANAGEMENT COMPONENTS

 PROVIDERS/ENTITIES ARE TO:

 •  Promote the health, safety, rights and enhance the dignity of individuals receiving services.

 •  Develop provider-specific policy/procedures for incident management.

 •  Ensure that staff and others associated with the individual have proper orientation and training to respond to, report and prevent incidents.

 • Provide ongoing training to individuals and families on the recognition of abuse and neglect.

 • Ensure when incidents occur that affect a person’s health, safety or rights, that the people who are present:

 — Take prompt action to protect the person’s health, safety and rights. This includes separation of the target when the individual’s health and safety are jeopardized. This separation shall continue until an investigation is completed. In addition, the target shall not be permitted to work directly with any other service recipient during the investigation process. When the target is another individual receiving supports or services, and complete separation is not possible, the provider shall institute additional protections.

 — Notify the responsible person designated in provider policy.

 • Assign trained individual(s) Point Person(s) to whom incidents are reported when they occur and who will make certain that all immediate steps to assure health and safety have been implemented and follow the incident through closure.

 • Contact appropriate law enforcement agencies when there is suspicion that a crime has occurred.

 • Comply with all applicable laws, regulations and policies.

 • Conduct certified investigations.

 • Analyze the quality of investigations.

 • Respond to concerns from individuals/family about the reporting and investigation processes.

 • Inform the family of the incident unless otherwise indicated in the individual’s plan.

 • Notify the family of the findings of any investigation unless otherwise indicated in the individual’s plan.

 • Maintain an investigation file within the agency.

 • Create an incident management process which:

 — Designates an individual with overall responsibility for incident management.

 — Considers possible immediate and long-term effects to the individual resulting from an incident or multiple incidents.

 — Uses trend analyses to identify systemic issues.

 — Analyzes and shares information with relevant staff, including direct care staff.

 — Periodically assesses the effectiveness of the incident management process.

 — Monitors quality and responsiveness of all ancillary services (such as health, therapies, etc.) and acts to change vendors or subcontractors, or assists the individual to file available grievances or appeals procedures to secure appropriate services.

 COUNTIES ARE TO:

 • Promote the health, safety, rights and dignity of individuals receiving services.

 • Develop county policies and procedures necessary to implement this bulletin.

 • Have an administrative structure sufficient to meet mandates of this bulletin:

 — Designate an individual with overall responsibility for incident management.

 — Train staff in incident management procedures.

 — Assure that supports coordinators have proper orientation and training to respond to, document and prevent incidents.

 — Support providers with appropriate training and resources to meet the mandates of the bulletin.

 • Provide ongoing training to individuals, families, guardians, and advocates regarding their rights, roles and responsibilities that are outlined in this bulletin.

 • Provide training to individuals and families on the recognition of abuse and neglect.

 • Have the Incident Management Processes in this bulletin referenced in county/provider contracts.

 • Maintain an investigation file within the county.

 • Create an incident management process which:

 — Assures accuracy of incident reports.

 — Reviews and closes all provider generated incidents.

 — Reviews and analyzes data.

 — Identifies and implements individual and systemic changes based on data analysis.

 — Analyzes and shares information with relevant staff.

 — Regularly reviews trend and occurrence data compiled by providers.

 — Assesses provider’s incident management and investigative processes.

 — Assures provider compliance with plans of correction resulting from incidents and investigations.

 • Conduct certified investigations.

 • Analyze the quality of investigations.

 • Respond to concerns from individuals/family about the reporting and investigation processes.

 • In collaboration with the individual’s planning team, revise the individual’s plan as needed in response to issues identified through the incident management process.

 • Comply with all applicable laws, regulations and policies.

 • Coordinate with other agencies as necessary.

 • In those instances where the county is the initial reporter of the incident, the county will assume the responsibility of the point person.

 THE OFFICE OF MENTAL RETARDATION IS TO:

 • Promote the health, safety, rights and dignity of individuals receiving services.

 • Create an incident management review process which:

 — Maintains the statewide data system.

 — Analyzes data for statewide trends and issues.

 — Identifies issues and initiates systemic changes and provides periodic feedback.

 — Evaluates county and provider reports and analysis of trends.

 • Monitor implementation of this bulletin.

 • Support providers and counties with appropriate training to meet the mandate of the bulletin.

 • Certify investigators.

 • Provide support and technical assistance to counties to implement the incident reporting system.

 • Conduct certified investigations.

 • Analyze the quality of investigations.

 • Respond to concerns from individuals/families about the reporting and investigation processes.

 • Review and revise this bulletin as needed.

 • Ensure compliance with all applicable laws, regulations and policies.

 • Coordinate with other agencies as necessary.

   The provisions of this Appendix E adopted February 27, 2004, effective February 21, 2004, 34 Pa.B. 1234.

   This appendix cited in 55 Pa. Code §  6000.902 (relating to purpose).

APPENDIX F
RELATED LAWS, REGULATIONS AND POLICIES

 The incident management and reporting detailed in this subchapter are related to a variety of laws, regulations and policies. The applicable licensing regulations (and facilities licensed under those regulations) include:

 Related Laws:

 • The Mental Health and Mental Retardation Act of 1966 (50 P. S. § §  4101—4704)

 • Title XIX Social Security Act (42 U.S.C.A. § §  1396—1396v)

 • 18 Pa.C.S. §  2713 (relating to the neglect of care-dependent person)

 • The Child Protective Services Law (23 Pa.C.S. § §  6301—6385)

 • The Older Adults Protective Services Act (35 P. S. § §  10225.101—10225.5102)

 • Elder Care Payment Restitution Act (35 P. S. § §  10226.101—10226.107)

 • Early Intervention Services System Act (11 P. S. § §  875.101—875.503)

 • The Whistleblower Law (43 P. S. § §  1422—1428)

 Title 55 of the Pennsylvania Code.

 • Chapter 20—Relating to Licensure or Approval of Facilities and Agencies

 • Chapter 2380—Relating to Adult Training Facilities

 • Chapter 2390—Relating to Vocational Facilities

 • Chapter 3490—Relating to Child Protective Services

 • Chapter 3800—Relating to Child Residential and Day Treatment Facilities

 • Chapter 5310—Relating to Community Residential Rehabilitation Services for the Mentally Ill

 • Chapter 6400—Relating to Community Homes for Individuals with Mental Retardation

 • Chapter 6500—Relating to Family Living Homes

 • Chapter 6600—Relating to Intermediate Care Facilities for the Mentally Retarded

 Title 6 of the Pennsylvania Code (Aging).

 • Chapter 11—Relating to Older Adult Daily Living Centers

 Related Policy Guidelines:

 • Medical Assistance Bulletin—Revised Medical and Treatment Self-Directive Statement: Your Rights As a Patient In Pennsylvania: Making Decisions About Your Care and Treatment (effective June 19, 1998)

 • Mental Retardation Bulletin 00-98-08—Procedures for Substitute Health Care Decision Making (effective November 30, 1998)

 • Mental Retardation Bulletin 00-94-32—Assessments: Lifetime Medical History (effective December 6, 1994)

 • Mental Retardation Bulletin 00-03-01—Passage of Act 171 relating to the Older Adults Protective Services Act (OAPSA)

 ADDITIONAL REPORTING:

 In addition to the reporting methodologies described in this statement of policy, the following is provided as a guide to assist in identifying additional reporting. This does not fully define, nor is it intended to substitute for, the applicable statutes and regulations.

 Reportable incidents involving individuals who reside in facilities licensed as ICF/MRs (both state and privately-operated), are to be reported to the appropriate Regional Field Office of the Pennsylvania Department of Health, Division of Intermediate Care Facilities.

 Reportable incidents that occur in facilities licensed by OMR, involving individuals whose support needs are not funded through the Commonwealth or county mental retardation systems, are to be reported to whomever funds the individual’s support and to the Commonwealth/Regional Office of Mental Retardation. This includes individuals from other states, individuals who are funded by agencies not part of the mental retardation system and individuals whose support needs are privately funded.

   Neglect of care-dependent person (18 Pa.C.S. §  2713)

 The neglect of care-dependent person 18 Pa.C.S. §  2713 covers any adult who, due to physical or cognitive disability or impairment, requires assistance to meet his needs for food, shelter, clothing, personal care or health care. 18 Pa.C.S. §  2713 extends to certain listed facilities and to home health services provided to care-dependent persons in their residence. The statute criminalizes intentional, knowing or reckless conduct by a caregiver which results in bodily injury or serious bodily injury to a care-dependent person by the failure to provide treatment, care, goods or services necessary to preserve the health, safety or welfare of a care-dependent person for whom the caregiver is responsible to provide care. A caregiver may also be prosecuted if he intentionally or knowingly uses a physical restraint, a chemical restraint or medication on a care-dependent person, or isolates that person, contrary to law or regulation, such that bodily or serious bodily injury results.

 Anyone aware of possible violations of this may make a report to the appropriate law enforcement authorities. The reporting requirements of this bulletin are to be followed even if a report of a possible violation of this statute is made to law enforcement authorities. Copies of the statute were distributed via Mental Retardation Bulletin 00-95-25, issued December 26, 1995 and Mental Retardation Bulletin 00-97-06, issued August 29, 1997.

   The Child Protective Services Law (23 Pa.C.S. § §  6301—6385)

 The Child Protective Services Law (CPSL) establishes procedures for the reporting and investigation of suspected child abuse. Certain types of suspected child abuse must be reported to law enforcement officials for investigation of criminal offenses. Children under the age of 18 are covered by the act including those who receive supports and services from the mental retardation system. Providers covered within the scope of this bulletin are required to report suspected child abuse in accordance with the procedures established in the CPSL and the Protective services Regulations. The CPSL defines child abuse as any of the following when committed upon a child under 18 years of age by a parent, person responsible for a child’s welfare, an individual residing in the same home as a child or a paramour of a child’s parent.

 • Any recent act or failure to act that causes non-accidental serious physical injury.

 • Any act or failure to act that causes nonaccidental serious mental injury or sexual abuse or sexual exploitation.

 • Any recent act or series of such acts or failures to act that creates an imminent risk of serious physical injury or sexual abuse or sexual exploitation.

 • Serious physical neglect constituting prolonged or repeated lack of supervision or the failure to provide essentials of life including adequate medical care which endangers a child’s life or development or impairs the child’s functioning.

 Reports of suspected abuse are received by the Department of Public Welfare’s (DPW) ChildLine and Abuse Registry (800) 932-0313, which is the central register for all investigated reports of abuse. Individuals who come into contact with children in the course of practicing theirprofession are required to report when they have reasonable cause to suspect on the basis of their medical, professional or other training or experience, that a child is an abused child. Every facility or agency is required by the CPSL to funnel reports to the director or a designee to be promptly reported to ChildLine. The reporting, investigation and documentation requirements of this statement of policy must also be followed when a report of suspected child abuse is made. It must be noted that the definition of abuse found in the CPSL differs greatly from the definition promulgated in this statement. Because of this difference it is possible that an allegation may be ‘‘unconfirmed’’ in terms of the CPSL but still substantiated with reference to these guidelines. Likewise, the scope of reports subject to investigation differs so it is important to be familiar with the requirements of the CPSL.

   The Older Adults Protective Services Act (35 P. S. § §  10225.101— 10225.5102)

 The Older Adults Protective Services Act (OAPSA) of 1987 was enacted to protect all Pennsylvanians age 60 and older. The OAPSA established a detailed system for reporting and investigating suspected abuse, neglect, exploitation, and abandonment for care-dependent individuals. Act 13 was signed into law in 1997 as an amendment to the OAPSA. Unlike the other provisions of OAPSA that applied only to adults age 60 and above, Act 13 applied to adults age 18 and above who were considered ‘‘care-dependent’’ individuals and to ‘‘care-dependent’’ individuals under age 18 if they resided in a facility serving individuals over 18. Employees or administrators of a covered entity reported suspected abuse incidents to the local Area Agency on Aging, where indicated, to the Pennsylvania Department of Aging and to local law enforcement pursuant to Chapter 7 of the OAPSA. These requirements existed in addition to the reporting procedures contained in this Bulletin. In 2002, the OAPSA was further amended by the Elder Care Payment Restitution Act.

   The Elder Care Payment Restitution Act (35 P. S. § §  10226.101—10226.107)

 The Elder Care Payment Restitution Act eliminated the requirements of Act 13 for which suspected abuse of individuals with mental retardation under the age of 60 was reported to the Area Agency on Aging and in some cases, to the Department of Aging. This act became effective February 9, 2003.

   Health Insurance Portability and Accountability Act of 1996 (HIPAA) (Pub lic Law 104-191)

 HIPAA and the applicable regulations at 45 CFR Parts 160 and 164 (Privacy Rule) established a set of National standards for the protection of personal health information. The Privacy Rule addresses the use and disclosure of individuals’ health information or ‘‘protected health information’’ by organizations subject to the Privacy Rule or ‘‘covered entities.’’ The Privacy Rule establishes standards for individuals’ rights to understand and control how their personal health information is used. The U. S. Department of Health and Human Services, Office of Civil Rights is responsible to implement and enforce the Privacy Rule.

REPORTING MATRIX

 The following is provided as a guide to assist in identifying additional reporting. This does not fully define, nor is it intended to substitute for, the applicable statutes and regulations.

   ¹ If an individual is not funded by OMR or by County MR services a report should be made to the funding agent.
² Allegations of abuse or neglect involving children under 18 who reside in a facility that primarily serves adults must be reported to Child Line.
³ Allegations of abuse or neglect involving children under 18 who reside in a facility that primarily serves adults must be reported to Child Line.
⁴ Reporting under Acts 28/26 is only mandated for Commonwealth employees.

   The provisions of this Appendix F adopted February 27, 2004, effective February 21, 2004, 34 Pa.B. 1234.

   This appendix cited in; and 55 Pa. Code §  6000.951 (relating to initial reporter).

APPENDIX G
VICTIM’S ASSISTANCE PROGRAMS

 When individuals are abused, neglected, injured or victims of crimes, there are resources to assist them physically, emotionally, financially and legally. Organizations have been developed based on the need to support victims through the criminal justice system, recognizing that victim’s needs are oftentimes overlooked. Individuals with disabilities who fall victim to crimes, especially physical violence and sexual assaults, should be encouraged and assisted to access these resources. It is suggested that providers develop relationships with local entities and assist individuals in accessing such services when appropriate.

 There are two main types of victim assistance programs: system and community-based organizations. System-based programs that generally operate out of a District Attorney’s office provide notification to victims/witnesses of court proceedings. Community based programs are designed to provide support and assistance to victims. Usually, the programs fall under the categories of:

 • Rape Crisis/Sexual Assault programs providing services to victims and their family/supporters. Domestic Violence programs provide counseling and temporary housing to victims, as needed.

 • Crime Victim Services provide supports and assistance to victims of crimes excluding sexual assaults and domestic violence.

 There are domestic violence centers, rape crisis centers and victim assistance offices throughout the Commonwealth. In order to locate the most appropriate resource for individuals, you may contact the following statewide organizations. Additional information regarding local resources is available through these organizations:

 PA Commission on Crime and Delinquency (PCCD)
(717) 787-2040

 PA Coalition Against Rape (PCAR)
(800) 692-7445
(717) 728-9740

 PA Coalition Against Domestic Violence (PCADV)
(800) 932-4632

 Office of Victim Advocate (crime victim compensation)
(717) 783-7501

 Pennsylvania Protection and Advocacy (PP&A)
(800) 692-7443

   The provisions of this Appendix G adopted February 27, 2004, effective February 21, 2004, 34 Pa.B. 1234.

   This appendix cited in 55 Pa. Code §  6000.921 (relating to categories of incidents).

APPENDIX H
ABBREVIATED INCIDENT REPORT

Medication Error

 The data entry screen is to include the following information:

 • DEMOGRAPHICS (pre-populated from HCSIS demographics)

 Name of the individual for whom the Medication Error is being reported.

 Individual’s Base Service Unit (BSU) number.^rr1;sup

   ¹ If the individual is not registered with a County MH/MR Program, the report is to list the county or state where the person is/was a resident. ¹

 • CATEGORIZATION

 Secondary category of Medication Error.

 Date and time when the incident was recognized/discovered.

 • MEDICATION ERROR INCIDENT INFORMATION

 Staff position of the person giving medication.

 Name of medication(s).

 Indication if the error occurred over multiple consecutive administrations.

 The reason(s) why the Medication Error occurred.

 The response(s) to the Medication Error.

 The agency system response to prevent this type of error from occurring in the future.

 Any additional comments.

 Indication if another Incident Report was filed as a result of the Medication Error.

 If another Incident Report was filed, the Incident ID number.

 In addition to the required information, providers may choose to include optional information to further analyze their medication errors.

 • OPTIONAL MEDICATION ERROR INFORMATION

 The name or unique identifier of person making the Medication Error.

 Indication if the person making the Medication Error was working longer than their regular work hours at the time of the Medication Error.

 The length of time the staff person who made the Medication Error has been giving medications.

 The number of medications supposed to be given to this person at the same time as the Medication Error was made including the medication when the Medication Error was made.

 The number of medications this person receives on a daily basis.

 The number of people that the staff person who made the Medication Error has to give medications to around the same time as the Medication Error occurred.

   The provisions of this Appendix H adopted February 27, 2004, effective February 21, 2004, 34 Pa.B. 1234.

   This appendix cited in 55 Pa. Code §  6000.923 (relating to incidents to be reported within 72 hours); and 55 Pa. Code §  6000.924 (relating to incident management contingency plan).

APPENDIX I
ABBREVIATED INCIDENT REPORT

Restraint

 The data entry screen is to include the following information:

 • DEMOGRAPHICS (prepopulated from HCSIS demographics)

 Name of the individual for whom the Restraint was used.

 Individual’s Base Service Unit (BSU) number.^r1;sup

   ¹ If the individual is not registered with a County MH/MR Program, the report is to list the county or state where the person is/was a resident. ¹

 • CATEGORIZATION

 Secondary category of Restraint.

 Date of the Restraint.

 Time in Restraint.

 Time out of Restraint.

 • RESTRAINT INCIDENT INFORMATION

 Restraint agent.

 Antecedent to the Restraint.

 Reason for the Restraint.

 Indication if the Restraint was used on a planned or emergency basis.

 Authorizing Staff.

 Indication if Prone (face down) Restraint was used.

 Indication if another Incident Report was filed as a result of the Restraint.

 If another Incident Report was filed the Incident ID number.

   The provisions of this Appendix I adopted February 27, 2004, effective February 21, 2004, 34 Pa.B. 1234.

   This appendix cited in 55 Pa. Code §  6000.923 (relating to incidents to be reported within 72 hours).

APPENDIX J
INCIDENT MANAGEMENT CONTINGENCY PLAN

 In the event that a provider or county or entity is unable to report a 24-hour incident through the Home and Community Services Information System (HCSIS), faxed contingency reporting is to be utilized.

 Incidents that are reported via fax are to be recorded on a copy of the attached Incident Management Contingency Form. This reporting method will satisfy regulatory requirements to report an incident. In the event of a serious incident (such as abuse with injury, suspicious death), a provider should also call its OMR Regional Office and County MH/MR Program to alert OMR and the county of the incident.

 Once complete, the Incident Management Contingency Form is to be faxed to the appropriate OMR Regional Office and to the County MH/MR Program. The form should have a fax cover sheet that identifies the fax as a reportable incident and states the reason that the report needed to be faxed. Faxing the Incident Management Contingency Form is a short-term solution for meeting regulatory requirements for reporting incidents; however, once access to HCSIS can be established, the incident must be entered into HCSIS.

 CONTACT INFORMATION:

 OMR Regional Office Fax Numbers:

 • Northeast Region (570) 963-3177

 • Southeast Region (215) 560-3043

 • Central Region (717) 772-6483

 • Western Region (412) 565-5479

 OMR Regional Office Phone Numbers:

 • Northeast Region (570) 963-4391

 • Southeast Region (215) 560-2242

 • Central Region (717) 772-6507

 • Western Region (412) 565-5144

   The provisions of this Appendix J adopted February 27, 2004, effective February 21, 2004, 34 Pa.B. 1234.

   This appendix cited in 55 Pa. Code §  6000.924 (relating to incident management contingency plan).

APPENDIX K
STANDARDIZED INCIDENT REPORT

 FIRST SECTION (completed within 24 hours)

 The First Section is to include the following information:

 • DEMOGRAPHICS (pre-populated from HCSIS demographics)

 Name of the individual involved/affected by the incident.

 Individual’s Base Service Unit (BSU) number.^ak1;sup

   ¹ If the individual is not registered with a County MH/MR Program, the report is to list the county or state where the person is/was a resident. ¹

 County of Registration.

 Gender.

 Individual’s date of birth.

 MR Diagnosis.

 Home address of the individual.

 Living Arrangement of the individual.

 Name and address of the reporting entity.

 Location where the incident occurred.

 Name of the point person.

 • CATEGORIZATION

 Date and time when the incident was recognized/discovered.

 Primary and secondary category of the incident.

 Determination if an investigation is required or desired.

 Name of the Certified Investigator assigned, if the incident requires investigation.

 • HEALTH AND SAFETY ASSURANCE

 Description of the immediate and subsequent steps taken by the point person or other representatives of the provider to ensure the individual’s health, safety and response to the incident, including date, time and by whom those steps were taken.

 • INCIDENT DESCRIPTION

 Narrative description of the incident completed by staff or other person(s) who were present when the incident occurred or who discovered that an incident had occurred.^ak2;sup

   ² Providers may summarize the narrative description, but the written statements of the person(s) directly invilved are to be available for review, if needed. ²

 FINAL SECTION (completed within 30 days)

 The reporting entity will complete the Final Section of the incident report within 30 days from the date of the incident or of the date the provider learns of the incident (unless an extension has been made). The Final Section will retain all of the preceding information from the First Section and will add:

 Name of the initial reporter.

 Name of the individual’s supports coordinator (pre-populated).

 Whether CPR was administered.

 Weather the Heimlich was administered.

 If 911 was called, the time, date and person who called.

 If the incident involves an illness or injury, the name of the practitioner/facility by whom the individual was treated initially, the date and time of the initial contact with a health-care/medical practitioner, the nature/content of the initial treatment/evaluation, and the nature of, date of, time of, and practitioner involved in any subsequent treatments, evaluations.

 In the event of a death, indication if the individual was in hospice care, had a diagnosis of terminal illness, if a ‘‘Do Not Resuscitate’’ order was in effect, if the coroner was contacted, if an autopsy has been or will be performed.

 Identification of all persons to whom the incident notification has been (or will be) submitted (i.e., family, law enforcement agency), the date the notification has been made, and the person who has/will notify the necessary parties.

 Update of incident description, as needed.

 Specific description of any injury received by the individual.

 Present status of the individual in reference to the incident.

 Identification of other persons who may have witnessed or been directly involved in the incident.

 Specific signs and symptoms of any illness (acute or chronic) which may be contributory to the incident.

 Any relevant background information on the individual, including medical history and diagnoses.

 Date on which the investigation began, if required.

 Summary of the investigator’s findings and conclusions, if required.

 If the incident involves an allegation of abuse or neglect, the conclusion reached on the basis of the investigation (i.e., the allegation is confirmed, not confirmed, inconclusive) and the status of the target.

 Description of the steps taken by the provider in response to the conclusions reached as a result of the investigation.

 If the incident involves an injury of unknown origin, confirmation of the cause (if one has been identified) and steps taken to prevent recurrence.

 Description of any changes in the individual’s plan of support necessitated by or in response to the incident.

 Verification by the provider that all necessary corrective actions have been identified.

 If any corrective action cannot/has not been completed by the time the Final Section is submitted, the expected date of completion must be provided along with the identity of the person responsible for carrying the extended action through to completion.

 If the nature of the incident requires contact with local law enforcement, the name and department/office of the person(s) contacted, the date of the contact, the name of the person who initiated the contact, and a description of any steps taken by law enforcement officials.

 If the individual has been hospitalized, the date of admission, name of the hospital, the admitting diagnosis(es), indication if the admission was from the emergency room, what occurred during the hospitalization, change in voluntary/involuntary status, the date of discharge, the discharge diagnosis(es), an indication that the Hospital Discharge Instructions were provided, what changed after discharge, current status and any plans for subsequent medical follow-up.

 If the individual is deceased, the Final Section is to be supplemented by a hard copy of the following:^ak3;sup

   ³ Documents, which are not immediately available, must be forwarded to the appropriate parties (county and/or OMR Regional Office) as they become available. If, after attempting to acquire the document, it is determined to be unobtainable, the expecting party will be notified. ³

 — Lifetime medical history.

 — Copy of the Death Certificate.

 — Autopsy Report, if one has been completed.

 — Discharge Summary from the final hospitalization, if the individual died while hospitalized.

 — Results of the most recent physical examination.

 — Most recent Health and Medical assessments.

 Name of the family member notified of the results of the investigation, if required.

 The incident classification the provider believes is most appropriate.

 The date and time the provider believes is most appropriate.

 After final submission by the provider, the county and OMR will perform a management review and close the incident.

   The provisions of this Appendix K adopted February 27, 2004, effective February 21, 2004, 34 Pa.B. 1234.

   This appendix cited in 55 Pa. Code §  6000.961 (relating to standardized incident report).¹ If the individual is not registered with a County MH/MR Program, the report is to list the county or state where the person is/was a resident.