TITLE 8               SOCIAL SERVICES

CHAPTER 321  SPECIALIZED BEHAVIORAL HEALTH SERVICES

PART 6                REQUIREMENTS FOR COMMUNITY MENTAL HEALTH CENTERS

 

8.321.6.1               ISSUING AGENCY:  New Mexico Health Care Authority - Division of Health Improvement.

[8.321.6.1 NMAC - N, 7/1/2024]

 

8.321.6.2               SCOPE:

                A.            These regulations apply to the following:

                                (1)           outpatient facilities which are certified by the behavioral health services division of the New Mexico health care authority (authority) to provide psychosocial rehabilitation services to adults with priority given to individuals with severe disabling mental illness (SDMI); and

                                (2)           any facility providing services as outlined by these regulations which by federal regulation must be certified by the behavioral health services division of the authority to obtain or maintain full or partial, permanent or temporary federal funding.

                B.            These regulations do not apply to offices and treatment facilities of licensed private practitioners.

[8.321.6.2 NMAC - N, 7/1/2024]

 

8.321.6.3               STATUTORY AUTHORITY:  The regulations set forth herein are promulgated pursuant to the general authority granted under Subsection E of Section 9-8-6 NMSA 1978; and the authority granted under Subsection D of Section 24-1-2, Subsection I of Section 24-1-3, and Section 24-1-5 of the Public Health Act, NMSA 1978, as amended.  Section 9-8-1 et seq. NMSA 1978 establishes the health care authority as a single, unified department to administer laws and exercise functions relating to health care purchasing and regulation.

[8.321.6.3 NMAC - N, 7/1/2024]

 

8.321.6.4               DURATION:  Permanent.

[8.321.6.4 NMAC - N, 7/1/2024]

 

8.321.6.5                               EFFECTIVE DATE:  July 1, 2024, unless a later date is cited at the end of a section.

[8.321.6.5 NMAC - N, 7/1/2024]

 

8.321.6.6               OBJECTIVE:

                A.            to establish minimum standards for licensing of community mental health centers;

                B.            to monitor community mental health centers through surveys to identify any areas which could be dangerous or harmful to the clients or staff; and

                C.            to ensure the provision of quality services which maintain or improve the health and quality of life to the clients.

[8.321.6.6 NMAC - N, 7/1/2024]

 

8.321.6.7                               DEFINITIONS:

                A.            “Applicant” means the organization that applies for a license.  The individual signing the application on behalf of the organization must have authority from the organization.

                B.            “Branch” means a part of the certified community mental health center, which is part of the corporation or campus that is certified by HCA, where client care takes place.  Branches of facilities must meet the intent of these regulations.  The parent facility is responsible for their branches’ compliance.  A separate state license is required for separate geographic locations under each certified facility.

                C.            “Client” means any individual who is requesting or receiving mental health services from a community mental health center as defined in this regulation.

                D.            “Community-based crisis intervention” means, at a minimum, 24 hour telephone crisis services, initial face-to-face crisis intervention and follow-up crisis support services.

                E.            “Community mental health center” means a facility certified by the health care authority to provide and manage a comprehensive array of mental health services with priority given to serving adults with severe disabling mental illness (SDMI) in a community-based setting.  At a minimum, the following core services must be available and accessible:

                                (1)           professional consultation;

                                (2)           community-based crisis intervention;

                                (3)           therapeutic interventions;

                                (4)           medication services; and

                                (5)           psychosocial interventions.

                F.            “Deficiency” means a violation of or failure to comply with a provision(s) of these regulations

                G.            “Facility” means a building or buildings, including all branches, in which outpatient mental health services are provided to the public and which is licensed pursuant to these regulations.

                H.            “Governing body” means the governing authority of a facility, which has the ultimate responsibility for all planning, direction, control, and management of the activities and functions of a facility licensed pursuant to these regulations.

                I.             “License” means the document issued by the licensing authority pursuant to these regulations granting the legal right to operate for a specified period of time, not to exceed one year.

                J.             “Licensee” means the organization which has an ownership, leasehold, or similar interest in the facility and in whose name a license for a facility has been issued and who is legally responsible for compliance with these regulations.

                K.            “Licensing authority” means the agency within the New Mexico health care authority vested with the authority by HCA to regulate and enforce these regulations.

                L.            “Medication services” means assessing the need for psychoactive medications and management of pharmacological treatments.

                M.           “NMSA” means the New Mexico statutes annotated, 1978 compilation, and all the revisions and compilations thereof.

                N.            “Plan of correction” means the plan submitted by the licensee or representative of the licensee addressing how and when deficiencies identified at the time of a survey will be corrected.

                O.            “Policy” means a statement of principle that guides and determines present and future decisions and actions.

                P.            “Premises” means buildings, grounds, and equipment of a facility.

                Q.            “Procedure” means the action(s) that must be taken in order to implement a policy.

                R.            “Professional consultation” means the initial assessment of the client’s needs and resources, the development of the patient’s treatment plan, its monitoring and review and the access of specialized expertise to provide tests.

                S.             “Psychosocial interventions” means an array of services designed to help an individual capitalize on their personal strengths, develop coping strategies, and to develop a supportive environment in which to function as independently as possible.  This array must include, at a minimum:

                                (1)           basic living skills;

                                (2)           psychosocial skills training; and

                                (3)           therapeutic socialization.

                T.            “Psychosocial rehabilitation services” means a set of treatment strategies which help persons with mental disorders, including those with co-occurring substance abuse issues, achieve optimum functioning in the personal and social dimensions of their lives.  The treatment strategies must be rehabilitative in nature and create, sustain, and encourage empowerment through a recovery process.

                U.            “Therapeutic interventions” means interactive therapies which, when used in conjunction with other treatment strategies, assist persons with severe disabling mental illness to achieve optimum functioning in the personal and social dimensions of their lives.

                V.            “U/L approved” means approved for safety by the national underwriters laboratory.

                W.           “Variance” means to refrain from pressing or enforcing compliance with a portion or portions of these regulations for an unspecified period of time where the granting of a variance will not create a danger to the health, safety, or welfare of clients or staff of a facility, and is issued at the sole discretion of the licensing authority.

                X.            “Waive/waiver” means to refrain from pressing or enforcing compliance with a portion or portions of these regulations for a limited period of time provided the health, safety, or welfare of the clients and staff are not in danger.  Waivers are issued at the sole discretion of the licensing authority.

[8.321.6.7 NMAC - N, 7/1/2024]

 

8.321.6.8               STANDARD OF COMPLIANCE:  The degree of compliance required throughout these regulations is designated by the use of the words “shall” or “must” or “may.”  “Shall” or “must” means mandatory.  “May” means permissive.  The use of the words “adequate,” “proper,” and other similar words means the degree of compliance that is generally accepted throughout the professional field by those who provide outpatient mental health services to the public in facilities governed by these regulations.

[8.321.6.8 NMAC - N, 7/1/2024]

 

8.321.6.9               PROHIBITION ON UNLICENSED OPERATION:  These regulations apply to all community mental health centers operating within New Mexico as set out in 8.321.2 NMAC, above.  No community mental health center, or branch thereof, may operate in New Mexico without being duly licensed according to these regulations.

[8.321.6.9 NMAC - N, 7/1/2024]

 

8.321.6.10             INITIAL LICENSURE PROCEDURES:  To obtain an initial license for a facility pursuant to these regulations the following procedures must be followed by the applicant.

                A.            Application phase:  These regulations apply to the design of a new building or renovation or addition to an existing building for licensure as a facility pursuant to these regulations.  Prior to starting construction, renovations or additions to an existing building the applicant of the proposed facility shall:

                                (1)           advise the licensing authority in writing of intention to open a facility pursuant to these regulations.

                                (2)           submit a set of floor plans for the building which must be of professional quality, be on substantial paper of at least 18 inches by 24 inches, and be drawn to an accurate scale of one-quarter inch to one foot.  These plans must include:

                                                (a)           proposed use of each room e.g., waiting room, counseling/therapy room, office, et cetera;

                                                (b)           interior dimensions of all rooms;

                                                (c)           one building or wall section showing exterior and interior wall construction. Section must include floor, wall, ceiling, and the finishes, e.g., carpet, tile, gyp board with paint, wood paneling;

                                                (d)           door types, swing, and sizes of all doors, e.g. solid core, hollow core, three feet by six feet, eight inches, one and three-quarters inches thick;

                                                (e)           if the building is air-conditioned;

                                                (f)            all sinks;

                                                (g)           furnaces and hot water heaters, and if gas or electric;

                                                (h)           windows including size and type;

                                                (i)            any level changes within the building, e.g., steps or ramps;

                                                (j)            fire extinguishers, heat and smoke detectors and alarm systems;

                                                (k)           location of the building on a site/plot plan to determine surrounding conditions, include all  steps, ramps, parking areas, walks, and any permanent structures; and

                                                (l)            plans if the building is new construction, remodeled or alteration, or an addition.  If remodeled or an addition, indicate existing and new construction on the plans.

                                (3)           Blueprints or floor plans must be reviewed by the licensing authority for compliance with current licensing regulations, building and fire codes.

                                (4)           If blueprints or plans are approved, the licensing authority will advise the applicant that construction may begin.

                B.            Construction phase:  During the construction of a new building or renovations or additions to an existing building, the applicant must coordinate with the licensing authority and submit any changes to the blueprints or plans for approval before making such changes.

                C.            Licensing phase:  Prior to completion of construction, renovation or addition to an existing building, the applicant will submit to the licensing authority the following:

                                (1)           Application forms:  appropriately completed and notarized.

                                (2)           Fees:

                                                (a)           Current fee schedules must be provided by the licensing authority.

                                                (b)           Fees must be in the form of a certified check, money order, personal, or business check made payable to the state of New Mexico.

                                                (c)           Fees are non-refundable.

                                (3)           Zoning and building approval:

                                                (a)           All initial applications must be accompanied with written zoning approval from the appropriate authority (city, county or municipality).

                                                (b)           Prior to licensure, initial applicants must submit written building approval (certificate of occupancy) from the appropriate authority (city, county, or municipality).

                                (4)           Fire authority approval:  Prior to licensure, initial applicants must submit written approval of the fire authority having jurisdiction.

                                (5)           New Mexico environment department approval:  Prior to licensure, initial applicants are responsible for submission of the written approval of the New Mexico environment department for the following:

                                                (a)           private water supply, if applicable;

                                                (b)           private waste or sewage disposal, if applicable; and

                                                (c)           kitchen, if meals are prepared on site.

                                (6)           Copy of appropriate drug permit issued by the state board of pharmacy, if applicable.

                D.            Initial survey:  Upon receipt of a properly completed application with all supporting documentation as outlined above, an initial life safety code on-site survey and an on-site health survey of the proposed facility will be scheduled by the licensing authority.

                E.            Issuance of license:  Upon completion of the initial survey and determination that the facility is in compliance with these regulations, the licensing authority will issue a license.

[8.321.6.10 NMAC - N, 7/1/2024]

 

8.321.6.11             LICENSES:

                A.            Annual license:  An annual license is issued for a one year period to a facility which has met all requirements of these regulations.

                B.            Temporary license:  The licensing authority may, at its sole discretion, issue a temporary license prior to the initial survey or when it finds partial compliance with these regulations.

                                (1)           A temporary license shall cover a period of time not to exceed 120 days, during which the facility must correct all specified deficiencies.

                                (2)           In accordance with Subsection D of Section 24-1-5 NMSA 1978, no more than two consecutive temporary licenses shall be issued.

                C.            Amended license:  A licensee must apply to the licensing authority for an amended license when there is a change of administrator/director or when there is a change of name for the facility.

                                (1)           Application must be on a form provided by the licensing authority.

                                (2)           Application must be accompanied by the required fee for amended license.

                                (3)           Application must be submitted within 10 working days of the change.

[8.321.6.11 NMAC - N, 7/1/2024]

 

8.321.6.12             LICENSE RENEWAL:

                A.            Licensee must submit a renewal application on forms provided by the licensing authority, along with the required fee at least 30 days prior to expiration of the current license.

                B.            Upon receipt of renewal application and required fee prior to expiration of their current license, the licensing authority will issue a new license effective the day following the date of expiration of the current license if the facility is in compliance with these regulations.

                C.            If a licensee fails to submit a renewal application with the required fee and the current license expires, the facility shall cease operations until it obtains a new license through the initial licensure procedures.  Subsection A of Section 24-1-5 NMSA 1978, as amended, provides that no health facility shall be operated without a license.

[8.321.6.12 NMAC - N, 7/1/2024]

 

8.321.6.13             POSTING OF LICENSE:  The facility's license must be posted on the licensed premises in an area visible to the public.

[8.321.6.13 NMAC - N, 7/1/2024]

 

8.321.6.14             NON-TRANSFERABLE RESTRICTION OF LICENSE:  A license shall not be transferred by assignment, or otherwise, to other persons or locations. The license shall be void and must be returned to the licensing authority when any one of the following situations occur:

                A.            ownership of the facility changes;

                B.            the facility changes location;

                C.            licensee of the facility changes;

                D.            the facility discontinues operation; or

                E.            a facility wishing to continue operation as a licensed facility under circumstances in Subsections A - D of 8.321.6.14 NMAC, above must submit an application for initial licensure in accordance with 8.321.10 NMAC of these regulations at least 30 days prior to the anticipated change.

[8.321.6.14 NMAC - N, 7/1/2024]

 

8.321.6.15             AUTOMATIC EXPIRATION OF LICENSE:  A license will automatically expire at midnight on the day indicated on the license as the expiration date, unless renewed, suspended, or revoked, or

                A.            on the day a facility discontinues operation;

                B.            on the day a facility is sold, leased, or otherwise changes ownership or licensee; or

                C.            on the day a facility changes location.

[8.321.6.15 NMAC - N, 7/1/2024]

 

8.321.6.16             SUSPENSION OF LICENSE WITHOUT PRIOR HEARING:  In accordance with Subsection H of Section 24-1-5 NMSA 1978, if immediate action is required to protect human health and safety, the licensing authority may suspend a license pending a hearing, provided such hearing is held within five working days of the suspension, unless waived by the licensee.

[8.321.6.16 NMAC - N, 7/1/2024]

 

8.321.6.17             GROUNDS FOR REVOCATION OR SUSPENSION OF LICENSE, DENIAL OF INITIAL OR RENEWAL APPLICATION FOR LICENSE, OR IMPOSITION OF INTERMEDIATE ACTIONS OR CIVIL MONETARY PENALTIES:  A license may be revoked or suspended, an initial or renewal application for license may be denied, or intermediate sanctions or civil monetary penalties may be imposed after notice and opportunity for a hearing, for any of the following:

                A.            failure to comply with any provision of these regulations;

                B.            failure to allow survey by authorized representatives of the licensing authority;

                C.            allowing any person active in the operation of a facility licensed pursuant to these regulations to be under the influence of, or impaired by, alcohol or other behavior altering substances;

                D.            misrepresentation or falsification of any information on application forms or other documents provided to the licensing authority;

                E.            repeated violations of these regulations; or

                F.            failure to provide the required care and services as outlined by these regulations for the clients receiving care at the facility.

[8.321.6.17 NMAC - N, 7/1/2024]

 

8.321.6.18             HEARING PROCEDURES:

                A.            Hearing procedures for an administrative appeal of an adverse action taken by the licensing authority against a facility's license as outlined in Section 16 and 17 above will be held in accordance with adjudicatory hearings, New Mexico health care authority, 8.370.2 NMAC.

                B.            A copy of the above regulations will be furnished to a facility at the time an adverse action is taken against its license by the licensing authority.  A copy may be requested at any time by contacting the licensing authority.

[8.321.6.18 NMAC - N, 7/1/2024]

 

8.321.6.19                             LICENSED FACILITIES:

                A.            Any community mental health center, currently licensed as a limited diagnostic and treatment center on the date these regulations are promulgated and which provides the services prescribed under these regulations, may continue to be licensed as such until that license expires and renewal is required.  At that time, the facility must seek licensure as a community mental health center.

                B.            Any community mental health center, not currently licensed on the date these regulations are promulgated and which provides the services prescribed under these regulations, must seek licensure as a community mental health center.

                                (1)           Community mental health centers may seek variances for those building requirements the facility cannot meet under the criteria outlined in these regulations if not in conflict with existing building and fire codes.

                                (2)           Variances or waivers may be considered for circumstances where the facility demonstrates an extreme financial hardship to comply with requirements outlined in these regulations.

[8.321.6.19 NMAC - N, 7/1/2024]

 

8.321.6.20             NEW FACILITY:  A new facility may be opened in an existing building or a newly constructed building.

                A.            If opened in an existing building, a variance may be granted for those building requirements the facility cannot meet under the criteria outlined in these regulations if not in conflict with existing building and fire codes.  This is at the sole discretion of the licensing authority.

                B.            A new facility opened in a newly constructed building must meet all requirements of these regulations.

[8.321.6.20 NMAC - N, 7/1/2024]

 

8.321.6.21             FACILITY SURVEYS:

                A.            Application for licensure, whether initial or renewal, shall constitute permission for entry into, and survey of, a facility by authorized licensing authority representatives at reasonable times during the status of the application and, if licensed, during the licensure period.

                B.            Surveys may be announced or unannounced at the sole discretion of the licensing authority.

                C.            Upon receipt of a written notice of deficiency from the licensing authority, the licensee, or their representative, will be required to submit a plan of correction to the licensing authority within 10 working days stating how the facility intends to correct each violation noted and the expected date of correction.

                D.            The licensing authority may at its sole discretion accept the plan of correction as written or require modifications of the plan by the licensee.

[8.321.6.21 NMAC - N, 7/1/2024]

 

8.321.6.22             REPORTING OF INCIDENTS:  All facilities licensed pursuant to these regulations must report incidents in accordance with the policies established by the division of health improvement of the authority.

[8.321.6.22 NMAC - N, 7/1/2024]

 

8.321.6.23             QUALITY ASSURANCE:  All facilities licensed pursuant to these regulations must be in compliance with the quality assurance standards established by the division of health improvement of the authority.

[8.321.6.23 NMAC - N, 7/1/2024]

 

8.321.6.24                             CLIENT RECORDS:  Each facility licensed pursuant to these regulations must maintain a record for each client in accordance with the client record standards set forth by the division of health improvement of the authority.

[8.321.6.24 NMAC - N, 7/1/2024]

 

8.321.6.25                             REPORTS AND RECORDS REQUIRED TO BE ON FILE IN THE FACILITY:  Each facility licensed pursuant to these regulations must keep the following reports and records on file and make them available for review upon request of the licensing authority:

                A.            a copy of the latest fire inspection report by the fire authority having jurisdiction;

                B.            a copy of the last survey conducted by the licensing authority and any variances granted;

                C.            record of fire and emergency evacuation drills conducted by the facility;

                D.            licensing regulations:  A copy of these regulations;

                E.            a copy of the current license, registration or certificate, of each staff member for which a license, registration, or certification is required by the state of New Mexico; facilities with satellite or branch locations that maintain personnel records in a central location may make arrangements with licensing authority inspectors for viewing such records.

                F.            valid drug permit as required by the state board of pharmacy; and

                G.            New Mexico environment department approval of private water system and private waste or sewage disposal, if applicable.

[8.321.6.25 NMAC - N, 7/1/2024]

 

8.321.6.26                             CLIENT RIGHTS:  All facilities licensed pursuant to these regulations shall support, protect and enhance the rights of clients in accordance with the standards set forth by the division of health improvement of the authority.

[8.321.6.26 NMAC - N, 7/1/2024]

 

8.321.6.27                             STAFF RECORDS:  Each facility licensed pursuant to these regulations must maintain a complete record on file for each staff member or volunteer working more than half-time.  Staff records will be made available for review upon request of the licensing authority.

                A.            Staff records will contain at least the following:

                                (1)           name;

                                (2)           address and telephone number;

                                (3)           position for which employed;

                                (4)           date of employment; and

                                (5)           health certificate stating that the employee is free from tuberculosis in a transmissible form as required by New Mexico health care authority regulations, control of communicable disease in health facility personnel, 7.4.4 NMAC.

                B.            A daily attendance record of all staff must be kept in the facility.

                C.            The facility must keep weekly or monthly schedules of all staff.  These schedules must be kept on file for at least six months.

[8.321.6.27 NMAC - N, 7/1/2024]

 

8.321.6.28             POLICIES AND PROCEDURES:  All community mental health centers licensed pursuant to these regulations must have written policies and procedures in accordance with the standards set forth by the division of health improvement of the authority.

[8.321.6.28 NMAC - N, 7/1/2024]

 

8.321.6.29                             GENERAL BUILDING REQUIREMENTS:

                A.            New construction, additions and alterations:  When construction of new buildings, additions, or alterations to existing buildings are contemplated, plans and specifications covering all portions of the work must be submitted to the licensing authority for plan review and approval prior to beginning actual construction.  When an addition or alteration is contemplated, plans for the entire facility must be submitted.

                B.            Access to the disabled:  Community mental health centers licensed pursuant to these regulations must be accessible to and useable by disabled employees, staff, visitors, and clients.

                C.            Extent of a facility:  All buildings of the premises providing client care and services will be considered part of the facility and must meet all requirements of these regulations.  Where a part of the facility services are contained in another facility, separation and access shall be maintained as described in current building and fire codes.

                D.            Additional requirements:  A facility applying for licensure pursuant to these regulations may have additional requirements not contained herein.  The complexity of building and fire codes and requirements of city, county, or municipal governments may stipulate these additional requirements.  Any additional requirements will be outlined by the appropriate building and fire authorities, and by the licensing authority through plan review, consultation and on-site surveys during the licensing process.

[8.321.6.29 NMAC - N, 7/1/2024]

 

8.321.6.30             MAINTENANCE OF BUILDING AND GROUNDS:  Facilities must maintain the building(s) in good repair at all times. Such maintenance shall include, but is not limited to, the following:

                A.            all electrical, mechanical, water supply, heating, fire protection, and sewage disposal systems must be maintained in a safe and functioning condition, including regular inspections of these systems;

                B.            all equipment and materials used for client care shall be maintained clean and in good repair;

                C.            all furniture and furnishings must be kept clean and in good repair; and

                D.            the grounds of the facility must be maintained in a safe and sanitary condition at all times.

[8.321.6.30 NMAC - N, 7/1/2024]

 

8.321.6.31             HOUSEKEEPING:

                A.            The facility must be kept free from offensive odors and accumulations of dirt, rubbish, dust, and safety hazards.

                B.            Counseling/therapy rooms, waiting areas and other areas of daily usage must be cleaned as needed to maintain a clean and safe environment for the clients.

                C.            Floors and walls must be constructed of a finish that can be easily cleaned.  Floor polishes shall provide a slip resistant finish.

                D.            Deodorizers must not be used to mask odors caused by unsanitary conditions or poor housekeeping practices.

                E.            Storage areas must be kept free from accumulation of refuse, discarded equipment, furniture, paper, et cetera.

[8.321.6.31 NMAC - N, 7/1/2024]

 

8.321.6.32             WATER:

                A.            A facility licensed pursuant to these regulations must be provided with an adequate supply of water that is of a safe and sanitary quality suitable for domestic use.

                B.            If the water supply is not obtained from an approved public system, the private water system must be inspected, tested, and approved by the New Mexico environment department prior to licensure.  It is the facility's responsibility to insure that subsequent periodic testing or inspection of such private water systems be made at intervals prescribed by the New Mexico environment department or recognized authority.

                C.            Hot and cold running water under pressure must be distributed at sufficient pressure to operate all fixtures and equipment during maximum demand periods

                D.            Back flow preventers (vacuum breakers) must be installed on hose bibbs, laboratory sinks, janitor's sinks, and on all other water fixtures to which hoses or tubing can be attached.

                E.            Water distribution systems are arranged to provide hot water at each hot water outlet at all times. Hot water to hand washing facilities must not exceed 120 degrees F.

[8.321.6.32 NMAC - N, 7/1/2024]

 

8.321.6.33             SEWAGE AND WASTE DISPOSAL:

                A.            All sewage and liquid wastes must be disposed of into a municipal sewage system where such facilities are available.

                B.            Where a municipal sewage system is not available, the system used must be inspected and approved by the New Mexico environment department or recognized local authority.

                C.            Where municipal or community garbage collection and disposal service are not available, the method of collection and disposal of solid wastes generated by the facility must be inspected and approved by the New Mexico environment department or recognized local authority.

                D.            All garbage and refuse receptacles must be durable, have tight fitting lids, must be insect and rodent proof, washable, leak proof and constructed of materials which will not absorb liquids.  Receptacles must be kept clean.

[8.321.6.33 NMAC - N, 7/1/2024]

 

8.321.6.34             FIRE SAFETY COMPLIANCE:  All current applicable requirement of state and local codes for fire prevention and safety must be met by the facility.

[8.321.6.34 NMAC - N, 7/1/2024]

 

8.321.6.35             FIRE CLEARANCE AND INSPECTIONS:  Each facility must request from the fire authority having jurisdiction an annual fire inspection. If the policy of the fire authority having jurisdiction does not provide for annual inspection of the facility, the facility must document the date the request was made and to whom.  If the fire authorities do make annual inspections, a copy of the latest inspection must be kept on file in the facility.

[8.321.6.35 NMAC - N, 7/1/2024]

 

8.321.6.36             STAFF FIRE AND SAFETY TRAINING:

                A.            All staff of the facility must know the location of, and be instructed in, proper use of fire extinguishers and other procedures to be observed in case of fire or other emergencies.  The facility should request the fire authority having jurisdiction to give periodic instruction in fire prevention and techniques of evacuation.

                B.            Facility staff must be instructed as part of their duties to constantly strive to detect and eliminate potential safety hazards such as frayed electrical cords, faulty equipment, blocked exits or exit pathways and any other condition which could cause burns, falls, or other personal injury to the clients or staff.

[8.321.6.36 NMAC - N, 7/1/2024]

 

8.321.6.37             EVACUATION PLAN:  Each facility must have a fire evacuation plan posted in each separate area of the building showing routes of evacuation in case of fire or other emergency.

[8.321.6.37 NMAC - N, 7/1/2024]

 

8.321.6.38             PROVISIONS FOR EMERGENCY CALLS:  An easily accessible telephone for summoning help, in case of emergency, must be available in the facility.

[8.321.6.38 NMAC - N, 7/1/2024]

 

8.321.6.39             FIRE EXTINGUISHERS:

                A.            Fire extinguishers as approved by the state fire marshal or fire prevention authority having jurisdiction must be located in the facility.

                B.            Fire extinguishers must be properly maintained as recommended by the manufacturer, state fire marshal or fire authority having jurisdiction.

                C.            All fire extinguishers must be inspected yearly and recharged as specified by the manufacturer, state fire marshal, or fire authority having jurisdiction. All fire extinguishers must be tagged, noting the date of inspection.

[8.321.6.39 NMAC - N, 7/1/2024]

 

8.321.6.40             ALARM SYSTEM:  A manually operated, electrically supervised fire alarm system shall be installed in each facility only as required by national fire protection association (NFPA) 101 (Life Safety Code).  Multiple story facilities do require manual alarm systems.

[8.321.6.40 NMAC - N, 7/1/2024]

 

8.321.6.41             FIRE DETECTION SYSTEM:  The facility must be equipped with smoke detectors as required by the NFPA 101 (Life Safety Code) and approved in writing by the fire authority having jurisdiction as to number, type and placement.

[8.321.6.41 NMAC - N, 7/1/2024]

 

8.321.6.42             JANITOR’S CLOSET(S):

                A.            Each facility shall have at least one janitor's closet.

                B.            Each janitor's closet shall contain:

                                (1)           a service sink; and

                                (2)           storage for housekeeping supplies and equipment.

                C.            Each janitor's closet must be vented.

                D.            Janitor closets are hazardous areas and must be provided with one hour fire separation and one and three-quarters inches solid core doors which are rated at a 20 minute fire protection rating.

[8.321.6.42 NMAC - N, 7/1/2024]

 

8.321.6.43             EMERGENCY LIGHTING:

                A.            A facility must be provided with emergency lighting that will activate automatically upon disruption of electrical service.

                B.            The emergency lighting must be sufficient to illuminate paths of egress and exits of the facility.

[8.321.6.43 NMAC - N, 7/1/2024]

 

8.321.6.44             ELECTRICAL STANDARDS:

                A.            All electrical installation and equipment must comply with all current state and local codes.

                B.            Circuit breakers or fused switches that provide electrical disconnection and over current protection shall be:

                                (1)           enclosed or guarded to provide a dead front assembly;

                                (2)           readily accessible for use and maintenance;

                                (3)           set apart from traffic lanes;

                                (4)           located in a dry, ventilated space, free of corrosive fumes or gases;

                                (5)           able to operate properly in all temperature conditions.

                                (6)           Panel boards servicing lighting and appliance circuits shall be on the same floor and in the same facility area as the circuits they serve.

                                (7)           each panel board will be marked showing the services; and

                                (8)           the use of jumpers or devices to bypass circuit breakers or fused switches is prohibited.

[8.321.6.44 NMAC - N, 7/1/2024]

 

8.321.6.45             LIGHTING:

                A.            All spaces occupied by people, machinery, or equipment within buildings, approaches to buildings, and parking lots shall have lighting.

                B.            Lighting will be sufficient to make all parts of the area clearly visible.

                C.            All lighting fixtures must be shielded.

                D.            Lighting fixtures must be selected and located with the comfort and convenience of the staff and clients in mind.

[8.321.6.45 NMAC - N, 7/1/2024]

 

8.321.6.46             ELECTRICAL CORDS AND RECEPTACLES:

                A.            Electrical cords and extension cords:

                                (1)           Electrical cords and extension cords must be U/L approved.

                                (2)           Electrical cords and extension cords must be replaced as soon as they show wear.

                                (3)           Under no circumstances shall extension cords be used as a general wiring method.

                                (4)           Extension cords must be plugged into an electrical receptacle within the room where used and must not be connected in one room and extended to some other room.

                                (5)           Extension cords must not be used in series.

                B.            Electrical receptacles:

                                (1)           Duplex-grounded type electrical receptacles (convenience outlets) must be installed in all areas in sufficient quantities for tasks to be performed as needed. Each examination must have access to a minimum of two duplex receptacles.

                                (2)           The use of multiple sockets (gang plugs) in electrical receptacles is strictly prohibited.

[8.321.6.46 NMAC - N, 7/1/2024]

 

8.321.6.47             HEATING, VENTILATION, AND AIR-CONDITIONING:

                A.            Heating, air-conditioning, piping, boilers, and ventilation equipment must be furnished, installed and maintained to meet all requirements of current state and local mechanical, electrical, and construction codes.

                B.            The heating method used by the facility must have a minimum indoor-winter-design-capacity of 75 degrees F. with controls provided for adjusting temperature as appropriate for client and staff comfort.

                C.            The use of non-vented heaters, open flame heaters or portable heaters is prohibited.

                D.            An ample supply of outside air must be provided in all spaces where fuel fired boilers, furnaces, or heaters are located to assure proper combustion.

                E.            All fuel fired boilers, furnaces, or heaters must be connected to an approved venting system to take the products of combustion directly to the outside air.

                F.            A facility must be adequately ventilated at all times to provide fresh air and the control of unpleasant odors.

                G.            All gas-fired heating equipment must be provided with a one hundred percent automatic cutoff control valve in event of pilot failure.

                H.            The facility must be provided with a system for maintaining clients and staff's comfort during periods of hot weather.

                I.             All boiler, furnace or heater rooms shall be protected from other parts of the building by construction having a fire resistance rating of not less than one hour.  Door must be self-closing with three-quarters of an hour fire resistance.

[8.321.6.47 NMAC - N, 7/1/2024]

 

8.321.6.48             WATER HEATERS:

                A.            Must be able to supply hot water to all hot water taps within the facility at full pressure during peak demand periods and maintain a maximum temperature of 120 degrees F.

                B.            Fuel fired hot water heaters must be enclosed and separated from other parts of the building by construction as required by current state and local building codes.

                C.            All water heaters must be equipped with a pressure relief valve (pop-off valve).

[8.321.6.48 NMAC - N, 7/1/2024]

 

8.321.6.49                             TOILETS AND LAVATORIES:

                A.            All fixtures and plumbing must be installed in accordance with current state and local plumbing codes.

                B.            All toilets must be enclosed and vented.

                C.            All toilet rooms must be provided with a lavatory for hand washing.

                D.            All toilets must be kept supplied with toilet paper.

                E.            All lavatories for hand washing must be kept supplied with disposable towels for hand drying or provided with mechanical blower

                F.            The number of and location of toilets and lavatories will be mandated by requirements for each type facility.  Such factors as extent of services provided and size of facility will also dictate requirements.

[8.321.6.49 NMAC - N, 7/1/2024]

 

8.321.6.50             EXITS:

                A.            Each facility and each floor of a facility shall have exits as required by national fire protection association 101 (Life Safety Code).

                B.            Each exit must be marked by illuminated signs having letters at least six inches high whose principle strokes are at least three-quarters of an inch wide.

                C.            Illuminated exit signs must be maintained in operable condition at all times.

                D.            Exit ways must be kept free from obstructions at all times.

                E.            Exit doors to exit or exit access doors must be at least 36 inches wide.

[8.321.6.50 NMAC - N, 7/1/2024]

 

8.321.6.51             CORRIDORS:

                A.            Minimum corridor width shall be five feet except work corridors less than six feet in length may be four feet in width.

                B.            Facilities will often be contained within existing commercial or residential buildings and less stringent corridor widths may be allowed other than those contained in Subsection A of 8.321.51 NMAC, above if not in conflict with building or fire codes and approved by the licensing authority prior to occupying the licensed part of the building.

[8.321.6.51 NMAC - N, 7/1/2024]

 

8.321.6.52             DOORS:

                A.            The minimum door width for client's use shall be 34 inches in width.

                B.            Rooms where client treatment takes place shall have a minimum door width of 36 inches.

[8.321.6.52 NMAC - N, 7/1/2024]

 

8.321.6.53             COMMON ELEMENTS FOR FACILITIES:

                A.            Entrance shall be able to accommodate wheelchairs.

                B.            Public services shall include:

                                (1)           conveniently accessible wheelchair storage;

                                (2)           a reception and information counter or desk;

                                (3)           waiting areas;

                                (4)           conveniently accessible public toilets; and

                                (5)           drinking fountain(s) easily accessible to clients or other visitors.

                C.            Interview space(s) for private interviews related to mental health, medical information, etc., shall be provided.

                D.            General or individual office(s) for business transactions, records, administrative, and professional staff shall be provided.  These areas shall be separated from public areas for confidentiality.

                E.            Special storage for staff personal effects with locking drawers or cabinets shall be provided.

                F.            General storage facilities for supplies and equipment shall be provided.

                G.            Drug distribution stations shall be in accordance with standards set forth by the New Mexico board of pharmacy.

[8.321.6.53 NMAC - N, 7/1/2024]

 

8.321.6.54             FLOORS AND WALLS:

                A.            Floor and wall areas penetrated by pipes, ducts, and conduits shall be tightly sealed to minimize entry of rodents and insects.  Joints of structural elements shall be similarly sealed.

                B.            Threshold and expansion joint covers shall be flush with the floor surface to facilitate use of wheelchairs and carts.

[8.321.6.54 NMAC - N, 7/1/2024]

 

8.321.6.55             GOVERNING BODY:  All facilities licensed pursuant to these regulations must have a governing body that assumes full legal responsibility for determining, implementing, and monitoring policies governing the total operation of the facility.  The governing body must ensure that these policies are administered so as to provide quality health care in a safe environment.  When services are provided through a contract with an outside resource, the governing body is responsible for assuring that these services are provided in a safe and effective manner.

[8.321.6.55 NMAC - N, 7/1/2024]

 

8.321.6.56             ADMINISTRATOR/DIRECTOR/MANAGER:  Each facility must have an administrator, director or manager hired or appointed by the governing body to whom authority has been delegated to manage the daily operation of the facility and implement the policies and procedures adopted by the governing body.

[8.321.6.56 NMAC - N, 7/1/2024]

 

8.321.6.57             STAFF EVALUATION AND DEVELOPMENT:  A facility licensed pursuant to these regulations must be in compliance with staff evaluation and development standards set forth by the division of health improvement of the authority.

[8.321.6.57 NMAC - N, 7/1/2024]

 

8.321.6.58             DIRECT SERVICE STAFF:  A facility licensed pursuant to these regulations must be in compliance with direct service staff standards set forth by the division of health improvement of the authority.

[8.321.6.58 NMAC - N, 7/1/2024]

 

8.321.6.59             EMERGENCY MEDICAL SERVICES:  Each facility licensed pursuant to these regulations must maintain a list of emergency phone numbers co-located with telephones in the facility.  This list must include fire and police departments, ambulance or EMS crew numbers, the New Mexico poison control center and the nearest hospital.

[8.321.6.59 NMAC - N, 7/1/2024]

 

8.321.6.60             HOURS OF OPERATION:  Each facility licensed pursuant to these regulations must post its hours of operation where it can clearly seen by clients and visitors.

[8.321.6.60 NMAC - N, 7/1/2024]

 

8.321.6.61             PHARMACEUTICAL SERVICES:

                A.            Drugs must be stored, prepared and administered in accordance to acceptable standards of practice and in compliance with the New Mexico state board of pharmacy.

                B.            Outdated drugs and biologicals must be disposed of in accordance with methods outlined by the New Mexico state board of pharmacy.

                C.            One individual shall be designated responsibility for pharmaceutical services to include accountability and safeguarding.

                D.            Keys to the drug room or pharmacy must be made available only to personnel authorized by the individual having responsibility for pharmaceutical services.

                E.            Adverse reactions to medications must be reported to the physician responsible for the client and must be documented in the client's record.

[8.321.6.61 NMAC - N, 7/1/2024]

 

8.321.6.62             LABORATORY SERVICES:

                A.            All lab test results performed either at the facility or by contract or arrangement with another entity must be entered into the client’s record.

                B.            All laboratory procedures including specimen collection will be conducted in accordance with acceptable standards of practice.  A CLIA certificate will be appropriately maintained if so required by federal CLIA standards.

[8.321.6.62 NMAC - N, 7/1/2024]

 

8.321.6.63                             RELATED REGULATIONS AND CODES:  Facilities or agencies subject to these regulations are also subject to other regulations, codes and standards as the same may from time to time be amended as follows.

                A.            Health facility licensure fees and procedures, New Mexico health care authority, 8.370.3 NMAC;

                B.            Health facility sanctions and civil monetary penalties, 8.370.4 NMAC; and

                C.            Adjudicatory hearings, New Mexico health care authority, 8.370.2 NMAC.

[8.321.6.63 NMAC - N, 7/1/2024]

 

HISTORY OF 8.321 NMAC:  [RESERVED]