TITLE 8 SOCIAL SERVICES
CHAPTER 321 SPECIALIZED BEHAVIORAL HEALTH SERVICES
PART 11 CRISIS TRIAGE CENTERS
8.321.11.1 ISSUING AGENCY: New Mexico Health Care Authority.
[8.321.11.1
NMAC - N, 7/1/2024]
8.321.11.2 SCOPE: These regulations apply to public, profit and
not for profit crisis triage centers providing the services specified in these
regulations. Any crisis triage center
providing services specified in these regulations must be licensed under these
regulations.
[8.321.11.2
NMAC - N, 7/1/2024]
8.321.11.3 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 NMSA 1978. Section 9-8-1 et seq. NMSA 1978 establishes the health care
authority (authority) as a single, unified department to administer laws and
exercise functions relating to health care purchasing and regulation.
[8.321.11.3
NMAC - N, 7/1/2024]
8.321.11.4 DURATION: Permanent.
[8.321.11.4
NMAC - N, 7/1/2024]
8.321.11.5 EFFECTIVE DATE: July 1, 2024, unless a later date is cited at
the end of a section.
[8.321.11.5
NMAC - N, 7/1/2024]
8.321.11.6 OBJECTIVE:
A. To establish minimum standards for
licensing crisis triage centers that provide quality crisis stabilization
services outside of a hospital setting.
B. To ensure the provision of quality
services which maintain or improve the health and quality of life to the
clients.
C. To monitor compliance under these
regulations through surveys and to identify any facility areas which could be
dangerous or harmful.
[8.321.11.6
NMAC - N, 7/1/2024]
8.321.11.7 DEFINITIONS:
A. Definitions
beginning with “A”:
(1) “Administrator” means the person
who is delegated the administrative responsibility for interpreting,
implementing, and applying policies and procedures at the crisis triage
center. The administrator is responsible
for establishing and maintaining safe and effective management, control and
operation of the CTC and all of the services provided at the CTC including
fiscal management. The administrator
must meet the minimum administrator qualifications in these regulations.
(2) “Advanced practice registered nurse” means a
registered nurse that includes a certified nurse practitioner, or a clinical
nurse specialist as defined and licensed under the Nursing Practice Act, as
amended, and related regulations, and is currently in good standing.
(3) “Applicant”
means the individual or legal entity that applies for a CTC license to provide
services in a particular facility. If
the applicant is a legal entity, the individual signing the license application
on behalf of the legal entity must have written legal authority from the legal
entity to act on its behalf and execute the application. The license applicant must be the legal owner
of the entity providing services, but not necessarily the facility.
B. Definitions
beginning with “B”: “Basic life support” (BLS) means training
and current certification in adult cardiopulmonary resuscitation equivalent to
American heart association class C basic life support and in emergency
treatment of a victim of cardiac or respiratory arrest through cardiopulmonary
resuscitation and emergency cardiac care.
C. Definitions
beginning with “C”:
1) “Caregivers
criminal history screen” means pursuant to the criminal history screening for
Caregivers Act, Section 29-17-1 through Section 29-17-5 NMSA 1978, the process
for health facilities and medicaid home and community-based waiver providers to
complete a caregiver criminal history screening for all caregivers no later
than 20 calendar days after the employment hire date. The screening or background check includes
the submission of fingerprints required for obtaining state and federal
criminal history used to conduct the fitness determination. The caregiver’s criminal history screening
program receives and processes background check applications for criminal
history screenings from care providers in the state of New Mexico. Caregivers may be prohibited from employment
if the caregiver has a disqualifying condition.
(2) “Chemical
restraint”
means a drug or medication when it is used as a restriction to manage a
client’s behavior or restrict a client’s freedom of movement and is not a
standard treatment or dosage for a client’s condition. If a drug or medication is used as a standard
treatment to address the assessed current symptoms and needs of a client with a
particular medical or psychiatric condition, its use is not considered a
chemical restraint.
(3) “CLIA”
means clinical laboratory improvement amendments of 1988 as amended.
(4) “Client”
means any person who receives care at a crisis triage center.
(5) “Compliance”
means the CTC’s adherence to these regulations, as well as all other applicable
state and federal statutes and regulations.
Compliance violations may result in sanctions, civil monetary penalties
and revocation or suspension of the CTC license.
(6) “Crisis
stabilization services” means behavioral health services that are provided
to help the client return his baseline level of functioning before the crisis.
(7) “Crisis triage center” means a health facility that:
(a) is licensed by the health care
authority; and
(b) provides stabilization of behavioral
health crises and may include residential and nonresidential stabilization.
(8) “CYFD”
means the New Mexico children youth and families department.
(9) “CYFD
criminal records and background checks” means pursuant to the Criminal
Offender Employment Act, Section 28-2-1 to Section 28-2-6 NMSA 1978, the New
Mexico Children’s and Juvenile Facility Criminal Records Screening Act, Section
32A-15-1 to Section 32A-15-4 NMSA 1978, amended, and 8.8.3 NMAC, the process of
conducting a nationwide criminal history records check, background check and
employment history verification on all operators, staff and employees and
prospective operators, staff and employees of treatment facilities and programs
with the objective of protecting children/youth and promoting the
children's/youth’s safety and welfare while receiving service from the
facilities and programs. The process
shall include submission of electronic fingerprints for those individuals to
the department of public safety and the federal bureau of investigation for the
purpose of conducting a criminal history and background check; identification
of information in applicants’ background bearing on whether they are eligible
to provide services; a screening of CYFD’s information databases in New Mexico
and in each state where the applicant resided during the preceding five years;
and any other reasonably reliable information about an applicant in order to
identify those persons who pose a continuing threat of abuse or neglect to care
recipients in settings to which these regulations apply.
D. Definitions
beginning with “D”:
(1) “Deficiency”
means a violation of or failure to comply with any provision(s) of these
regulations.
E. Definitions beginning with
“E”: “Employee” means any person
who works at the CTC and is a direct hire of the owner entity or management
company, if applicable.
F. Definitions beginning with “F”: “Facility” means the
physical premises, building(s) and equipment where the crisis triage center
services are provided, whether owned or leased and which is licensed pursuant
to these regulations.
G. Definitions
beginning with “G”: [RESERVED]
H. Definitions
beginning with “H”:
(1) “HCA”
means the New Mexico health care authority.
(2) “High
risk behavior” means behaviors that place clients, staff or visitors’
physical and mental health and safety at risk.
I. Definitions beginning with “I”:
(1) “Incident”
means any known, alleged or suspected event of abuse, neglect, exploitation,
injuries of unknown origin or other reportable incidents.
(2) “Incident
management system” means the written policies and procedures adopted or
developed by the CTC for reporting abuse, neglect, exploitation, injuries of
unknown origin or other reportable incidents.
(3) “Incident
report form” means the reporting format issued by the authority for the
reporting of incidents or complaints.
J. Definitions
beginning with “J”: [RESERVED]
K. Definitions beginning with “K”: [RESERVED]
L. Definitions
beginning with “L”:
(1) “Level
III.7-D: Medically monitored inpatient
detoxification” means the types of detoxification services described by American
Society of Addiction Medicine (ASAM) in its Patient Placement Criteria,
Second Edition, Revised (PPC-2R) Level III &-D includes 24-hour
medically supervised detoxification services requiring 24-hour nursing care and
physician visits as necessary, unlikely to complete detox, without medical,
nursing monitoring and more intensive detoxification services.
(2) “Licensee”
means the person(s) or legal entity that operates the CTC and in whose name the
CTC license has been issued and who is legally responsible for compliance with
these regulations.
(3) “Licensing
authority” means the New Mexico health care authority.
(4) “Licensed
mental health professional” means a psychologist, social worker, physician,
psychiatrist, physician assistant, registered nurse, practical nurse, advanced
practice registered nurse, each shall have behavioral health training and shall
be licensed in the state of New Mexico.
M. Definitions
beginning with “M”:
“Management company” means the legal
entity that manages the CTC program, if different from the legal owner of the
facility.
N. Definitions beginning with “N”:
(1) “NFPA”
means the national fire protection association which sets codes and standards
for fire and life safety. NFPA 11 and
related standards, current edition as required by the authority.
(2) “NMSA”
means the New Mexico Statutes Annotated 1978 compilation and all subsequent
amendments, revisions and compilations.
O. Definitions beginning with “O”:
(1) “Onsite medical professional”
means in this regulation a registered nurse, emergency medical service
provider, emergency medical technician, licensed practical nurse, medical
assistant, mental health technician, and certified nurse assistant.
(2) “Outpatient
services” means immediate crisis stabilization services provided to clients
who are not admitted to the residential setting. Outpatient crisis stabilization services are
not ongoing behavioral health treatment services.
P. Definitions beginning with “P”:
(1) “Physical
restraint” means the use of physical force, consistent with state and federal
laws and regulations, without the use of any device or material that restricts
the free movement of all or a portion of a body, but does not include: briefly holding a client in order to calm or
comfort the client; holding a client's hand or arm to escort the client safely
from one area to another; or intervening in a physical fight.
(2) “Physician”
means a licensed individual, currently in good standing, authorized to practice
medicine as defined and licensed under the New Mexico Medical Practice Act,
Section 61-6-1 to Section 61-6-34 NMSA 1978, as amended, and related
regulations or osteopathic medicine as defined and licensed under Section
61-10-1 to Section 61-10-22 NMSA 1978, as amended, and related regulations.
(3) “Physician's
assistant” means an individual, currently in good standing, who is licensed
and authorized to provide services to patients under the supervision and
direction of a licensed physician under the Physician Assistant Act, Section
61-6-7 to Section 61-6-10 NMSA 1978, as amended and related regulations, or is
authorized and licensed to provide services to patients under the supervision
and direction of a licensed osteopathic physician under the Osteopathic
Physicians' Assistants Act, Section 61-10A-1 to Section 61-10-7 NMSA 1978 as
amended, and related regulations.
(4) “Plan
of correction” (POC) means the plan submitted by the licensee or its
representative(s) addressing how and when deficiencies identified through a
survey or investigation will be corrected.
A plan of correction is a public
record once it has been approved by the regulatory authority and is admissible
for all purposes in any adjudicatory hearing and all subsequent appeals
relating to a CTC license, including to prove licensee compliance violations or
failures.
(5) “Policy”
means a written statement that guides and determines present and future CTC
decisions and actions.
(6) “Premises”
means all of the CTC including buildings, grounds and equipment.
(7) “Primary
source verification” means the act of obtaining credentials directly from
the original or primary source(s).
(8) “Procedure”
means the action(s) that must be taken in order to implement a written policy.
Q. Definitions
beginning with “Q”:
(1) “Quality assurance”
means the CTC’s on-going comprehensive self-assessment of compliance with these
regulations and other applicable statutes and regulations.
(2) “Quality committee”
means a committee comprised at a minimum of the administrator, clinical
director, director of nursing, licensed mental health professional, and
psychiatrist. Other committee members
may be specified by rules governing payor requirements. The committee shall establish and implement
quality assurance and quality improvement systems that monitor and promote
quality care to clients.
(3) “Quality
improvement system” means systematic and continuous actions that lead to
measurable improvement in services and focus on reduction and stabilization of
crises for clients.
R. Definitions
beginning with “R”:
(1) “Registered nurse”
means an individual, currently in good standing, who is licensed and authorized
to provide nursing services under the Nursing Practice Act, Section 61-3-1 to
Section 61-3-30 NMSA 1978, as amended, and related regulations.
(2) “Residential
services” means any crisis stabilization services provided to a client
admitted to the residential setting.
(3) “Restraint
clinician” means a New Mexico licensed medical doctor, doctor of
osteopathy, advanced practice registered nurse, clinical nurse specialist,
physician assistant or doctoral level psychologist (Psy.D., Ph.D., or E.D.),
who is trained in the use of emergency safety interventions.
S. Definitions
beginning with “S”:
(1) “Sanitize clothes” means the use of
water at a temperature of 212 degrees or use of a disinfectant agent to wash
clothes.
(2) “Scope of practice”
means the procedures, actions, and processes that a healthcare practitioner is
permitted to undertake under the terms of their professional license. The scope of practice is limited to that
which the applicable law allows for specific education, training, experience
and demonstrated competency.
(3) “Seclusion”
means the involuntary confinement of a client alone in a room where the client
is physically prevented from leaving.
(4) “Short-term
residential stay” means the limit of a client’s stay is eight days for the
residential setting.
(5) “Staff” means
any person who works at the CTC, and includes employees, contracted persons,
independent contractors and volunteers who perform work or provide goods and
services at the CTC.
T. Definitions
beginning with “T”: [RESERVED]
U. Definitions beginning with “U”: “U/L
approved”
means approved for safety by the national underwriter’s laboratory.
V. Definitions
beginning with “V”:
(1) “Variance”
means a written decision, made at the licensing authority’s sole discretion, to
allow a CTC to deviate from a portion(s) or a provision(s) of these regulations
for a period that expires upon remodel of the CTC or change of ownership,
providing the variance does not jeopardize the health, safety or welfare of the
CTC’s clients, visitors and staff and is not in violation of other applicable
state and federal statutes and regulations.
A variance can be renewed upon approval of the licensing authority. A variance may be revoked at the discretion
of the licensing authority due to changes in state or federal regulations and
statutes, or change of circumstances that may jeopardy the health, safety or
welfare of clients.
(2) “Violation”
means all actions or procedures by the CTC or licensee that are not in
compliance with these regulations and all other applicable state and federal
statutes and regulations.
W. Definitions beginning with “W”:
(1) “Waiver” means
a written decision, made at the licensing authority’s sole discretion, to allow
a CTC to deviate from a portion(s) or a provision(s) of these regulations for a
limited and specified time period not to exceed the duration of the license,
providing the waiver does not jeopardize the health, safety or welfare of the
CTC’s clients, visitors and staff and is not in violation of other applicable
state and federal statutes and regulations.
A waiver can be renewed on an annual basis upon approval of the
licensing authority. A waiver may be
revoked at the discretion of the licensing authority due to changes in state or
federal regulations, or change of circumstances that may jeopardy the health,
safety or welfare of clients.
(2) “Withdrawal
management” means the immediate psychological stabilization, diagnosis and
treatment of a client who is intoxicated, incapacitated, or experiencing
withdrawal of alcohol or drugs.
X. Definitions beginning with “X”: [RESERVED]
Y. Definitions
beginning with “Y”:
(1) “Youth”
means residents 14 years of age and older up to age 18.
(2) “Youth
staff” means a person who has contact with youth in a licensed facility and
includes the owner, operator or director of a program, volunteers, full-time,
part-time, and contract employees.
Z. Definitions
beginning with “Z”: [RESERVED]
[8.321.11.7
NMAC - N, 7/1/2024]
8.321.11.8 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
compliance. “May” means permissive
compliance. The words “adequate”,
“proper”, and other similar words mean the degree of compliance that is
generally accepted throughout the professional field by those who provide
services to the public in facilities.
[8.321.11.8
NMAC - N, 7/1/2024]
8.321.11.9 SCOPE OF SERVICES:
A. General
scope of services: These regulations
apply to crisis triage centers (CTC) which are health facilities offering youth
and adult outpatient and residential care services. A CTC provides stabilization of behavioral
health crises as outpatient stabilization or short-term residential
stabilization in a residential rather than institutional setting, which may
provide an alternative to hospitalization or incarceration. The CTC services may vary in array of
services offered to meet the specific needs of different communities in New
Mexico. A CTC may provide limited
detoxification services but is differentiated from a detoxification center in
that it does treat individuals who require treatment beyond Level III.7-D: Medically Monitored Inpatient
Detoxification. The CTC provides
emergency behavioral health triage and evaluation. The CTC may serve individuals 14 years of age
or older who meet admission criteria.
The CTC shall offer services to manage individuals at high risk of
suicide or intentional self-harm. The
CTC shall not refuse service to any individual who meets criteria for services.
B. Type
of services:
(1) a CTC structured for less than
24-hour stays providing only outpatient withdrawal management or other
stabilization services;
(2) a CTC providing outpatient and
residential crisis stabilization services; and
(3) a CTC providing residential crisis
stabilization services.
C. Limitations
on scope of services:
(1) the CTC may accept voluntary
admissions, individuals who are voluntarily seeking treatment, involuntary
admissions and individuals who are not voluntarily seeking treatment;
(2) the CTC shall not provide
detoxification services beyond Level III.7-D: Medically Monitored Inpatient
Detoxification services;
(3) the CTC shall not provide medical
care not related to crisis triage intervention services beyond basic medical
care of first aid and CPR;
(4) the CTC shall not provide residential
services in excess of 14 calendar days, unless an involuntary admission is
accepted and the CTC shall comply with all hearing and treatment provisions of
Section 43-1-1 et al. NMSA;
(5) the CTC shall not provide ongoing
outpatient behavioral health treatment;
(6) the CTC shall not exceed the capacity
for which the CTC is licensed;
(7) a CTC with both adult and youth
occupants must locate youth rooms and restrooms in a unit or wing that is
physically separated from the adult facilities;
(8) A
CTC shall not administer emergency psychotropic medications as described in
Subsection M of Section 43-1-15 NMSA 1978 if admitting only voluntary
admissions. Any use of emergency psychotropic medications for involuntary
admissions shall only be done in accordance with Subsection M of Section
43-1-15 NMSA 1978.
D. License
required:
(1) a CTC shall not be operated without a
license issued by the authority;
(2) any facility providing the services
described in these regulations on the effective date of these regulations,
shall apply for a CTC license within 180 days;
(3) a CTC licensed under these
regulations shall not assert, represent, offer, provide or imply that the CTC
is or may render care or services other than the services it is permitted to
render under these regulations and within the scope of all applicable professional
license(s);
(4) if an unlicensed CTC is found to be
providing services for which a license is required under these regulations, the
secretary may issue a cease-and-desist order, to protect human health or safety
or welfare. The unlicensed facility may
request a hearing that shall be held in the manner provided under these
regulations and all other applicable regulations.
[8.321.11.9
NMAC - N, 7/1/2024]
8.321.11.10 INITIAL
LICENSE PROCEDURES: These regulations should be thoroughly understood and used by the applicant, when applying for the initial CTC license. The applicant for an initial
CTC license under these regulations must follow these procedures when applying for a license.
A. Notification and letter of intent: The owner shall advise the licensing authority of its intent
to open a crisis triage center pursuant to these regulations by submitting a letter of intent. The letter of intent
must be on the applicant's letterhead and signed by a person with authority to make legal decisions for the owner and the CTC
and
at a minimum, include the following:
(1) the name of CTC;
(2) the name of the legal owner and licensee and the type of legal entity under which the
CTC shall be owned;
(3) the name of the management company, if any;
(4) the type of facility license requested;
(5) the name and
resume of the proposed administrator;
(6) the anticipated number of residential and non-residential clients to be served;
(7) the intended
population and age range of the clients to be served;
(8) the number of residential beds in the proposed CTC;
(9) the physical address of CTC including building name or suite number;
(10) the mailing address, if different from physical address;
(11) the
applicant’s contact name(s), address, e-mail address, and telephone number(s);
(12) the anticipated payers and sources of reimbursement; and
(13) a list of all services to be provided at the CTC location which is requesting the license.
B. License application and fees: After review by the authority
of the letter of intent for general compliance with these regulations and verification that an application is appropriate
under these regulations, the
owner shall be required to complete a license application on a form provided by the authority. Prior to any
construction, renovation or addition to an existing building and after review and approval of the letter of intent by the authority, the applicant must submit to the licensing authority an application form provided by the authority,
fully completed, printed or typed, dated, signed, and notarized accompanied by the required fee. If electronic filing
of
license applications is available at the time of application, the applicant will be required to follow all electronic filing requirements, and may forgo any notary requirements, if specifically allowed under the applicable electronic filing statutes, regulations and requirements. The
licensing authority will provide current fee schedules. The
authority reserves the right to require additional documentation to verify the
identity of the applicant in order to verify whether any federal or state
exclusions may apply to the applicant. Fees must be paid in the form of a
certified check, money order, personal, or business check, or electronic transfer (if available), made payable to the state of New Mexico, and are non-refundable. The applicant must
also attach to the application and submit to the authority, a set of building plans which includes all of the information required by these rules, accompanied by proof of zoning approvals by the applicable building
authority.
C. Building plans: The CTC
building plans must be of professional quality, prepared and stamped by an
Architect licensed by the state of New Mexico pursuant to Subsection B of Section
61-15-9 NMSA 1978. One copy of the building
plans must be submitted, printed on substantial paper measuring at least 24
inches by 36 inches and drawn to an accurate scale of at least one-eighth inch
to 1 foot. The building plans for
renovated or building additions to an existing building must include sufficient
information to clearly distinguish between new and existing construction, for
the authority to make a compliance determination. The following plans are the minimum required
for all facilities in new and /or renovated construction:
(1) Site plan: showing the location of the building on a
site/plot plan to determine surrounding conditions, driveways, all walks and
steps, ramps, parking areas, handicapped and emergency vehicle spaces,
accessible route to the main entrance, secure yard for clients, any permanent
structures, including notes on construction materials used.
(2) Life safety and code compliance plan: noting applicable
code requirements and compliance data, locations of rated fire walls, smoke
partitions (if any), exit paths & distances, fire extinguishers locations.
(3) Floor plans: showing location use
of each room, (e.g., waiting room, examination room, office, client (resident)
rooms, kitchen, common elements, door locations (swings), window locations,
restrooms, locations of all restrooms, plumbing fixtures (sinks, toilets, tubs-showers;
location a of all level changes within and outside the building (e.g. steps or
ramps, etc.); and all other pertinent explanatory information addressing the requirements in applicable regulations.
(4) Dimensioned floor plan: showing all exterior
and interior dimensions of all rooms, spaces, and corridors, etc.
(5) Exterior building elevations: noting all building
heights, locations of exterior doors, and any operable and fixed windows (sill
heights).
(6) Building and wall sections: showing at least one
building or wall section showing an exterior and interior wall construction
section including the material composition of the floor, walls, and
ceiling/roof construction.
(7) Schedule sheets: room finish: noting
all room finishes, (e.g., carpet, tile, gypsum board with paint, etc); door schedule;
noting door sizes/thickness, door types & ratings; window schedule, noting
sizes, type and operation; skylight schedule, noting size, type.
(8) Special systems plan: location of fire
extinguishers, heat and smoke detectors, nurse call systems, and operational
elements of alarm system.
(9) Mechanical plans: noting location of
heating units, furnaces, hot water heaters, and fuel type and source; all heating,
ventilating and air conditioning/cooling systems including locations of fire
dampers.
(10) Plumbing plan: noting
all plumbing fixture locations, fixture types.
(11) Electrical plan: noting power and
lighting layouts, exit lighting, emergency lighting fixtures, emergency power
systems (if any), electrical panel information.
(12) Other plans: As necessary (ie; phasing
plan) to describe compliance with the other requirements in applicable
regulations.
D. New construction: Building
plans must be submitted, and will be reviewed by the authority
for compliance with
these licensing regulations, and applicable building and fire safety codes. If the
authority approves the CTC’s building plans and local building officials have issued a construction permit, construction may begin. This provision is an ongoing
requirement and applies to, and includes all construction at the CTC,
which occurs before and after
issuance of the initial license. This provision does not generally apply to maintenance and repair. However, if the maintenance or repair impacts or alters any of the CTC requirements
under these regulations, the applicant or licensee must notify the authority
and verify ongoing compliance with these regulations. The authority
shall not
be
liable for any costs or damages incurred by the applicant relating to
construction in the event the applicant incurs costs or damages in order to comply with these regulations or to
obtain a license under these regulations. For all
new and proposed construction, the applicant or licensee must submit for building plan approval by the authority before
construction begins.
E. Existing or renovated construction: If the proposed CTC includes any remodeling,
renovations or additions or new construction of any type, the building plans and specifications
covering all portions
of
the proposed work delineating all existing construction and all new or proposed
construction shall be and
submitted to the authority
for review and approval.
Submit phasing plan if project construction will be phased. New facilities proposed for licensure in
existing buildings must comply with all requirements building requirements as
if it were completely new construction.
If the CTC is located within another licensed facility such as a
hospital, the life safety inspection will still be required for compliance with
8.321.11 NMAC requirements. For
residential CTC programs, the bed count must be separate from the licensed bed
count of the original licensed facility.
If a CTC is a separate building associated with an existing license,
requirements of this regulation apply to that building.
F. Completed construction: All new or renovated construction
completed shall comply
with the plans and specifications approved by the authority in the plan review process and prior to construction, these rules, and all other applicable rules
and codes; and any of the authority’s approval(s) shall not waive any
other rules or other applicable building
and
code requirements enforceable by other authorities
having jurisdiction. Applicant must
receive initial life safety code approval and a temporary license from this authority
prior to accepting or admitting any clients into the CTC.
G. Additional documents required for
license application: The
authority reserves the right to require an applicant to provide all additional documents, as part of its license
application, in order for the authority
to determine whether the applicant and the CTC are in full compliance with these regulations, as well as all other applicable statutes and regulations. At minimum, additional documents required to be provided as part of the initial licensure
process prior to the issuance of a temporary license, include, but are not limited to:
(1) Building approvals: The applicant must submit all building approvals required for the CTC to operate in the jurisdiction
in which it is located, including but not limited to:
(a) written zoning approval, building permit final approval, or certificates
of occupancy from the appropriate authority
(state, city, county, or municipality) for business occupancy; and
(b) written fire marshal approvals from the fire safety authority having jurisdiction.
(2) Environment
department approvals: If applicable or required, the applicant must provide written approval from the New Mexico environment department for the following:
(a) private water supply;
(b) private waste or sewage disposal;
(c) kitchen/food service:
(d) x-ray equipment (if any).
(3) Board of pharmacy approvals: A copy of CTC’s drug permit issued by the state board of
pharmacy must be provided.
(4) Program description: The applicant must submit with its license application a program outlines consistent with these regulations which includes at a minimum, the following information:
(a) a list and description of all
services and the scope of those services to be provided by the proposed CTC;
(b) projected number of clients to be
served monthly, both residential and non-residential;
(c) a list of staffing and personnel
requirements and duties to be performed;
(d) proposed staffing plans for both residential and
non-residential programs;
(e) photocopies of written operating
agreements with the following: treatment facilities for behavioral health and
physical health care needs that are beyond the scope of the CTC;
(f) admission and discharge criteria;
and
(g) an organizational structure diagram
or chart including the administrator, governing body, clinical director,
director of nursing, direct care staff, and other staff.
(5) Policies and procedures: The applicant must submit with its license application a copy of the CTC’s policies and procedures with a crosswalk to these regulations to
show compliance.
[8.321.11.10
NMAC - N, 7/1/2024]
8.321.11.11 LICENSE TYPES, VARIANCES &
WAIVERS:
A. Temporary
license:
(1) The licensing authority may, at its
sole discretion, issue a temporary license prior to the initial survey, or when
the licensing authority finds partial compliance with these regulations.
(2) The licensing authority may, at its
sole discretion, issue a temporary license before clients are admitted,
provided that the CTC has:
(a) submitted a license application, with
required supporting documents;
(b) has met all of the applicable life
safety code requirements; and
(c) its program, policies, and procedures
have been reviewed and approved for compliance with these regulations.
(3) a temporary license is not guaranteed
under these regulations and shall be limited and restricted to:
(a) a period, not to exceed 120 days,
during which the CTC must correct all specified deficiencies;
(b) no more than two consecutive
temporary licenses shall be issued in accordance with applicable statutes and regulations;
(c) a finding that the applicant is
qualified and in full compliance with life safety code requirements;
(d) the CTC being allowed to accept
clients and provide care services, subject to any requirements and restrictions
attached to the temporary license;
(e) a statement from the applicant that
they are qualified and in full compliance with these regulations and the owner
has requested an initial health survey from the licensing authority.
B. Annual
license: An annual license is issued
for a one-year period to a CTC which has met all requirements of these
regulations. If a temporary license is
issued, once the authority has issued a written determination of full
compliance with these regulations, an annual license will be issued with the
renewal date of the annual license based upon the initial date of the first
temporary license.
C. Amended
license: A licensee must apply to the licensing authority for an amended
license when there is a change of administrator or when there is a change of
name for the CTC, but an amended license shall only be issued if the
administrator is not an owner. If the
administrator is also the owner, a new license application must be submitted as
provided in this regulation. The amended
license application must:
(1) be on a form, or filed electronically
if available, as required by the licensing authority;
(2) be accompanied by the required fee
for the amended license; and
(3) be submitted within 10 working days
of the change.
D. Variances
and waivers: At the licensing
authority’s sole discretion, an applicant or licensee may be granted variances
and waivers of these regulations, provided the granting of such variance or
waiver shall not jeopardize the health, safety or welfare of the CTC’s clients,
patients and staff and is not in violation of other applicable state and
federal statutes and regulations. Variances
and waivers are non-transferrable.
Waivers and variances may be revoked at the discretion of the licensing
authority due to changes in state or federal regulations, or change of
circumstances that may jeopardy the health, safety or welfare of clients.
(1) all variances shall be in writing,
attached to the license and shall expire upon remodel of the CTC or change of
ownership;
(2) all waivers shall be in writing,
attached to the license and shall be limited to the term of the license. Upon renewal of a license, waivers shall only
be extended or continued at the sole discretion of the licensing authority.
[8.321.11.11
NMAC - N, 7/1/2024]
8.321.11.12 LICENSE RENEWAL:
A. Licensee must submit a renewal
application, electronically, if available, or on forms authorized by the
licensing authority, along with the required license fee at least 30 days prior
to expiration of the current license. The
applicant shall certify that the CTC complies with all applicable state and
federal regulations in force at the time of renewal and that there has been no
new construction or remodeling or additions, which differ from the plans
provided and reviewed with the prior license application. If there has been any construction,
remodeling, or additions to the CTC since issuance of the last license, and the
construction has not been previously approved by the authority, the license
renewal applicant shall be required to comply with all construction
documentation requirements under these regulations when applying for the
license renewal. The authority reserves
the right to require that a renewal applicant provide all additional documents,
including any necessary proof of current compliance, as part of its license
renewal application for the authority to determine whether the applicant and
the CTC are in full compliance with these regulations.
B. Upon receipt of the renewal
application and the required fee, the licensing authority will issue a new
license effective the day following the date of expiration of the current
license, if the CTC is in substantial compliance with these regulations and all
other applicable state and federal regulations.
C. If the existing license expires and
the licensee has failed to submit a renewal application, the authority may
charge the applicant a civil monetary penalty of $100 for each day, in
accordance with Section 24-1-5 NMSA 1978, as amended, that
the CTC continues to operate without a license providing that during such time
the CTC remains in full compliance with these regulations. If the CTC does not renew its license and
continues to operate without paying civil monetary penalties and without being
in full compliance with these regulations, the CTC shall cease operations until
it obtains a new license through the initial licensure procedures, and shall
still be required to pay civil monetary penalties. Under Section 24-1-5 NMSA 1978, as amended, no
crisis triage center shall be operated without a license and any such failure
may subject the operators to various sanctions and legal remedies, including at
a minimum the imposition of civil monetary penalties.
D. It shall be the sole responsibility
and liability of the licensee to be aware of the status, term and renewal date
of its license. The licensing authority
shall not be responsible to notify the CTC of the renewal date or the
expiration date of the CTC’s license.
E. After issuance of the initial
license, if there has been no construction, remodeling or additions to the CTC
and the CTC is in substantially the same condition as the plans on file with
the authority, and the CTC is in substantial compliance with these regulations
and provides an application and fee the CTC may be issued a license renewal. The authority, at its sole discretion,
reserves the right to require additional documentation of compliance with these
regulations and all applicable state and federal statutes and regulations by
the licensee at the time of license renewal.
[8.321.11.12
NMAC - N, 7/1/2024]
8.321.11.13 POSTING OF LICENSE: The CTC's official license must be posted in a
conspicuous place on the licensed premises in an area visible to the public.
[8.321.11.13
NMAC - N, 7/1/2024]
8.321.11.14 NON-TRANSFERABLE RESTRICTION ON
LICENSE:
A license granted under these
regulations is not transferable to any other owner, whether an individual or
legal entity, or to another location. The
authority shall not guarantee or be liable for or responsible for guaranteeing
the transfer of the license to any other owner or other location. The existing license shall be void and must be
returned to the licensing authority when any one of the following situations
occurs:
A. any ownership interest in the CTC
changes;
B. the CTC changes location;
C. the licensee of the CTC changes; or
D. the CTC discontinues operation.
[8.321.11.14
NMAC - N, 7/1/2024]
8.321.11.15 CHANGE
OF OWNERSHIP: When a change of ownership occurs, an initial license
application must be submitted by the new owner per the requirements in this
section. The new owner must demonstrate
compliance with these regulations the instant it takes responsibility of the CTC. The licensing authority may, at its sole
discretion, approve a change of ownership.
In addition to the requirements in Section 8.321.11.10 NMAC - application
for licensure, the new owner must submit the following at least 60 days prior
to completion of the change of ownership:
A. An
explanation of terms of the change of ownership and the date the ownership will
change.
B. Documents
evidencing the change of ownership such as proof of sale or donation, lease of
any portion of the CTC or other relevant documents.
C. Building
plans of the current structure with any modifications known to the current or
new owner.
D. A
continuity of care transition plan that describes how the new owner will
maintain the provision of services and continuity of care, keep residential
clients safe and meet the requirements of these regulations at the instant it
takes responsibility of the CTC. The
plan must state the actions that will occur, the party responsible for taking
each action, and the expected date of completion for each action. The plan must include the following:
(1) list
of all residential clients at the time of notice to the licensing authority;
(2) review
and update of all residential client assessments. All assessments must be current and accurate;
(3) review
and update of all crisis intervention plans for clients receiving service at
the time of transition and for all residential clients. All plans must be current and accurate;
(4) staffing
as required in Section 8.321.11.29 NMAC of these rules and the number and
positions of current staff that will be hired by the new owner;
(5) staff
training as required in Section 8.321.11.32 NMAC;
(6) identification
of all waivers or variances held by the current owner, and submission of any
necessary waivers or variances. All
waivers or variances held by the current owner are void upon the change of
ownership;
(7) signed
transfer agreements as required in Section 8.321.11.22 NMAC of these rules.
(8) Failure by any individual or entity
to apply for and obtain a new license while continuing to operate under these
regulations, shall be considered in violation of these regulations and the
secretary may issue a cease-and-desist order, to protect human health or safety
or welfare. The unlicensed CTC may
request a hearing that shall be held in the manner provided under these
regulations and all other applicable regulations.
[8.321.11.15
NMAC - N, 7/1/2024]
8.321.11.16 AUTOMATIC EXPIRATION OR TERMINATION OF
LICENSE:
An existing license shall automatically
expire at midnight on the day indicated on the license, unless it is renewed sooner,
or it has been suspended or revoked.
A. If a CTC discontinues operation, is
sold, leased or otherwise changes any ownership interest or changes location,
the existing license shall automatically expire at midnight on the date of such
action.
B. Failure by any owner or new owner to
apply for a renewal or new license, while continuing to operate under these
regulations, shall be considered a violation and subject to the imposition of
civil monetary penalties, sanctions or other actions for operating without a
license, allowed under these regulations and all other applicable statutes and
regulations.
[8.321.11.16
NMAC - N, 7/1/2024]
8.321.11.17 ENFORCEMENT:
A. Suspension of license without prior
hearing: If immediate action is required
to protect human health and safety, the licensing authority may act in
accordance with Section 24-1-5 NMSA 1978, as amended, and suspend a license
pending a hearing, provided such hearing is held within five working days of
the suspension, unless waived by the licensee.
B. An initial license application or a
renewal license application may be denied, or an existing license may be
revoked or suspended, or intermediate sanctions or civil monetary penalties may
be imposed, after notice and opportunity for a hearing, for any of the
following:
(1) failure to comply with any provision
of these regulations;
(2) failure to allow access to the CTC
and survey(s) by authorized representatives of the licensing authority;
(3) allowing any person to work at the CTC
while impaired physically or mentally or under the influence of alcohol or
drugs in a manner which harms the health, safety or welfare of the clients,
staff or visitors;
(4) allowing any person, subject to all
applicable statutes and regulations, to work at the CTC if that person is
listed on the employee abuse registry, nurse aid registry, or considered an
unemployable caregiver or has a disqualifying conviction under the caregiver’s
criminal history screen act, as amended, and related regulations, as amended.
(5) the list above shall not limit the authority
from imposing sanctions and civil monetary penalties under all applicable
statutes, regulations and codes.
[8.321.11.17
NMAC - N, 7/1/2024]
8.321.11.18 HEARING PROCEDURES: Hearing procedures for an administrative
appeal of an adverse action taken by the authority against a CTC's license will
be held in accordance with applicable rules relating to adjudicatory hearings,
including but not limited to, Section 8.370.2 NMAC. A copy of the above regulations will be
furnished at the time an adverse action is taken against a CTC’s license by the
licensing authority, if the regulations cannot be obtained from a public
website.
[8.321.11.18
NMAC - N, 7/1/2024]
8.321.11.19 FACILITY SURVEYS:
A. Application for licensure, whether
initial or renewal, shall constitute permission for unrestricted entry into and
survey of a CTC by authorized licensing authority representatives at times of
operation during the pendency of the license application, and if licensed,
during the licensure period.
B. Surveys may be announced or
unannounced at the sole discretion of the licensing authority.
C. Upon receipt of a report of
deficiency from the licensing authority, the licensee or their representative
shall be required to submit a plan of correction to the licensing authority
within 10 working days stating how the CTC intends to correct each violation
noted and the expected date of completion. All plans of correction for deficiencies, if
any, shall be disclosed in compliance with applicable statutes and regulations.
A plan of correction is not confidential
once it has been approved and is admissible for all purposes in any
adjudicatory hearing and all subsequent appeals relating to a CTC license,
including to prove licensee compliance violations. The plan of correction must contain the
following:
(1) what measures will be put into place
or what systematic changes will be made to ensure the deficient practice does
not recur;
(2) the anticipated implementation date
(a reasonable time-frame is allowed);
(3) how the corrective action will be
monitored to ensure compliance;
(4) what quality assurance indicators
will be put into place;
(5) who will be responsible to oversee
their monitoring; and
(6) plan of correction shall be signed
and dated by the administrator or authorized representative.
D. The licensing authority may at its
sole discretion accept the plan of correction as written or require
modifications of the plan by the licensee.
[8.321.11.19
NMAC - N, 7/1/2024]
8.321.11.20 REPORTING OF INCIDENTS: All CTC’s licensed under these regulations
must comply with all incident intake, processing, training and reporting
requirements under these regulations, as well as with all other applicable
statutes and regulations. All facilities
shall report to the licensing authority any serious incidents or unusual
occurrences which have threatened, or could have threatened the health, safety
and welfare of the clients, including but not limited to:
A. fire, flood or other man-made or
natural disasters including any damage to the CTC caused by such disasters and
any incident which poses or creates any life safety or health hazards;
B. any outbreak of contagious diseases
and diseases dangerous to the public health;
C. any human errors by staff and
employees which may or has resulted in the death, serious illness,
hospitalization, or physical impairment of a client or staff; and
D. abuse, neglect, exploitation, and
injuries of unknown origin and other reportable incidents in accordance with 8.370.9
NMAC.
[8.321.11.20
NMAC - N, 7/1/2024]
8.321.11.21 GOVERNING BODY: All CTC’s licensed under these regulations
must have a formally constituted governing body or operate under the governing
body of the legal entity, which has ultimate authority over the CTC.
A. The governing body shall:
(1) establish and adopt bylaws that
govern its operation;
(2) approve policies and procedures;
(3) appoint an on-site administrator or
chief executive officer/administrator for the CTC; and
(4) review the performance of the
administrator/chief executive officer at least annually.
B. The governing body may appoint
committees consistent with the size and scope of the CTC.
[8.321.11.21
NMAC - N, 7/1/2024]
8.321.11.22 POLICIES AND PROCEDURES: The CTC shall establish written policies
and procedures that are reviewed annually and approved by the governing body,
which govern the CTC’s operation. The
administrator shall ensure that these policies and procedures are adopted,
administered and enforced to provide quality services in a safe environment. At a minimum, the CTC’s written policies and
procedures shall include how the CTC intends to comply with all requirements of
these regulations and address:
A. the establishment, composition, and
responsibilities of the governing body;
B. administration including the minimum
qualifications of the administrator, the process to hire an administrator, and
define the administrator’s authority, responsibility, and accountability
including plans for the administrator’s absence;
C. quality assurance and improvement
systems;
D. incident management system;
E. the maintenance of the CTC,
equipment and supplies; inspection and maintenance of emergency equipment;
maintenance of emergency supplies; maintenance, upkeep and cleaning of the
building(s) and equipment; fire and emergency evacuation procedures; and proper
disposal of waste liquids used for cleaning contaminated areas;
F. quality of care and services
including appropriate and inappropriate admission and discharge criteria; and
client risk assessment;
G. referral of clients for services;
transfer of clients to a hospital or other CTC or program; ambulance transfer
services; and emergency procedures and resuscitative techniques;
H. infectious waste and biohazard
disposal in accordance with all applicable statutes and regulations;
I. infection control and prevention;
J. staffing plan, personnel records,
and personnel including written job descriptions for all staff with necessary
qualifications consistent with these rules; minimum staffing; and staff
development;
K. maintenance of the client health
record including protection of client confidentiality and privacy as required
by law; secure release of medical information and records; and safe handling
and storage of client records including appropriate document destruction
procedures;
L. the retention, maintenance, security
and destruction of client, personnel and CTC records;
M. research procedures for any research
being conducted at the CTC in compliance with these regulations;
N. dietary services including: meal
service; staff in-service training; dietary records; clean and sanitary
conditions; and food management;
O. housekeeping services to keep the CTC
safe, clean, and free of hazards and clutter;
P. laundry services for the CTC’s
laundry and resident’s laundry including handling, process and storage of clean
and dirty laundry;
Q. pharmacy practices including the
storage, administration, and disposal of medications; medication management;
and documentation;
R. laboratory services;
S. client’s personal belongings
including locked storage and contraband;
T. client rights;
U. safety management plan including,
but not limited to, risk assessment, control of potentially injurious items,
crisis prevention and intervention, physical restraint, and mitigation of high
risk behaviors including suicide and assault. The safety plan shall follow a least to most
restrictive sequence;
V. authorized entry to or exit from the
CTC including the residential and outpatient components;
W. withdrawal management services; and
X. primary source verification of
licenses, credentials, experience and competence of staff.
[8.321.11.22
NMAC - N, 7/1/2024]
8.321.11.23 QUALITY IMPROVEMENT SYSTEMS: Each CTC shall establish and maintain quality
improvement systems including policies and procedures for quality assurance and
quality improvement and have a quality committee.
A. The CTC shall establish a quality
committee comprised at a minimum of the administrator, clinical director,
director of nursing, licensed mental health professional, certified peer
support worker, and psychiatrist. Other
committee members may be specified by rules governing payor requirements. Members may participate on the quality
committee by teleconference. The
committee shall establish and implement quality assurance and quality
improvement systems that monitor and promote quality care to clients. The systems are approved by the governing
body and updated annually.
(1) the quality improvement systems must
include:
(a) chart reviews;
(b) annual review of policies and
procedures;
(c) data collection, and other program
monitoring processes;
(d) data analyses;
(e) identification of events, trends and
patterns that may affect client health, safety or treatment efficacy;
(f) identification of areas for
improvement;
(g) intervention plans, including action
steps, responsible parties, and completion time; and,
(h) evaluation of the effectiveness of
interventions.
(2) when areas of concern or potential
problems are identified by the committee, the CTC shall act as soon as possible
to avoid and prevent risks to clients.
(3) the quality committee shall take and
maintain meeting minutes.
B. The quality committee shall review
at a minimum, the following:
(1) high-risk situations and critical
incidents (such as suicide, death, serious injury, violence and abuse, neglect
and exploitation) within 24 hours;
(2) medical emergencies;
(3) medication variance;
(4) infection control;
(5) emergency safety interventions
including any instances physical
restraints; and
(6) environmental safety and maintenance.
C. The quality committee is responsible
for the implementation of quality improvement processes.
D. The quality committee shall submit a
quarterly report to the governing body for review and approval.
E. The governing body shall evaluate
the CTC’s effectiveness in improving performance.
[8.321.11.23
NMAC - N, 7/1/2024]
8.321.11.24 RISK ASSESSMENT:
A. The
CTC shall develop policies and procedures addressing risk assessment and
mitigation including, but not limited to:
assessments, crisis intervention plans, treatment, approaches to
supporting, engaging, and problem solving, staffing, levels of observation and
documentation. The policies and
procedures must prohibit seclusion and address physical restraint, if used, and
the CTC’s response to clients that present with imminent risk to self or
others, assaultive and other high-risk behaviors.
B. Use
of seclusion is prohibited unless the facility is joint commission accredited,
and unless the facility has obtained a prior waiver from the authority
authorizing the facility to use seclusion.
The use of physical restraint or seclusion must be consistent with
federal and state laws and regulation (e.g., Section 32A-6A-10 NMSA 1978,
concerning physical restraint and seclusion of minors).
C. Physical
restraint, as defined in these regulations, shall be used only as an emergency
safety intervention of last resort to ensure the physical safety of the client
and others, and shall be used only after less intrusive or restrictive
interventions have been determined to be ineffective.
D. Physical
restraint shall not be used as punishment or for the convenience of staff.
E. Physical
restraint is implemented only by staff who have been trained and certified by a
CYFD or HCA recognized program in the prevention and use of physical
restraint. This training emphasizes
de-escalation techniques and alternatives to physical contact with clients as a
means of managing behavior and allows only the use of reasonable force
necessary to protect the client or other person from imminent and serious
physical harm. Clients and youth do not
participate in the physical restraint of other clients and youth.
F. Crisis
intervention plans must document the use of physical restraints and
address: the client’s medical
condition(s); the role of the client’s history of trauma in their behavioral
patterns; specific suggestions from the client regarding prevention of future
physical interventions.
G. All
clients physically restrained shall be afforded full privacy away from other
clients receiving services.
H. A
chemical restraint shall not be utilized under any circumstance. A chemical restraint is a drug or medication
when it is used as a restriction to manage the client’s behavior or restrict
the client’s freedom of movement, and is not a standard treatment or dosage for
the client’s condition. If a drug or
medication is used as a standard treatment to address the assessed current
symptoms and needs of a client with a particular medical or psychiatric
condition, its use is not considered a chemical restraint.
I. Mechanical restraint
shall not be utilized under any circumstances unless the facility is joint
commission accredited, and unless the facility has obtained a prior waiver from
the authority authorizing it to utilize mechanical restraint. Mechanical restraint is the use of a
mechanical device(s) to physically restrict a client’s freedom of moment,
performance of physical activity or normal access to their body and is distinct
from physical restraint. The use of
mechanical restraint must be consistent with federal and state laws and
regulation (e.g., Section 32A-6A-10 NMSA 1978, concerning mechanical restraint
of minors).
J. The staff
implementing the physical restraint shall conduct a debriefing, with the client
present if possible, immediately following the incident to include the
identification of the precipitating event, unsafe behavior and preventive
measures with the intent of reducing or eliminating the need for future
physical restraint. The debriefing shall
be documented in the client’s record.
K. The
client’s crisis intervention plan shall be updated: within 24 hours of admission or prior to
discharge, whichever comes first; and following physical restraint use to
incorporate the debriefing and changes needed to lessen the chance of the
situation reoccurring.
L. Each
incident of physical restraint shall be documented in the client’s record
including:
(1) the
less intrusive interventions that were attempted or determined to be
inappropriate prior to the incident;
(2) the
precipitating event immediately preceding the behavior that prompted the use of
physical restraint;
(3) the
behavior that prompted the use of a physical restraint;
(4) the names of the
mental health professional who observed the behavior that prompted the use of
the physical restraint;
(5) the names of the staff
members implementing and monitoring the use of physical restraint; and
(6) a description of the
of the physical restraint incident, including the type and length of the use of
physical restraint, the client’s behavior during and reaction to the physical
restraint and the name of the supervisor informed of the use of physical restraint.
M. Physical restraints
orders are issued by a restraint/clinician within one hour of initiation of
physical restraint and include documented clinical justification for the use of
physical restraint.
(1) if the client has a
treatment team physician or advanced practice registered nurse and he or she is
available, only he or she may order physical restraint;
(2) if physical restraint
is ordered by a restraint clinician, not the client’s treatment team physician
or advanced practice registered nurse, the restraint clinician will contact the
client’s treatment team physician or advanced practice registered nurse as soon
as possible to inform him or her of the situation requiring the physical
restraint, and document in the client’s record the date and time the treatment
team physician or advanced practice registered nurse was consulted and the
information imparted;
(3) if the order for
physical restraint is verbal, the verbal order must be received by a
restraint/clinician or a New Mexico licensed registered nurse (RN) or
practical nurse (LPN). The restraint/
clinician must verify the verbal order in a signed, written form placed in the
client’s record within 24 hours after the order is issued;
(4) each order for
physical restraint must be documented in the client’s record and must include:
(a) the name of the
restraint/clinician ordering the physical restraint;
(b) the
date and time the order was obtained;
(c) the
emergency safety intervention ordered, including the length of time;
(d) the
time the emergency safety intervention began and ended;
(e) the
time and results of one-hour assessment(s), if ordered;
(f) the
emergency safety situation that required the client to be physically
restrained; and
(g) the
name, title, and credentials of staff involved in the emergency safety
intervention.
N. Suicide
risk interventions must include the following:
(1) a
registered nurse or other licensed mental health professional may initiate
suicide precautions and must obtain physician or advanced practice registered
nurse order within one hour of initiating the precautions;
(2) modifications
or removal of suicide precautions shall require clinical justification
determined by an assessment and shall be ordered by a physician or advanced
practice registered nurse and documented in the clinical record;
(3) staff
and client shall be debriefed immediately following an episode of a suicide
attempt or gesture, identifying the circumstances leading up to the suicide
attempt or gesture;
(4) an
evaluation of the client by a medical, psychiatric or independently licensed
mental health provider must be done immediately, or the client must be
transferred to a higher level of care immediately.
[8.321.11.24 NMAC - N, 7/1/2024]
8.321.11.25 CLIENT ACCEPTANCE, ADMISSION AND
DISCHARGE CRITERIA:
A. The CTC shall develop admission and
discharge criteria related to stabilization of behavioral health crises
including out-patient and short-term residential stabilization.
B. The CTC shall post operating and
admission hours in a location visible from the exterior of the facility.
C. If a client is not admitted to the CTC,
the CTC shall maintain documentation of the rationale for the denial of
services to the individual and any referrals made.
D. Admission criteria for adults and
youth must be available in writing to all clients and visitors to the CTC.
E. Materials describing services
offered, eligibility requirements and client rights and responsibilities must
be provided in a form understandable to the client with consideration of the
client’s primary language, and the mode of communication best understood by
persons with visual or hearing impairments, as applicable.
F. The CTC shall not refuse to admit a
client solely on the basis of the individual living in the community on a court
ordered conditional release.
G. The CTC shall conduct an assessment
for each client presenting for admission. The admission assessment shall contain an
assessment of past trauma or abuse, how the individual served would prefer to
be approached should he become dangerous to himself or to others and the
findings from this initial assessment shall guide the process for determining
interventions.
H. All residential
admissions of youth 14 years of age and older must comply with applicable state
and federal laws.
I. Staff shall inspect clients, their
clothing, and all personal effects for contraband and weapons before admission
to the residential component to ensure the safety of the patient and staff.
J. Discharge planning shall begin upon
admission.
K. Prior to a client returning to a
less restrictive environment, staff, with the consent of the client, shall work
with the client’s support system, as appropriate, to prepare the client for
discharge.
L. Discharge plan and summary
information shall be provided to the client at the time of discharge that
includes:
(1) significant findings relevant to the
client’s recovery;
(2) client crisis stabilization plan and
progress;
(3) recommendations and documentation for
continued care, including appointment times, locations and contact information for
providers;
(4) recommendations for community
services if indicated with contact information for the services;
(5) documentation of notification to the
client’s primary care practitioner, if applicable;
(6) evidence of involvement by the client
as documented by his signature or refusal to sign; and
(7) signatures of all staff
participating in the development of plan.
M. A copy of the discharge plan shall be
provided to post discharge service provider(s).
[8.321.11.25
NMAC - N, 7/1/2024]
8.321.11.26 PROGRAM SERVICES: A licensed mental health professional must
assess each individual with the assessment focusing on the stabilization needs
of the client. It must be done in a
timely manner congruent with the urgency of the presenting crisis, and
consistent with the policies and procedures. The assessment must include: medical and mental health history and status,
the onset of illness, the presenting circumstances, risk assessment, cognitive
abilities, communication abilities, social history and history as a victim of
physical abuse, sexual abuse, neglect, or other trauma as well as history as a
perpetrator of physical or sexual abuse.
A. The CTC shall provide education and
clinical programing designed to meet the stabilization needs of each client and
implement crisis stabilization plans.
B. Crisis stabilization plan - A
licensed mental health professional must document a crisis stabilization plan
to address needs identified in the assessment.
(1) the crisis stabilization plan shall
include at a minimum:
(a) diagnosis, a problem statement or
statement of needs to be addressed;
(b) identification of behavioral health
crisis leading to intake;
(c) goals that address the presenting
crisis, and are consistent with the client’s needs, realistic, measurable,
linked to symptom reduction, and attainable by the client during the client’s
projected length of stay;
(d) specific treatment(s) provided,
method(s) and frequency of treatment, and staff responsible for delivering
treatment;
(e) criteria describing evidence of
stabilization;
(f) discharge planning;
(g) evidence of involvement by the client
and legal guardian as documented by his signature or refusal to sign; and
(h) signatures of all staff participating
in the development of plan.
(2) A copy of the individual crisis
stabilization plan shall be provided to the client, and guardian if applicable.
(3) When program services are offered in
a group setting, groups for adults and groups for youth must be separate.
[8.321.11.26
NMAC - N, 7/1/2024]
8.321.11.27 CLIENT RIGHTS:
A. All licensed facilities shall
understand, protect and respect the rights of all residents. Prior to admission to a CTC, a client,
parent, shall be given the applicable written description of the adult’s or
youth’s legal rights, translated into client’s preferred language, if
necessary, to meet the client’s understanding.
B. A written copy of the adult client's
legal rights shall be provided to the adult client, or agent, if applicable, or
to the most significant responsible party in the following order:
(1) the client's spouse;
(2) significant other;
(3) any of the client's adult children;
(4) the client's parents;
(5) the client’s advocate.
C. The client rights shall be posted in
a conspicuous public place in the facility and shall include the telephone
numbers to contact the authority to file a complaint.
D. To protect client rights, the CTC
shall:
(1) treat all clients with courtesy,
respect, dignity and compassion;
(2) not discriminate in admission or
services based on gender, gender identity, sex, sexual orientation, client's
age, race, color, religion, physical or mental disability, or national origin;
(3) provide clients written information
about all services provided by the CTC and their costs and give advance written
notice of any changes;
(4) provide clients with a clean, safe
and sanitary living environment;
(5) provide a humane psychological and
physical environment of care for all clients;
(6) provide the right to privacy,
including privacy during assessments, examinations, consultations and
treatment;
(7) protect the confidentiality of the
client’s clinical record;
(8) protect the right to personal
privacy, including privacy in personal hygiene; privacy during visits with a
spouse, family member or other visitor; and reasonable privacy in the client's
own room;
(9) protect the client's right to receive
visitors during designated visiting hours except when restricted for good cause
pursuant to a physician’s order;
(10) protect the client's right to receive
visits from his attorney, physician, psychologist, clergyman, or social worker
in private irrespective of visiting hours;
(11) provide clients the ability to send and
receive private correspondence, as well as reasonable private access to
telephone calls and, in cases of personal emergencies, reasonable use of
long-distance calls;
(12) ensure that clients:
(a) are free from physical and emotional
abuse, neglect, and exploitation;
(b) are free to participate or abstain
from the practice of religion and shall be afforded reasonable accommodations
to worship;
(c) have the right to reasonable daily
opportunities for physical exercise and outdoor exercise and shall have
reasonable access to recreational areas and equipment;
(d) have the right to voice grievances to
the CTC staff, public officials, any state agency, or any other person, without
fear of reprisal or retaliation;
(e) have the right to prompt and adequate
medical attention for physical ailments;
(f) have the right to have their
grievance addressed within five days;
(g) have the right to participate in the
development of their crisis stabilization plan;
(h) have the right to participate in
treatment decisions and formulate advance directives such as living wills and
powers of attorney;
(i) have the right to refuse treatment
and to be free from unnecessary or excessive medication; and
(j) have the right to manage and control
their personal finances.
[8.321.11.27
NMAC - N, 7/1/2024]
8.321.11.28 CLIENT CLINICAL RECORD: The client clinical records maintained by a
crisis triage center in a paper-based or electronic system shall document the
degree and intensity of the treatment provided to clients who are furnished
services by the CTC. A client’s clinical
record shall contain at a minimum:
A. the client’s name and address;
B. name, address, and telephone number
of agent, or representatives;
C. the source of referral and relevant
referral information;
D. all reports from client assessment
(see program services assessment);
E. the signed and dated informed
consent for treatment including all medications and transfers;
F. all additional medical and clinical
documentation;
G. the original crisis stabilization
plan and all revisions;
H. documentation of all treatment;
I. laboratory and radiology results,
if applicable;
J. documentation of physical restraint
observations, if utilized;
K. a record of all contacts with
medical and other services;
L. a record of medical treatment and
administration of medication, if administered;
M. an original or original copy of all
physician medication and treatment orders signed by the physician;
N. signed consent for the release of information, if
information is released;
O. discharge plan.
[8.321.11.28
NMAC - N, 7/1/2024]
8.321.11.29 STAFFING REQUIREMENTS:
A. Minimum staffing requirements:
(1) The CTC shall have an on-site administrator,
which can be the same person as the clinical director.
(2) The CTC shall have a full time
clinical director appropriately licensed to provide clinical oversight.
(3) The CTC shall have an RN present
on-site 24 hours a day, seven days a week or as long as clients are present in
programs that do not offer residential services, to provide direct nursing
services. This requirement does not
apply to CTCs offering 23 hours or less non-residential services; instead these
CTCs may have onsite medical professionals who have access to immediate support
and supervision by an RN or a higher-level provider in accordance with Section
24-25-1 et al. NMSA 1978 New Mexico Telehealth Act.
(4) An on-call physician or advanced
practice registered nurse shall be available 24 hours a day by phone, and
available on-site as needed or through telehealth.
(5) Consultation by a psychiatrist or
prescribing psychologist may be provided through telehealth.
(6) The CTC shall maintain sufficient
staff including direct care and mental health professionals to provide for
supervision and the care of residential and non-residential clients served by
the CTC, based on the acuity of client needs.
(7) At least one staff trained in basic
cardiac life support (BCLS) and first aid shall be on duty at all times. In addition, one staff trained in the use of
the automated external defibrillator (AED) equipment shall also be on duty.
B. Other staff requirements:
(1) The CTC shall ensure that the type
and number of professional staff are:
(a) licensed, certified or credentialed
in the professional field as required, and practice within the scope of the
license;
(b) present in numbers to provide
services, supports, care, treatment and supervision to clients as required; and
(c) experienced and competent in the
profession they are licensed or practice.
(2) The CTC shall comply with all
applicable laws, rules and regulations governing caregivers’ criminal history
screen requirements and employee abuse registry requirements.
(3) The CTC shall ensure that, within the
first 60 days of providing direct care to individuals, all staff, volunteers
and contractors having direct contact with clients shall receive required
training.
(4) The CTC shall be staffed to ensure
the safety of clients when staff are accused of abuse, neglect or exploitation.
(5) In instances of involuntary admission as allowed under
amendments to Section 43-1-1 NMSA, Mental Health and Developmental Disabilities Code, adequate staffing must be provided to ensure patient and staff safety, and the CTC must meet medical records requirements for licensure of psychiatric hospitals
as set forth, in 8.370.12 NMAC.
[8.321.11.29
NMAC - N, 7/1/2024]
8.321.11.30 MINIMUM STAFF QUALIFICATIONS:
A. Administrator:
(1) Must be at least 21 years of age.
(2) The administrator shall possess
experience in acute mental health and hold at least a bachelor’s degree in the
human services field or be a registered nurse with experience or training in
acute mental health treatment.
B. Clinical director:
(1) Be at least 21 years of age.
(2) Be a licensed independent mental
health professional or certified nurse practitioner or certified nurse
specialist with experience and training in acute mental health treatment and
withdrawal management services, if withdrawal management services are provided.
C. Registered nurse:
(1) Must be at least 18 years of age.
(2) Must have a current NM Registered
Nurse license.
(3) Must possess experience and training
in acute mental health treatment, and withdrawal management services if
withdrawal management services are provided.
D. Direct service staff must be at
least 18 years of age.
[8.321.11.30
NMAC - N, 7/1/2024]
8.321.11.31 PERSONNEL RECORDS:
A. The CTC shall have policies and
procedures for managing personnel information and records.
B. Staff scheduling records shall be
maintained for at least three years.
C. Employee records shall be kept at
the CTC and include:
(1) employment application;
(2) training records;
(3) licenses and certifications;
(4) caregiver criminal history screening
documentation pursuant to Section 8.370.5 NMAC; and
(5) employee abuse registry documentation
pursuant to Section 8.370.8. NMAC.
[8.321.11.31
NMAC - N, 7/1/2024]
8.321.11.32 STAFF TRAINING:
A. Training for each new employee and
volunteer who provides direct care shall include a minimum of 16 hours of training
and be completed prior to providing unsupervised care to clients.
B. At least 12 hours of on-going
training shall be provided to staff that provides direct care at least
annually; the training and proof of competency shall include at a minimum:
(1) behavioral health interventions;
(2) crisis interventions;
(3) substance use disorders and
co-occurring disorders;
(4) withdrawal management protocols and
procedures, if withdrawal management is provided;
(5) clinical and psychosocial needs of
the population served;
(6) psychotropic medications and possible
side effects;
(7) ethnic and cultural considerations of
the geographic area served;
(8) community resources and services
including pertinent referral criteria;
(9) treatment and discharge planning with
an emphasis on crisis stabilization;
(10) fire safety and evacuation training;
(11) safe food handling practices (for
persons involved in food preparation), to include:
(a) instructions in proper storage;
(b) preparation and serving of food;
(c) safety in food handling;
(d) appropriate personal hygiene; and
(e) infectious and communicable disease
control.
(12) confidentiality of records and client
information;
(13) infection control;
(14) client rights;
(15) reporting requirements for abuse,
neglect or exploitation in accordance with Section 8.370.9 NMAC;
(16) smoking policy for staff, clients and
visitors;
(17) methods to provide quality client care;
(18) emergency procedures; and
(19) adverse medication reactions;
(20) the proper way to implement a crisis
intervention plans.
C. Documentation of orientation and
subsequent trainings shall be kept in the personnel records at the facility.
[8.321.11.32
NMAC - N, 7/1/2024]
8.321.11.33 MINIMUM SAFETY REQUIREMENTS:
A. The CTC shall have policies and
procedures regarding authorized entry to or exit from the CTC including the
residential component.
B. Control of potentially injurious
items shall be clearly defined in policy to include:
(1) prohibition of flammables, toxins,
ropes, wire clothes hangers, sharp pointed scissors, luggage straps, belts,
knives, shoestrings, or other potentially injurious items;
(2) management of housekeeping supplies
and chemicals, including procedures to avoid access by individuals during use
or storage. Whenever practical, supplies
and chemicals shall be non-toxic or non-caustic;
(3) safeguarding use and disposal of
nursing and medical supplies including drugs, needles and other “sharps” and
breakable items;
(4) the use of durable materials for
furniture not capable of breakage into pieces that could be used as weapons or
present a hanging risk.
C. To the fullest extent permitted by
law, weapons shall be prohibited at the CTC.
D. All law enforcement officers or
other individuals authorized by law to carry firearms shall be asked to leave
their firearms locked in their vehicles or placed in a secure lockbox in an
area in the CTC which is not accessible to clients.
E. The CTC shall develop and implement
policies and procedures that describe interventions that prevent crises,
minimize incidents when they occur, and are organized in a least to most
restrictive sequence. The written
policies and procedures shall:
(1) emphasize positive approaches to
interventions;
(2) protect the health and safety of the
individual served at all times; and
(3) specify the methods for documenting
the use of the interventions.
[8.321.11.33
NMAC - N, 7/1/2024]
8.321.11.34 NUTRITION: The CTC shall provide planned and
nutritionally balanced meals to its residential clients and any client treated
at the CTC for eight hours or longer from the basic food groups in accordance
with the “recommended daily dietary allowance” of the American dietetic
association, the food and nutrition board of the national research council, or
the national academy of sciences. Meals
shall meet the nutritional needs of the residents in accordance with the
current USDA dietary guidelines for Americans, vending machines shall not be
considered a source of snacks. Dietary
services: The CTC will develop and
implement written policies and procedures that are maintained on the premises. All CTC food service operations for residents
shall comply with current federal and state laws and rules concerning food
service and shall include:
A. at least three nutritious meals per
day shall be served;
B. no more than 14 hours may elapse
between the end of an evening meal and the beginning of a morning meal;
C. therapeutic diets shall be provided
when ordered by the physician;
D. under no circumstances may food be
withheld for disciplinary reasons;
E. each CTC shall have seating capacity
to reflect the licensed capacity, although clients may eat or be served in shifts
during daily operations;
F. nutritional snacks shall be
available to each client; and
G. weekly menus shall be posted in the
dining area.
[8.321.11.34
NMAC - N, 7/1/2024]
8.321.11.35 PHARMACEUTICAL SERVICES:
A. Pharmacological services shall be
provided only on order by a prescribing professional and in accordance with the
terms and conditions of such professional’s license. These services may be administered or
monitored, if self-administered, by nursing staff.
B. The CTC shall establish and
implement policies, procedures and practices that guide the safe and effective
use of medications and shall, at a minimum, address the following:
(1) Medications shall be administered
upon direct order from a licensed prescriber, and the orders for medications
and care shall be written and signed by the licensed prescriber;
(2) Medications shall be used solely for
the purposes of providing effective treatment..
C. There shall be no standing orders
for psychotropic medication.
(1) Every order given by telephone shall
be received by an RN or LPN and shall be recorded immediately and read back to
the ordering physician. The order shall
include the ordering physician’s name and shall be signed by a physician within
24 hours. Such telephone orders shall
include a note on the order that an order was made by telephone, and the
content of, justification for, and the time and date of the order.
(2) Medication management policies and
procedures shall follow federal and state laws, rules and regulations, and
shall direct the management of medication ordering, procurement, prescribing,
transcribing, dispensing, administration, documentation, wasting or disposal
and security, to include the management of controlled substances, floor stock,
and physician sample medications.
(3) The CTC shall develop a policy on
informed consent on medication, including the right to refuse medication and
the CTC’s plan for transfer of patients who lack capacity to consent to
medications.
(4) The CTC shall develop and implement
policies and procedures that describe actions to follow when adverse drug
reactions and other emergencies related to the use of medications occur, and
emergency medical care that may be initiated by a registered nurse in order to
mitigate a life-threatening situation.
D. Medication distribution stations
shall be in accordance with standards set forth by the New Mexico board of
pharmacy.
E. Drugs and biologicals must be
stored, prepared and administered in accordance to acceptable standards of
practice and in compliance with the New Mexico state board of pharmacy.
F. Outdated drugs and biologicals must
be disposed of in accordance with methods outlined by the New Mexico state
board of pharmacy.
G. One individual shall be designated
responsible for pharmaceutical services to include accountability and
safeguarding.
H. Keys to the drug room or pharmacy
must be made available only to personnel authorized by the individual having
responsibility for pharmaceutical services.
I. Adverse reactions to medications
must be reported to the physician responsible for the patient and must be
documented in the patient's record.
[8.321.11.35
NMAC - N, 7/1/2024]
8.321.11.36 LABORATORY SERVICES:
A. Laboratory work and other diagnostic
procedures deemed necessary shall be performed as ordered by the physician.
B. The CTC shall comply with clinical
laboratory improvement amendments of 1988 (CLIA) requirements.
C. All lab test results performed
either at the CTC or by contract or arrangement with another entity must be
entered into the patient’s record.
[8.321.11.36
NMAC - N, 7/1/2024]
8.321.11.37 INFECTION CONTROL:
A. The CTC shall develop and implement
policies and procedures for infection control and prevention. Policies shall include: educational course
requirements; decontamination; disinfection and storage of sterile supplies;
cleaning; and laundry requirements, and address the following:
(1) universal precautions when handling
blood, body substances, excretions, secretions;
(2) proper disposal of biohazards;
(3) proper hand washing techniques;
(4) prevention and treatment of needle
stick or sharp injuries; and
(5) the management of common illness
likely to be emergent in the CTC service setting and specific procedures to
manage infectious diseases.
B. The CTC's infection control risk
assessment and plan is reviewed annually for effectiveness and revision, if
necessary.
C. Staff shall be trained in and shall
adhere to infection control practices, the release of confidential information
and reporting requirements related to infectious diseases.
D. Where cleaning and decontamination
of equipment and supplies are performed in the same room where clean or sterile
supplies and equipment are stored, there shall be a physical separation of the
clean or sterile supplies and equipment.
E. All special waste including blood,
body fluids, sharps and biological indicators shall be disposed of in
accordance with OSHA and the New Mexico environment department standards for
biohazardous waste.
F. Each CTC shall have policies and
procedures for the handling, processing, storing and transporting of clean and
dirty laundry.
[8.321.11.37
NMAC - N, 7/1/2024]
8.321.11.38 RESEARCH:
A. If a CTC is conducting research
activities, the CTC must have written policies and procedures for conducting
research, documentation that the study has received institutional review board
(IRB) approval, and a consent form for each client involved in the research in
the client's record.
B. When research is conducted by the CTC
or by the employees or by affiliates of the CTC or when the CTC is used as a
research site, such that the CTC's clients and staff are involved in or the
subjects of research; the research must be conducted:
(1) by qualified researchers, having
evidence in formal training and experience in the conduct of clinical, epidemiologic
or sociologic research;
(2) in accordance with the written,
approved research policies and procedures;
(3) by staff trained to conduct such research;
and
(4) in a manner that protects the
client’s health, safety and right to privacy and the CTC and its clients from
unsafe practices.
[8.321.11.38
NMAC - N, 7/1/2024]
8.321.11.39 CLIENT TRANSFERS:
A. The CTC shall have policies and
procedures to stabilize and transfer clients in need of a higher level of care.
B. The CTC shall:
(1) discuss recommendations for transfer
with the client or client’s legal guardian or agent and upon transfer, notify
the client’s legal guardian or agent;
(2) make the determination as to the time
and manner of transfer to ensure no further deterioration of the client during
the transfer between facilities;
(3) specify the benefits expected from
the transfer in the client’s record;
(4) coordinate care with receiving facility
prior to transfer; and
(5) send a copy of the client’s record
with the client upon transfer.
[8.321.11.39
NMAC - N, 7/1/2024]
8.321.11.40 BUSINESS HOURS: The CTC shall post hours of operation and
admissions on signage exterior to the building.
[8.321.11.40
NMAC - N, 7/1/2024]
8.321.11.41 PHYSICAL ENVIRONMENT AND GENERAL
BUILDING REQUIREMENTS:
A. When construction of new buildings,
additions, or alterations to existing buildings are contemplated, plans and
specifications covering all portions of the work must be submitted to the
licensing authority for plan review and approval prior to beginning actual
construction. When an addition or
alteration is contemplated, plans for the entire CTC must be submitted.
B. CTCs licensed pursuant to these
regulations must be accessible to and useable by disabled employees, staff,
visitors, and clients and in compliance with the American’s with Disabilities
Act (ADA), current edition.
C. All buildings of the premises
providing client care and services will be considered part of the CTC and must
meet all requirements of these regulations. Where a part of the CTC services is contained
in another facility, separation and access shall be maintained as described in
current building and fire codes.
D. A CTC applying for licensure
pursuant to these regulations may have additional requirements not contained
herein. The complexity of building and
fire codes and requirements of city, county, or municipal governments may
stipulate these additional requirements. Any additional requirements will be outlined
by the appropriate building and fire authorities, and by the licensing
authority through plan review, consultation and on-site surveys during the
licensing process.
[8.321.11.41
NMAC - N, 7/1/2024]
8.321.11.42 COMMON ELEMENTS FOR FACILITIES:
A. Public services shall include:
(1) conveniently accessible wheelchair
storage;
(2) an ADA compliant reception and
information counter or desk;
(3) waiting areas;
(4) conveniently accessible public
toilets; and
(5) drinking fountain (s) or water
dispensers easily accessible to clients or other visitors.
B. Interview space(s) for private
interviews related to mental health, medical information, etc., shall be
provided.
C. General or individual office(s) for
business transactions, records, administrative, and professional staff shall be
provided. These areas shall be separated from public areas for confidentiality.
D. Special storage for staff personal
effects with locking drawers or cabinets shall be provided.
E. General storage facilities for
supplies and equipment shall be provided.
[8.321.11.42
NMAC - N, 7/1/2024]
8.321.11.43 PROVISIONS FOR EMERGENCY CALLS:
A. An easily accessible hard-wired
telephone for summoning help, in case of emergency, must be available in the CTC.
B. A list of emergency numbers
including, but not limited to, fire department, police department, ambulance
services, local hospital, poison control center, and the authority’s division
of health improvement’s complaint hotline must be prominently posted by the
telephone(s).
[8.321.11.43
NMAC - N, 7/1/2024]
8.321.11.44 PARKING:
Sufficient
space for off-street parking for staff, clients and visitors shall be provided.
A designated parking space(s) for one
emergency, and one police vehicle shall be provided. Parking should be compliant with local zoning
requirements and the 2009 New Mexico commercial building code, or current
version.
[8.321.11.44
NMAC - N, 7/1/2024]
8.321.11.45 MAINTENANCE OF BUILDING AND GROUNDS: Facilities must maintain the building(s) in
good repair at all times. Such
maintenance shall include, but is not limited to, the following:
A. all electrical, mechanical, water
supply, heating, fire protection, and sewage disposal systems must be
maintained in a safe and functioning condition, including regular inspections
of these systems;
B. all equipment and materials used for
client care shall be maintained clean and in good repair;
C. all furniture and furnishings must
be kept clean and in good repair; and
D. the grounds of the CTC must be
maintained in a safe and sanitary condition at all times.
[8.321.11.45
NMAC - N, 7/1/2024]
8.321.11.46 HOUSEKEEPING:
A. The CTC must be kept free from
offensive odors and accumulations of dirt, rubbish, dust, and safety hazards.
B. Treatment rooms, waiting areas and
other areas of daily usage must be cleaned as needed to maintain a clean and
safe environment for the clients.
C. Floors and walls must be constructed
of a finish that can be easily cleaned. Floor
polishes shall provide a slip resistant finish.
D. Deodorizers must not be used to mask
odors caused by unsanitary conditions or poor housekeeping practices.
E. Storage areas must be kept free from
accumulation of refuse, discarded equipment, furniture, paper, et cetera.
[8.321.11.46
NMAC - N, 7/1/2024]
8.321.11.47 CUSTODIAL CLOSET(S):
A. Each CTC shall have at least one
custodial closet which must be locked and restricted from client access.
B. Each custodial closet shall contain:
(1) a service sink; and
(2) storage for housekeeping supplies and
equipment.
C. Each custodial closet must be
mechanically vented to the exterior.
D. Custodial closets are hazardous
areas and must be provided with one hour fire separation and one and
three-quarter inches solid core doors which are rated at a 20 minute fire
protection rating.
[8.321.11.47
NMAC - N, 7/1/2024]
8.321.11.48 HAZARDOUS AREAS:
A. Hazardous areas include the
following:
(1) fuel fired equipment rooms;
(2) bulk laundries or laundry rooms with
more than 100 sq. ft.;
(3) storage rooms with more than 50 sq.
ft. but less than 100 sq. ft. not storing combustibles;
(4) storage rooms with more than 100 sq.
ft. storing combustibles;
(5) chemical storage rooms with more than
50 sq. ft.; and
(6) garages, maintenance shops, or
maintenance rooms.
B. Hazardous areas on the same floor or
abutting a primary means of escape or a sleeping room shall be protected by
either:
(1) an enclosure of at least one-hour
fire rating with self-closing or automatic closing on smoke detection fire
doors having a three-quarter hour rating; or
(2) an automatic fire protection
(sprinkler) and separation of hazardous area with self-closing doors or doors
with automatic-closing on smoke detection; or
(3) any other hazardous areas shall be
enclosed with walls with at least a 20 minute fire rating and doors equivalent
to one and three-quarter inches solid bonded wood core, operated by
self-closures or automatic closing on smoke detection.
C. All boiler, furnace or fuel fired
water heater rooms shall be protected from other parts of the building by
construction having a fire resistance rating of not less than one hour. Doors to these rooms shall be one and three-quarter
inches solid core.
[8.321.11.48
NMAC - N, 7/1/2024]
8.321.11.49 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.
[8.321.11.49
NMAC - N, 7/1/2024]
8.321.11.50 EXITS:
A. Each floor of a CTC shall have exits
as required by the New Mexico commercial building code and applicable version
of the National fire protection association 11.
B. Each exit must be marked by
illuminated exit signs having letters at least six inches high whose principle
strokes are at least three quarters 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.
[8.321.11.50
NMAC - N, 7/1/2024]
8.321.11.51 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. For facilities contained within
existing commercial or residential buildings, less stringent corridor widths
may be allowed if not in conflict with building or fire codes. A waiver or variance may be requested but
must be approved by the licensing authority prior to occupying the licensed
part of the building.
[8.321.11.51
NMAC - N, 7/1/2024]
8.321.11.52 STAFF STATION:
A. Each client care area in the
residential unit shall have a staff station located to provide visual or
virtual monitoring of all resident room corridors and access to secured access
to outdoor area, equipped with access to residential clients’ records, a desk
or work counter, a cleaning area with a sink with hot and cold running water,
operational telephone, and emergency call system.
B. Locked storage area for drugs or
pharmacy grade, locked medication cart.
C. Access to a biohazard disposal unit
for needles, and other “sharps,” and breakable items.
D. A reliable monitored emergency call
system shall be provided for staff use in the event of an emergency.
E. If a kitchen is not open at all
times to residents, a nourishment station with sink, hot and cold running
water, refrigerator, and storage for serving residents between meal nourishment
shall be provided.
F. View of fire alarm control panel,
generator panel (if any), and any other life safety code components.
[8.321.11.52
NMAC - N, 7/1/2024]
8.321.11.53 SECURED ENVIRONMENT/OUTDOOR AREA:
A. The CTC shall provide a secure
environment for client safety. A secured
environment is a CTC and grounds that have secured or monitored exits. A secured environment for facilities that
offer residential services may include but is not limited to: double alarm
systems; gates connected to the fire alarm; or tab alarms for residents at risk
for elopement. Locked areas shall have
an access code or key which CTC employees shall have on their person or
available at all times in accordance with the Life Safety Code, NPFA 11, 212 or
subsequent updates. For a CTC located
within an existing licensed facility, a request for waiver may be submitted to
the licensing authority containing an alternate plan for providing security for
clients, provided that health, safety or welfare of the clients or staff would
not be adversely affected.
B. In addition to the interior common
areas required by this rule, a CTC providing residential services shall provide
an outdoor secured environment independently accessible to residents for their
year-round use.
(1) Fencing or other enclosures, not less
than six feet high, shall protect the safety, security and privacy of the
residents and have emergency egress gates that are connected to the emergency
call system.
(2) Outdoor area shall not provide access
to contact with the public.
[8.321.11.53
NMAC - N, 7/1/2024]
8.321.11.54 ASSESSMENT ROOMS:
A. general purpose assessment rooms
shall meet the following requirements:
B. minimum floor area of 80 square
feet, excluding vestibules, toilets, and closets;
C. room arrangement shall permit at
least two feet - eight inch clearance around furniture items used for exam or
assessment;
D. a lavatory or sink for hand washing.
[8.321.11.54
NMAC - N, 7/1/2024]
8.321.11.55 THERAPY/TREATMENT ROOMS:
A. Shall have a minimum floor area of
120 square feet, excluding vestibule, toilet, and closets.
B. All walls shall be constructed to a
minimum length of 10 feet.
[8.321.11.55
NMAC - N, 7/1/2024]
8.321.11.56 ACTIVITY OR MULTIPURPOSE ROOM: The CTC shall provide a minimum of 250 square
feet for common living area, dining and social spaces, or 40 square feet per
resident, whichever is greater.
A. The CTC shall have a living or
multipurpose room for the use of the residents. The furnishings shall be well constructed,
comfortable and in good repair.
B. The activity or multi-purpose room
may be used as a dining area.
C. The activity room or multipurpose
rooms shall be provided with supplies to reasonably meet the interests and
needs of the residents.
D. Each activity room shall have a
window area of at least one tenth of the floor area with a minimum of at least
10 square feet.
E. A dining area shall be provided for
meals. Facilities shall have tables and
chairs in the dining area to accommodate the total number of residents in one
sitting. All seating arrangements during
meals shall allow clear access to the exits. Lunch times for adults and youth must be
separate if there is only one lunch room.
[8.321.11.56
NMAC - N, 7/1/2024]
8.321.11.57 MEETING ROOM: The CTC shall have adequate meeting rooms and
office space for use by staff, the interdisciplinary care team and client and
family visits. Other rooms may serve as
meeting rooms, provided resident confidentiality is maintained. Meeting and treatment rooms must not hold both
adults and youth at the same time.
[8.321.11.57
NMAC - N, 7/1/2024]
8.321.11.58 RESIDENT ROOMS: The regulations in Section 8.321.11.58 NMAC
apply to those facilities providing a residential treatment program.
A. A CTC providing residential
treatment shall not exceed the bed capacity approved by the licensing
authority.
B. Resident rooms may be private or
semi-private or dormitory style depending on assessed, resident acuity and need
Resident rooms must be separated by gender.
C. Facilities serving youth and adults
must locate youth resident rooms and restrooms in a unit or wing that is
physically separated from the adult facilities.
(1) Private rooms shall have a minimum of
100 square feet of floor area. The
closet and locker area shall not be counted as part of the available floor
space.
(2) Semi-private rooms shall have a
minimum of 80 square feet of floor area for each resident and shall be
furnished in such a manner that the room is not crowded and passage out of the
room is not obstructed.
(3) A separate closet, bed (at least 36
inch wide), chair, towel bar, and non-metal trash receptacle, for each resident
shall be provided.
(4) The beds shall be spaced at least
three feet apart. Bunk beds, roll away
beds, stacked beds, hide-a-beds, or beds with springs, cranks, rails or wheels,
are not allowed.
D. Each resident room shall have a
window to the outside. The area of the
outdoor window shall be at least one tenth of the floor area of the room and
allow for emergency egress. Windows may
be textured or obscured glass to provide privacy without the use of any window
coverings.
E. Resident rooms shall not be less
than seven feet in any horizontal direction.
F. There must be no through traffic in
resident rooms. Resident rooms must
connect directly to hallway or other internal common areas of the facility.
[8.321.11.58
NMAC - N, 7/1/2024]
8.321.11.59 TOILETS, LAVATORIES AND BATHING
FACILITIES:
A. General
Requirements:
(1) All fixtures and plumbing must be
installed in accordance with current state and local plumbing codes.
(2) All toilets must be enclosed and
vented.
(3) All toilet rooms must be provided
with a lavatory for hand washing.
(4) All toilets must be kept supplied
with toilet paper.
(5) All lavatories for hand washing must
be kept supplied with disposable towels for hand drying or provided with
mechanical blower.
(6) The number of and location of
toilets, lavatories and bathing facilities shall be in accordance with
International Building Code (IBC) requirements. Toilets for public use shall be located
adjacent to the waiting area. Such
factors as extent of services provided and size of CTC will also dictate
requirements.
(7) Facilities serving youth must provide
separate toilet and shower facilities for adults and youth.
B. Residential
component: Separate facilities shall
be provided for male and female patients.
Toilet and bathing facilities shall be located appropriately to meet the
needs of residents.
(1) Facilities serving youth and adults
must locate youth resident rooms and restrooms in a unit or wing that is
physically separated from the adult facilities.
(2) A minimum of one toilet, one lavatory
and one bathing unit (tub, shower, or combo unit) shall be provided for every
eight residents or fraction thereof.
(3) Toilets to be flush meter type (no
tank).
(4) Mirrors
cannot be glass or polished metal. A
polycarbonate mirror, fully secured and flat mounted to the wall is required.
(5) Individual shower stalls and dressing
areas shall be provided. The shower head
shall be recessed or have as smooth curve from which items cannot be hung.
(6) There shall not be any overhead rods,
fixtures or privacy stall supports or protrusions capable of carrying more than
a 30-pound load.
C. Staff
restroom: The CTC shall provide a
separate staff toilet including, lavatory and shower, near staff station.
[8.321.11.59
NMAC - N, 7/1/2024]
8.321.11.60 COLLECTION/DRAW/LAB AREA: Facilities shall be reward to support
laboratory procedures, if provided.
Minimum facilities provided on-site shall include space for the
following:
A. A urine collection room equipped
with a toilet and hand washing sink.
B. Blood collection facilities with
space for a chair, work counter, and lavatory.
C. Each CTC shall have accommodations
for storage and refrigeration of blood, urine and other specimens in a
dedicated specimen refrigerator.
[8.321.11.60
NMAC - N, 7/1/2024]
8.321.11.61 NUTRITION: A CTC offering a residential treatment program
shall provide planned and nutritionally balanced meals from the basic food
groups in accordance with the “recommended daily dietary allowance” of the
American dietetic association, the food and nutrition board of the national
research council, or the national academy of sciences.
A. Menus must be approved by a licensed
nutritionist. Meals shall meet the
nutritional needs of the residents in accordance with the current USDA dietary
guidelines for Americans. Vending
machines shall not be considered a source of snacks.
B. Dietary services. The CTC will develop and implement written
policies and procedures that are maintained on the premises. All CTC food service operations for residents
shall comply with current federal and state laws and rules concerning food
service and shall include:
(1) at least three nutritious meals per
day shall be served;
(2) no more than 14 hours may elapse
between the end of an evening meal and the beginning of a morning meal;
(3) therapeutic diets shall be provided
when ordered by the physician;
(4) under no circumstances may food be
withheld for disciplinary reasons;
(5) each CTC shall have seating capacity
to accommodate the licensed capacity and be able to feed adult and youth
clients separately, although clients may eat or be served in shifts during
daily operations;
(6) nutritional snacks shall be available
to each client; and
(7) weekly menus shall be posted in the
dining area.
[8.321.11.61
NMAC - N, 7/1/2024]
8.321.11.62 FOOD SERVICE: Requirements of Section 8.321.11.62 NMAC
apply to facilities providing a residential treatment program.
A. The CTC shall have either contracted
food preparation or prepare food on site.
B. A CTC that contracts food
preparation shall have a dietary or a kitchen area adequate to meet food
service needs and arranged and equipped for the refrigeration, storage,
preparation, and serving of food, dish and utensil cleaning and refuse storage
and removal.
C. Dietary areas consisting of a food
warming and refrigeration area shall comply with the local health or food
handling codes. Food preparation space
shall be arranged for the separation of functions and shall be located to
permit efficient services to residents and shall not be used for non-dietary
functions.
D. A CTC that provides onsite food
preparation shall comply with the New Mexico environment department food
preparation regulations.
E. A CTC with a kitchen area, whether
used for on-site food preparation or not, must adhere to the following
requirements:
(1) limit traffic incidental to the
receiving, preparation and serving of food and drink;
(2) toilet facilities may not open
directly into the kitchen;
(3) food day-storage space shall be
provided adjacent to the kitchen and shall be ventilated to the outside;
(4) a separate hand washing sink with
soap dispenser, single service towel dispenser, or other approved hand drying
facility shall be located in the kitchen;
(5) a separate dishwashing area,
preferably a separate room, with mechanical ventilation shall be provided;
(6) at least a three compartment sink
shall be provided for washing, rinsing and sanitizing utensils, with adequate
drain boards, at each end. In addition, a single-compartment sink located
adjacent to the soiled utensil drain board shall be available for prewashing
and liquid waste disposal. The size of
each sink compartment shall be adequate to permit immersion of at least fifty
percent of the largest utensil used. In
lieu of the additional sink for prewashing, a well-type garbage disposal with
overhead spray wash may be provided.
(7) mechanical dishwashers and utensil
washers, where provided, shall meet the requirements of the current approved
list from the national sanitation foundation or equivalent with approval of the
authority;
(8) temperature gauges shall be located
in the wash compartment of all mechanical dishwashers and in the rinse water
line at the machine of a spray-type mechanical dishwasher or in the rinse water
tank of an immersion-type dishwasher. The
temperature gauges shall be readily visible, fast-acting and accurate to plus
or minus two degrees fahrenheit
or one degree celsius;
(9) approved automatic fire extinguishing
equipment shall be provided in hoods and attached ducts above all food cooking
equipment;
(10) the walls shall be of plaster or
equivalent material with smooth, light- colored, nonabsorbent, and washable
surface;
(11) the ceiling shall be of plaster or
equivalent material with smooth, light-colored, nonabsorbent, washable, and
seamless surface;
(12) the floors of all rooms, except the
eating areas of dining rooms, in which food or drink is stored, prepared, or
served, or in which utensils are washed, shall be of such construction as to be
non-absorbent and easily cleaned;
(13) an exterior door from a food
preparation area shall be effectively screened. Screen doors shall be self-closing;
(14) all rooms in which food or drink is
stored or prepared or in which utensils are washed shall be well lighted;
(15) rooms subject to sewage or wastewater
backflow or to condensation or leakage from overhead water or waste lines shall
not be used for storage of food preparation unless provided with acceptable
protection from such contamination.
[8.321.11.62
NMAC - N, 7/1/2024]
8.321.11.63 LAUNDRY SERVICES:
A. General requirements. The CTC shall provide laundry services, either
on the premises or through a commercial laundry and linen service.
(1) On-site laundry facilities shall be
located in areas separate from the resident units and shall be provided with
necessary washing and drying equipment.
(2) Soiled laundry shall be kept separate
from clean laundry, unless the laundry facility is provided for resident use
only.
(3) Staff shall handle, store, process
and transport linens with care to prevent the spread of infectious and
communicable disease.
(4) Soiled laundry shall not be stored in
the kitchen or dining areas. The
building design and layout shall ensure the separation of laundry room from
kitchen and dining areas. An exterior
route to the laundry room is not an acceptable alternative, unless it is
completely enclosed.
(5) All linens shall be changed as needed
and at least weekly or when a new resident is to occupy the bed.
(6) The mattress pad, blankets and
bedspread shall be laundered as needed and when a new resident is to occupy the
bed.
(7) Bath linens consisting of hand towel,
bath towel and washcloth shall be changed as needed and at least weekly.
(8) There shall be a clean, dry,
well-ventilated storage area provided for clean linen.
(9) CTC laundry supplies and cleaning
supplies shall not be kept in the same storage areas used for the storage of
foods and clean storage and shall be kept in a secured room or cabinet.
(10) CTC shall have a small washer and dryer
for immediate unit needs and to wash clients’ clothes. These washing and drying units shall be
equipped to sanitize clothes as a preventive measure of infection control.
(11) Residents may do their own laundry, if
it is their preference and they are capable of doing so.
[8.321.11.63
NMAC - N, 7/1/2024]
8.321.11.64 WATER:
A. A CTC licensed pursuant to these
regulations must be provided with an adequate supply of water that is of a safe
and sanitary quality suitable for domestic use.
B. If the water supply is not obtained
from an approved public system, the private water system must be inspected,
tested, and approved by the New Mexico environment department prior to
licensure. It is the CTC's
responsibility to ensure that subsequent periodic testing or inspection of such
private water systems be made at intervals prescribed by the New Mexico
environment department or recognized authority.
C. Hot and cold running water under
pressure must be distributed at sufficient pressure to operate all fixtures and
equipment during maximum demand periods.
D. Back flow preventers (vacuum breakers)
must be installed on hose bibs, laboratory sinks, service sinks, and on all
other water fixtures to which hoses or tubing can be attached.
E. Water distribution systems are
arranged to provide hot water at each hot water outlet at all times.
F. Hot water to hand washing facilities
must not exceed 120 degrees fahrenheit.
[8.321.11.64
NMAC - N, 7/1/2024]
8.321.11.65 SEWAGE AND WASTE DISPOSAL:
A. All sewage and liquid wastes must be
disposed of into a municipal sewage system where such facilities are available.
B. Where a municipal sewage system is
not available, the system used must be inspected and approved by the New Mexico
environment department or recognized local authority.
C. Where municipal or community garbage
collection and disposal service are not available, the method of collection and
disposal of solid wastes generated by the CTC must be inspected and approved by
the New Mexico environment department or recognized local authority.
D. All garbage and refuse receptacles
must be durable, have tight fitting lids, must be insect and rodent proof,
washable, leak proof and constructed of materials which will not absorb
liquids. Receptacles must be kept closed
and clean.
[8.321.11.65
NMAC - N, 7/1/2024]
8.321.11.66 ELECTRICAL STANDARDS:
A. All electrical installation and
equipment must comply with all current state and local codes.
B. Circuit breakers or fused switches
that provide electrical disconnection and over current protection shall be:
(1) enclosed or guarded to provide a dead
front assembly;
(2) readily accessible for use and
maintenance;
(3) set apart from traffic lanes;
(4) located in a dry, ventilated space,
free of corrosive fumes or gases;
(5) able to operate properly in all
temperature conditions;
(6) panel boards servicing lighting and
appliance circuits shall be on the same floor and in the same facility area as
the circuits they serve; and
(7) each panel board will be marked
showing the services.
C. The use of jumpers or devices to
bypass circuit breakers or fused switches is prohibited.
D. Light switches and electrical
devices in the residential unit shall be secured with tamper resistant screws.
[8.321.11.66
NMAC - N, 7/1/2024]
8.321.11.67 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.
E. Lighting fixtures in the residential
unit shall be recessed, tamperproof or protective translucent cover.
[8.321.11.67
NMAC - N, 7/1/2024]
8.321.11.68 ELECTRICAL CORDS AND RECEPTACLES:
A. Electrical
cords and extension cords shall:
(1) be U/L approved;
(2) be replaced as soon as they show
wear;
(3) be plugged into an electrical
receptacle within the room where used;
(4) not be used as a general wiring
method; and
(5) not be used in series.
B. Electrical
receptacles shall:
(1) Be duplex-grounded type electrical
receptacles (convenience outlets) and installed in all areas in sufficient
quantities for tasks to be performed as needed.
(2) Be a ground fault circuit interrupter
if located within six feet of a water source.
C. The use of
multiple sockets (gang plugs) in electrical receptacles is strictly prohibited.
[8.321.11.68
NMAC - N, 7/1/2024]
8.321.11.69 EMERGENCY POWER & LIGHTING: Emergency electrical service with an
independent power source which covers lighting at attendant stations, exit and
corridor lights, boiler room, and fire alarm systems shall be provided.
A. The service may be battery operated
if effective for at least four hours.
B. Facilities shall have emergency
lighting with a minimum of two bulbs to light exit passageways.
C. Independent power source shall be in
an exterior area near the exits and activate automatically upon disruption of
electrical service.
[8.321.11.69
NMAC - N, 7/1/2024]
8.321.11.70 FIRE SAFETY COMPLIANCE: All current applicable requirements of state
and local codes
for
fire prevention and safety must be met by the CTC.
[8.321.11.70
NMAC - N, 7/1/2024]
8.321.11.71 FIRE CLEARANCE AND INSPECTIONS: Each CTC must request from the fire authority
having
jurisdiction an annual fire inspection. If
the policy of the fire authority having jurisdiction does not provide
for
annual inspection of the CTC, the CTC must document the date the request was
made and to whom. If the
fire
authorities do make annual inspections; a copy of the latest inspection must be
kept on file in the CTC.
[8.321.11.71
NMAC - N, 7/1/2024]
8.321.11.72 AUTOMATIC FIRE PROTECTION (SPRINKLER)
SYSTEM:
Facilities with residential services
shall have an automatic fire protection (sprinkler) system. The system shall be in accordance with NFPA 13
or NFPA 13D or its subsequent replacement as applicable. Sprinkler heads in the residential unit shall
be of the protective type, either vandal proof or tamper resistant. Sprinkler systems for facilities without
residential services must be incompliance with current state building code
requirements regarding a sprinkler system.
[8.321.11.72
NMAC - N, 7/1/2024]
8.321.11.73 FIRE ALARMS, SMOKE DETECTORS AND OTHER
EQUIPMENT:
The system shall be in accordance with
NFPA 13 or NFPA 13D or its subsequent replacement as applicable.
A. Facilities shall have a manual fire
alarm system. The manual fire alarm
shall be inspected and approved in writing by the fire authority with
jurisdiction.
B. Approved smoke detectors shall be
installed on each floor that when activated provides an alarm which is audible
in all sleeping areas. Areas of
assembly, such as the dining, living or activity room(s) must also be provided
with smoke detectors.
(1) Detectors shall be powered by the
house electrical service and have battery backup.
(2) Construction of new facilities or
facilities remodeling or replacing existing smoke detectors shall provide
detectors in common living areas and in each sleeping room.
(3) Smoke detectors shall be installed in
corridors at no more than 30 feet spacing.
(4) Heat detectors shall be installed in
all kitchens and also powered by the house electrical service.
[8.321.11.73
NMAC - N, 7/1/2024]
8.321.11.74 FIRE EXTINGUISHERS: Fire extinguisher(s) must be located in the CTC,
as approved by the state fire marshal or the fire prevention authority with
jurisdiction.
A. Facilities must as a minimum have
two 2A10BC fire extinguishers:
(1) one extinguisher located in the
kitchen or food preparation area;
(2) one extinguisher centrally located in
the CTC;
(3) all fire extinguishers shall be
inspected yearly, recharged as needed and tagged noting the date of the
inspection;
(4) The maximum distance between fire
extinguishers shall be 50 feet.
B. Fire extinguishers, alarm systems,
automatic detection equipment and other firefighting equipment shall be
properly maintained and inspected as recommended by the manufacturer, state
fire marshal, or the local fire authority.
[8.321.11.74
NMAC - N, 7/1/2024]
8.321.11.75 STAFF FIRE AND SAFETY TRAINING:
A. All staff of the CTC must know the
location of and instructed in proper use of fire extinguishers and other
procedures to be observed in case of fire or other emergencies. The CTC should request the fire authority
having jurisdiction to give periodic instruction in fire prevention and
techniques of evacuation.
B. CTC staff must be instructed as part
of their duties to constantly strive to detect and eliminate potential safety
hazards, such as loose handrails, frayed electrical cords, faulty equipment,
blocked exits or exit ways, and any other condition which could cause burns,
falls, or other personal injury to the patients or staff.
C. Fire and evacuation drills: The CTC must conduct at least one fire and
evacuation drill for each work shift for each quarter. When drills are conducted between 9:00 pm and
6:00 am, a coded announcement shall be permitted for use instead of audible
alarms. A log must be maintained by the CTC
showing the date, time, number of staff participating and outlining any
problems noted in the conduct of the drill.
[8.321.11.75
NMAC - N, 7/1/2024]
8.321.11.76 EVACUATION PLAN: Each CTC must
have a fire evacuation plan conspicuously posted in
each
separate area of the building showing routes of evacuation in case of fire or
other emergencies.
[8.321.11.76
NMAC - N, 7/1/2024]
8.321.11.77 HEATING, VENTILATION, AND
AIR-CONDITIONING:
A. Heating, air-conditioning, piping,
boilers, and ventilation equipment must be furnished, installed and maintained
to meet all requirements of current state and local mechanical, electrical, and
construction codes.
B. The heating, ventilation and
air-conditioning system must be able to maintain interior temperatures in all
rooms used by clients, staff or visitors with interior temperatures between 65
degrees fahrenheit
and 78 degrees fahrenheit
year-round.
C. The use of non-vented heaters, open
flame heaters or portable heaters is prohibited.
D. An ample supply of outside air must
be provided in all spaces where fuel fired boilers, furnaces, or heaters are
located to assure proper combustion.
E. All fuel fired boilers, furnaces, or
heaters must be connected to an approved venting system to take the products of
combustion directly to the outside air.
F. A CTC must be adequately ventilated
at all times to provide fresh air and the control of unpleasant odors.
G. All gas-fired heating equipment must
be provided with a one hundred percent automatic cutoff control valve in event
of pilot failure.
H. The CTC must be provided with a
system for maintaining clients and staff's comfort during periods of hot
weather, evaporative cooling is not allowed.
I. All boiler, furnace or heater rooms
shall be protected from other parts of the building by construction having a
fire resistance rating of not less than one hour. The door must be self-closing with three -
quarter hour fire resistance.
J. Fireplace or wood burning stoves
are prohibited.
K. The ceiling and air distribution
devices (supply & return, etc.) in the residential component shall be a
tamper resistant type.
[8.321.11.77
NMAC - N, 7/1/2024]
8.321.11.78 WATER HEATERS:
A. Must be able to supply hot water to
all hot water taps within the CTC at full pressure during peak demand periods
and maintain a maximum temperature of 120 degrees fahrenheit.
B. Fuel fired hot water heaters must be
enclosed and separated from other parts of the building by construction as
required by current state and local building codes.
C. All water heaters must be equipped
with a pressure relief valve (pop-off valve).
[8.321.11.78
NMAC - N, 7/1/2024]
8.321.11.79 ADDITIONAL REQUIREMENTS FOR FACILITIES
SERVING YOUTH: All requirements in the above rules apply to
all facilities. For facilities serving
youth, the additional requirements of this section must also be met.
A. Physical environment for general building requirements:
Facilities serving adults and youth must
locate youth resident rooms and restrooms in a unit or wing that is separated
by sight and sound barriers from the adult facilities.
B. Enforcement involving suspension of license without
prior hearing: Any CTC that allows any person, subject to all
applicable statutes and regulations, to work at the CTC if that person is
listed on the CYFD unreasonable risk background check and related regulations,
as amended, may be subject to immediate suspension of its license without prior
hearing.
C. Reporting of incidents: All facilities licensed under these
regulations, must comply with all incident intake, processing, training and
reporting requirements under all applicable NM Children’s Code, Section 32A-1-1
NMSA 1978, Children’s Mental Health and Developmental Disabilities Act, Section
32A-6A-1 NMSA 1978, Section 7.20.11 and Section 7.20.12 NMAC.
D. Policies And Procedures: The CTC shall
establish written policies and procedures that are reviewed annually and
approved by the governing body, which govern the CTC’s operation. The administrator shall ensure that these
policies and procedures are adopted, administered and enforced to provide
quality services in a safe environment. At
a minimum, the CTC’s written policies and procedures shall include how the CTC
intends to comply with all requirements of these regulations and address:
(1) immediate
reporting of suspected child abuse, neglect or exploitation, pursuant to the NM
Children’s Code and these licensing regulations;
(2) actions
to be taken in case of accidents or emergencies involving a youth, including
death;
(3) immediate
personnel actions to be taken by the CTC if child abuse or neglect allegations
are made involving a direct service staff;
(4) confidentiality
of youth’ records;
(5) management
of a youth who is a danger to themselves or others or presents a likelihood of
serious harm to themselves or others.
The CTC procedures must specify that immediate actions be taken to
prevent such harm. At a minimum, the
policies and procedures require that the following actions be taken and
documented in the youth’s file:
(a) all
appropriate actions to protect the health and safety of other youth, clients
and staff who are endangered;
(b) all
appropriate efforts to manage the youth’s behavior prior to proposing emergency
discharge;
(6) Clinically
appropriate and legally permissible methods of youth behavior management and
discipline.
(7) The CTC
shall prohibit in policy and practice the following:
(a) degrading
punishment;
(b) corporal
or other physical punishment;
(c) group
punishment for one client’s behavior;
(d) deprivation
of a client’s rights and needs (e.g., food, phone contacts, etc.) when not
based on documented clinical rationale;
(e) aversive
stimuli used in behavior modification;
(f) punitive
work assignments;
(g) isolation
or seclusion;
(h) harassment;
and
(i) chemical
or mechanical restraints.
(8) For
those CTCs that serve mixed age occupants, the CTC shall establish policies and
procedures to ensure the health and safety of all residents.
[8.321.11.79
NMAC - N, 7/1/2024]
8.321.11.80 RISK ASSESSMENT: Use of physical restraint must be consistent
with federal and state laws and regulations and must include the following:
A. Physical restraints of youth are
implemented only by staff who have been trained and certified by a state
recognized body in the prevention and use of physical restraint. This training emphasizes de-escalation
techniques and alternatives to physical contact with clients as a means of
managing behavior. Clients and youth do
not participate in the physical restraint of other clients and youth.
B. Youth treatment plans document the
use of physical restraints and include: consideration of the client’s medical
condition(s); the role of the client’s history of trauma in their behavioral
patterns; the treatment team’s solicitation and consideration of specific
suggestions from the client regarding prevention of future physical
interventions.
C. Physical restraints orders for youth
are issued by a restraint clinician within one hour of initiation of physical restraint
and include documented clinical justification for the use of physical
restraint.
D. If the youth has a treatment team
physician or advanced practice registered nurse and they are available, only they
can order physical restraint.
E. If physical restraint is ordered by
someone other than the youth’s treatment team physician or advanced practice
registered nurse, the restraint clinician will consult with the youth’s
treatment team physician or advanced practice registered nurse as soon as
possible and inform them of the situation requiring the youth to be restrained
and document in the youth’s record the date and time the treatment team
physician or advanced practice registered nurse was consulted and the
information imparted.
F. The restraint clinician must order
the least restrictive emergency safety intervention that is most likely to be
effective in resolving the situation.
G. If the order for physical restraint
is verbal, the verbal order must be received by a restraint clinician or a New
Mexico licensed registered nurse (RN) or practical nurse (LPN). The restraint clinician must verify the
verbal order in a signed, written form placed in the youth’s record within 24
hours after the order is issued.
H. A restraint clinician’s order must
be obtained by a restraint clinician or New Mexico licensed RN or LPN prior to
or while the physical restraint is being initiated by staff, or immediately
after the situation ends.
I. Each order for physical restraint
must be documented in the youth’s record and will include:
(1) the name of the restraint clinician
ordering the physical restraint;
(2) the date and time the order was
obtained;
(3) the emergency safety intervention
ordered, including the length of time;
(4) the time the emergency safety
intervention actually began and ended;
(5) the time and results of any one-hour
assessment(s) required; and
(6) the emergency safety situation that
required the client to be restrained; and
(7) the name, title, and credentials of
staff involved in the emergency safety intervention.
J. The CTC will notify the parent(s)
or legal guardian(s) that physical restraint has been ordered as soon as
possible after the initiation of each emergency safety intervention. This will be documented in the client’s
record, including the date and time of notification, the name of the staff
person providing the notification, and who was notified.
K. After an
incident of restraint, the professionals involved in the incident shall conduct
a debriefing with the client to discuss the event with the intent of preventing
future incidents. Within five days of an
incident of restraint, the treatment team must meet to review the incident and
revise plan of treatment if appropriate.
[8.321.11.80
NMAC - N, 7/1/2024]
8.321.11.81 CLIENT RIGHTS: All licensed facilities shall understand,
protect and respect the rights of all youth demonstrating substantial
compliance with all applicable New Mexico Children's Code, Section 32A-1-1 NMSA
1978, including the NM Children’s Mental Health and Developmental Disabilities
Act, Section 32A-6A-1 NMSA 1978.
[8.321.11.81
NMAC - N, 7/1/2024]
8.321.11.82 CLIENT CLINICAL RECORD:
The
client clinical records maintained by a crisis triage center in a paper-based
or electronic system shall document the degree and intensity of the treatment
provided to clients who are furnished services by the CTC. A client’s clinical record shall contain at a
minimum all required NM Children’s Code documentation defined in Subsection A
through Subsection O of Section 32A-6A-10 NMSA 1978 associated with the use of
any emergency interventions such as physical restraint.
[8.321.11.82
NMAC - N, 7/1/2024]
8.321.11.83 STAFFING REQUIREMENTS: Other staff requirements:
A. All CYFD background check
requirements governing criminal records clearances must remain in effect while
a program is accredited.
B. When a prospective employee that
will work with or have access to youth has not lived in the United States
continuously for the five years prior to hire, the CTC must obtain the
equivalent of a criminal records and background clearance from any country in
which the prospective employee has lived within the last five years, for a
period longer than one year.
C. If the CTC
receives reliable evidence that indicates that an employee or prospective
employee poses an unreasonable risk, as defined or pursuant to Subsection W of Section
8.8.3.7 NMAC, the CTC may not hire the prospective employee or retain the
employee.
[8.321.11.83
NMAC - N, 7/1/2024]
8.321.11.84 PERSONNEL RECORDS: Each CTC licensed pursuant to these
regulations intending to work with youth must maintain a complete record on
file for each staff member or volunteer including:
A. Completed CYFD criminal records and background
check, including the FBI-approved electronic fingerprint for each employee that
serves as direct service staff working with youth including licensed and
certified staff. (supervisors, physicians, nurses, therapists, client care
workers, coordinators, or other agency personnel who work in immediate direct
unsupervised contact with youth.) The
agency must have received the background clearance from the CYFD background
check unit prior to the employee’s direct, unsupervised contact with youth.
B. The date the employee was first
employed and dates of transfers or changes in position.
C. Documentation that of a minimum of
three references were checked.
D. A clearance letter from CYFD stating
the applicant’s background check has been conducted with negative results or a
signed statement by the administrator, director, or operator attesting to
direct supervision of an uncleared employee by a cleared employee until
official clearance is received.
E. Documentation that each uncleared
employee is identified on the staff schedule.
[8.321.11.84
NMAC - N, 7/1/2024]
8.321.11.85 STAFF TRAINING: At least 12 hours of on-going training shall
be provided to staff that provides direct care at least annually; the training
and proof of competency shall include at a minimum: NM Children’s Mental Health and Developmental
Disabilities Act Section 32A-6A-1 et. seq., NMSA 1978.
[8.321.11.85
NMAC - N, 8.321.11.85 7/1/2024]
HISTORY of 8.321.11 NMAC: [RESERVED]