La. Admin. Code tit. 67 § V-7511

Current through Register Vol. 50, No. 11, November 20, 2024

Section V-7511 - [Effective 1/20/2025] Facility Responsibilities

A. Personnel

1. Policies and Procedures

a. The provider shall have written policies and procedures that establish the provider's staffing, recruiting, and review procedures for staff. The personnel policy manual shall be available for staff and shall include a minimum of the following areas:

i. organization chart (table of organization);

ii. recruitment to include equal employment opportunity provisions;

iii. job descriptions and qualifications, and if applicable, a physical fitness policy;

iv. personnel files and performance reviews;

v. staff development, including in-service training;

vi. termination;

vii. employee/management relations, including disciplinary procedures and grievance and appeals procedures; and

viii. employee code of ethics.

b. A written policy and procedure shall require that each staff sign a statement acknowledging access to the policy manual.

2. Job Qualifications

a. The administrator shall meet one of the following qualifications upon hire:

i. a bachelor's degree plus two years experience relative to the population being served; or

ii. a master's degree; or

iii. six years of administrative experience in health or social services, or a combination of undergraduate education and experience for a total of six years.

b. Direct care staff shall be at least 18 years of age and have a high school diploma or equivalency at the time of hire.

3. Volunteers

a. If the provider utilizes volunteers, a written policy and procedure shall establish responsibility for the screening and operating procedures of the volunteer program.

b. Program Coordination

i. There shall be a staff member who is responsible for operating a volunteer service program for the benefit of youth.

ii. The provider shall specify the lines of authority, responsibility, and accountability for the volunteer service program.

c. Screening and Selection

i. Relatives of a youth shall not serve as a volunteer with the youth to whom they are related or in the facility where that youth is detained.

d. Professional Services

i. Volunteers shall perform professional services only when they are certified or licensed to do so.

e. Each volunteer shall have documentation of a state central registry clearance from child welfare as required in §7508

B. Background Clearance

1. No staff of the facility shall be hired until such person has submitted his/her fingerprints to the Louisiana Bureau of Criminal Identification and Information so that it may be determined whether or not such person has a criminal conviction of a felony, or a plea of guilty, or nolo contendere of a felony, or a criminal conviction, or a plea of guilty or nolo contendere to any offense included in R.S. 15:587.1, or any offense involving a juvenile victim. CBC shall be dated no earlier than 30 days prior to the date of hire. If it is determined that such a person has a conviction or has entered a plea of guilty or nolo contendere to a crime listed in R.S. 15:587.1(C) or any offense involving a juvenile victim, that person shall not be hired. No staff shall be present on the JDF premises until such a clearance is received.

2. The provider shall contact all prior institutional employers for information on substantiated allegations of sexual abuse consistent with federal, state, and local laws.

3. A criminal record check shall be conducted on all volunteers that interact with the youth. No volunteer of the facility shall be allowed to work with youth until such person has submitted his/her fingerprints to the Louisiana Bureau of Criminal Identification and Information so that it may be determined whether or not such person has a criminal conviction, or a plea of guilty or nolo contendere to any offense included in R.S. 15:587.1, or any offense involving a juvenile victim. CBC shall be dated no earlier than 30 days prior to the volunteer being present on the JDF premises. If it is determined that such a person has a conviction or has entered a plea of guilty or nolo contendere to a crime listed in R.S. 15:587.1(C) or any offense involving a juvenile victim, that person shall not be allowed to volunteer with youth at the JDF. No volunteer shall be present on the JDF premises until such a clearance is received.

4. Documentation of a fingerprint-based satisfactory criminal background check (CBC) from Louisiana State Police is required for all qualified mental health professionals and all qualified medical professionals who interact with youth unless they are supervised by facility staff or court-appointed or requested by legal counsel. This check shall be obtained and dated prior to the individual being present in the facility or providing services for the facility. No person who has been convicted of, or pled guilty or nolo contendere to any offense included in R.S. 15:587.1, shall be present in any capacity in any licensed JDF. A criminal background check is satisfactory for purposes of this section if it shows no arrests for any enumerated offense or, if an arrest is shown on the background check, the background check or certified documentation from the jurisdiction of arrest affirmatively shows that the charges were disposed of without a conviction for any excludable offense. A plea of guilty or nolo contendere shall be deemed a conviction.

5. Documentation of a fingerprint-based satisfactory criminal background check (CBC) from Louisiana State Police is required for all Louisiana Department of Education staff or local school district staff that interact with youth. This check shall be obtained prior to the individual being present in the facility or providing services for the facility. No person who has been convicted of, or pled guilty or nolo contendere to any offense included in R.S. 15:587.1, shall be present in any capacity in any licensed JDF. CBC shall be dated prior to the individual being present on the premises. A criminal background check is satisfactory for purposes of this section if it shows no arrests for any enumerated offense or, if an arrest is shown on the background check, the background check or certified documentation from the jurisdiction of arrest affirmatively shows that the charges were disposed of without a conviction for any excludable offense. A plea of guilty or nolo contendere shall be deemed a conviction.

a. If an individual has previously obtained a certified copy of their criminal background check obtained from the Louisiana Bureau of Criminal Identification and Information Section of the Louisiana State Police, such certified copy shall be acceptable as meeting the CBC requirements. If an individual provides a certified copy of their criminal background check which he/she has previously obtained from the Louisiana State Police to the provider, this criminal background check shall be accepted for a period of one year from the date of issuance of the certified copy. An original certified copy or a photocopy of the certified copy shall be kept on file at the JDF. Prior to the one-year expiration of the certified criminal background check, a new fingerprint-based satisfactory criminal background check shall be obtained from Louisiana State Police in order for the individual to continue providing services at the JDF. If the clearance is not obtained prior to the one-year expiration of the certified criminal background check, the individual is no longer allowed on the premises until a clearance is received;

b. For the first school year that a LDE staff person or local school district staff person provides services to a child, that LDE staff person or local school district staff person shall provide documentation of a fingerprint based satisfactory criminal record check as required by §7511.B.5 or shall provide the original, completed, signed, notarized, DCFS-approved affidavit to the provider prior to being present and working with a child or children at the facility. A photocopy of the original affidavit shall be kept on file at the facility. This affidavit will be acceptable for the entire school year noted in the text of the affidavit and expires on May 31 of the current school year. For all subsequent school years following the first year, the LDE staff or local school district staff person shall present a new affidavit or an original, completed, and signed letter from the superintendent of the school district or designee or superintendent of LDE or designee. The provider will need to view the original letter presented by the LDE staff or local school district staff person and keep a photocopy of the original letter on file at the facility. This letter will be acceptable for the entire school year noted in the text of the letter and expires on May 31 of the current school year. The letter is acceptable only if the following conditions are met:

i. the LDE staff person or local school district staff person has remained employed with the same school district as noted in the affidavit the provider has on file;

ii. the provider has maintained a copy of the affidavit on file; and

iii. the letter is presented on school district letterhead or LDE letterhead and signed by the superintendent of the school district or designee or superintendent of LDE or designee.

c. Documentation of a state central registry clearance for all Louisiana Department of Education staff or local school district staff that interact with youth following the procedure outlined in §7508

6. Documentation of a state central registry clearance from child welfare as required in §7508

C. Health Screening

1. All staff shall receive a physical examination that includes screening for infectious and contagious diseases. Documentation of this examination shall be dated within three months prior to the staffs date of hire or within 30 days after staffs date of hire. Physical examinations shall be required every three years.

D. Performance Reviews

1. The provider shall conduct an annual written performance review of each staff and the results shall be discussed with the staff.

E. Drug-free Workplace

1. The provider shall have a written policy and procedure regarding a drug-free workplace for all staff.

F. Training and Staff Development

1. Policy and Procedure

a. The provider shall have written policies and procedures that require training and staff development programs, including training requirements for all categories of personnel.

b. Program Coordination and Supervision. The program coordinator shall ensure that the provider's staff development and training program is planned, coordinated and supervised.

2. Orientation

a. All new direct care staff and support staff that have direct contact with youth shall receive a minimum of 40 hours of orientation training before assuming any job duties. This training shall include, at a minimum, the following:

i. philosophy, organization, program, practices and goals of the facility;

ii. specific responsibilities of assigned job duties;

iii. administrative procedures;

iv. emergency and safety procedures including medical emergencies;

v. youth's rights;

vi. detecting and reporting suspected abuse and neglect;

vii. infection control to include blood borne pathogens;

viii. confidentiality;

ix. reporting of incidents;

x. intake to include classification procedures and release;

xi. discipline and due process rights of incarcerated youth;

xii. access to health care (dental, mental, and medical);

xiii. crisis/conflict management, de-escalation techniques, and management of assaultive behavior, including when, how, what kind, and under what conditions physical force, mechanical restraints, and room confinement, isolation may be used;

xiv. suicide prevention and emergency procedures in case of suicide attempt;

xv. sexual misconduct including but not limited to the following:

(a). youth's rights to be free from sexual misconduct, and from retaliation for reporting sexual misconduct;

(b). dynamics of sexual misconduct in confinement;

(c). common reactions of sexual misconduct victims; and

(d). agency policy for prevention and response to sexual misconduct.

3. First Year Training

a. Direct care staff shall receive an additional 120 hours of training during their first year of employment. This training shall include, at a minimum, the following:

i. within the first 60 calendar days of employment:

(a). adolescent development for males and females; and

(b). first aid/CPR;

ii. within the first year of employment:

(a). classification procedures to include intake screenings;

(b). an approved crisis/conflict intervention program;

(c). facility's policy and procedures for suicide prevention, intervention and response;

(d). lesbian, gay bisexual, transgender specific, cultural competence and sensitivity training;

(e). communication effectively and professionally with all youth;

(f). sexual misconduct including but not limited to the following:

(i). youth's rights to be free from sexual misconduct, and from retaliation for reporting sexual misconduct;

(ii). dynamics of sexual misconduct in confinement;

(iii). common reactions of sexual misconduct victims; and

(iv). the agency policy for prevention and response to sexual misconduct;

(g). key control;

(h). universal safety precautions;

(i). effective report writing; and

(j). needs of youth with behavioral health disorders and intellectual disabilities and medication.

b. All support (non-direct care) staff shall receive an additional 40 hours of training during their first year of employment. The training shall include, at a minimum, the following:

i. philosophy, organization, program, practices and goals of the facility;

ii. specific responsibilities of assigned job duties;

iii. youth's rights;

iv. detecting and reporting suspected abuse and neglect (mandatory reporting guidelines);

v. infection control to include blood borne pathogens;

vi. confidentiality;

vii. reporting of incidents;

viii. discipline and due process rights of incarcerated youth;

ix. sexual misconduct including but not limited to the following:

(a). youth's rights to be free from sexual misconduct, and from the retaliation for reporting sexual misconduct;

(b). dynamics of sexual misconduct in confinement;

(c). common reactions of sexual misconduct victims; and

(d). agency policy for prevention and response to sexual misconduct;

x. first aid/ CPR; and

xi. basic safety and security practices.

4. Annual Training

a. All direct care staff and support staff shall receive a minimum of 40 hours of training annually. This training shall include, at a minimum, the following:

i. classification procedures to include intake screenings;

ii. an approved crisis/conflict intervention program;

iii. facility's policy and procedures for suicide prevention, intervention and response;

iv. communication effectively and professionally with all youth;

v. sexual misconduct including but not limited to the following:

(a). youth's rights to be free from sexual misconduct, and from retaliation for reporting sexual misconduct;

(b). dynamics of sexual misconduct in confinement;

(c). common reactions of sexual misconduct victims-add additional; and

(d). the agency policy for prevention and response to sexual misconduct;

vi. key control;

vii. universal safety precautions;

viii. discipline and due process rights of incarcerated youth;

ix. detecting and reporting suspected abuse and neglect (mandatory reporting guidelines);

x. effective report writing; and

xi. needs of youth with behavioral health disorders and intellectual disabilities and medication.

5. Volunteer Training

a. All volunteers shall receive notification and acknowledge in writing their agreement to abide by the following prior to their beginning work and updated annually:

i. philosophy and goals of the facility;

ii. specific responsibilities and limitations;

iii. youth's rights;

iv. detecting and reporting suspected abuse and neglect;

v. confidentiality;

vi. reporting of incidents;

vii. discipline and due process rights of incarcerated youth;

viii. sexual misconduct including but not limited to the following:

(a). youth's rights to be free from sexual misconduct, and from retaliation for reporting sexual misconduct;

(b). dynamics of sexual misconduct in confinement;

(c). common reactions of sexual misconduct victims-add additional; and

(d). the agency policy for prevention and response to sexual misconduct.

ix. basic safety and security practices.

6. All staff employed longer than 60 days shall maintain documentation of current certification in first aid and CPR.

G. Staffing Requirements

1. The provider shall have sufficient available staff to meet the needs of all of the youth.

2. At least two direct care staff shall be on duty at all times in the facility.

3. There shall be a minimum of 1 to 8 ratio of direct care staff to youth during the hours that youth are awake.

4. A minimum of one direct care staff shall be maintained in rooms when educational services are being provided, with additional staff in close proximity of the educational service rooms in order to intervene, if necessary.

5. Youth shall be checked by a staff person at least every 15 minutes when in sleeping rooms, whether asleep or awake. Documentation of checks shall be maintained.

6. Direct care staff who are needed to satisfy the staff to youth ratio shall be able to directly see, hear, and speak with the youth when youth are not in their sleeping rooms.

7. There shall be a minimum of 1 to 16 ratio of direct care staff to youth during the hours that youth are asleep.

8. Direct care staff of one gender shall be the sole supervisor of youth of the same gender during showers, physical searches, pat downs, or during other times in which personal hygiene practices or needs would require the presence of a direct care staff of the same gender.

9. Video and audio monitoring devices shall not substitute for supervision of youth.

10. The provider shall provide youth that have limited English proficiency with meaningful access to all programs and activities. The provider shall provide reasonable modifications to policies and procedures to avoid discrimination against persons with disabilities.

H. Record Keeping

1. Personnel Files

a. The provider shall maintain a current, accurate, confidential personnel file on each staff. This file shall contain, at a minimum, the following:

i. an application for employment, including the resume of education, training, and experience, including evidence of professional or paraprofessional credentials/certifications according to state law, if applicable;

ii. a criminal background check in accordance with state law;

iii. documentation of staff orientation and annual training;

iv. staff hire and termination dates;

v. documentation of staff current driver's license, if applicable;

vi. annual performance evaluations;

vii. any other information, reports, and notes relating to the individual's employment with the facility; and

viii. documentation of a state central registry clearance for all owners and staff as required in §7508

2. Youth Files

a. Active Files. The provider shall maintain active files for each youth. The files shall be maintained in an accessible, standardized order and format. The files shall be current and complete and shall be maintained in the facility in which the youth resides. The provider shall have sufficient space, facilities, and supplies for providing effective storage of files. The files shall be available for inspection by the department at all times. Youth files shall contain at least the following information:

i. youth's name, date of birth, social security number, previous home address, sex, religion, and birthplace;

ii. dates of admission and discharge;

iii. other identification data including documentation of court status, legal status or legal custody, and who is authorized to give consents;

iv. name, address, and telephone number of the legal guardian(s), and parent(s), if appropriate;

v. name, address, and telephone number of a physician and dentist;

vi. the pre-admission assessment and admission assessment;

vii. youth's history including family data, educational background, employment record, prior medical history, and prior placement history;

viii. a copy of the physical assessment report;

ix. continuing record of any illness, injury, or medical or dental care when it impacts the youth's ability to function or impacts the services he or she needs;

x. reports of any incidents of abuse, neglect, or incidents, including use of time out, personal restraints, or seclusion;

xi. a summary of releases from the facility;

xii. a summary of court visits;

xiii. a summary of all visitors and contacts including dates, name, relationship, telephone number, address, the nature of such visits/contacts and feedback from the family;

xiv. a record of all personal property and funds, which the youth has entrusted to the provider;

xv. reports of any youth grievances and the conclusion or disposition of these reports;

xvi. written acknowledgment that the youth has received clear verbal explanation and copies of his/her rights, the facility rules, written procedures for safekeeping of his/her valuable personal possessions, written statement explaining his/her rights regarding personal funds, and the right to examine his/her file;

xvii. all signed informed consents; and

xviii. a release order, as applicable.

b. Confidentiality and Retention of Youth Files

i. The provider shall maintain records in accordance with public records and confidentiality laws.

ii. The provider shall maintain the confidentiality and security of all records. Staff shall not disclose or knowingly permit the disclosure of any information concerning the youth or his/her family, directly or indirectly, to any unauthorized person.

3. Administrative File

a. Insurance Policies. Provider shall have an administrative file that contains the following information:

i. documentation of a current comprehensive general liability insurance policy; and

ii. documentation of current insurance for all vehicles used to transport youth. This policy shall extend coverage to any staff member who provides transportation for youth in the course and scope of his/her employment.

I. Incident Reporting

1. Critical Incidents. The provider shall have written policies and procedures for documenting, reporting, investigating, and analyzing critical incidents.

a. The provider shall report any of the following critical incidents to parties noted in Section 7511.I.1.b below:

i. suspected abuse;

ii. suspected neglect;

iii. injuries of unknown origin;

iv. death;

v. attempted suicide;

vi. escape;

vii. sexual assault;

viii. any serious injury that occurs in a facility, including youth on youth assaults, that requires medical treatment; and/or

ix. injury with substantial bodily harm while in confinement, during transportation or during use of physical intervention.

b. The administrator or designee shall immediately report all critical incidents to the:

i. parent/legal guardian;

ii. law enforcement authority, if appropriate, in accordance with state law;

iii. DCFS Licensing Section management staff;

iv. defense counsel for the youth; and

v. judge of record.

c. At a minimum, the incident report shall contain the following:

i. date and time the incident occurred;

ii. a brief description of the incident;

iii. where the incident occurred;

iv. any youth or staff involved in the incident;

v. immediate treatment provided, if any;

vi. symptoms of pain and injury discussed with the physician if applicable;

vii. signature of the staff completing the report;

viii. name and address of witnesses;

ix. date and time the legal guardian, and other interested parties were notified;

x. any follow-up required;

xi. actions to be taken in the future to prevent a reoccurrence; and

xii. any documentation of supervisory and administrative reviews.

d. Investigation of Abuse and Neglect

i. The provider shall submit a final written report of the incident to Licensing, if indicated, as soon as possible but no later than five calendar days following the incident.

ii. An internal investigation shall be conducted of any allegations involving staff and/or youth of abuse or neglect of a youth.

iii. Until the conclusion of the internal investigation, any person alleged to be a perpetrator of abuse or neglect may be placed on administrative leave or may be reassigned to a position having no contact with the complainant or any youth in the facility, relatives of the alleged victim, participants in a juvenile justice program, or individuals under the jurisdiction of the juvenile court. The provider shall take any additional steps necessary to protect the alleged victim and witnesses.

iv. At the conclusion of the internal investigation, the administrator or designee shall take appropriate measures to provide for the safety of the youth.

v. In the event the administrator is alleged to be a perpetrator of abuse or neglect, the governing body or commission shall:

(a). conduct the internal investigation or appoint an individual who is not a staff of the facility to conduct the internal investigation;

(b). place the administrator on administrative leave, until the conclusion of the internal investigation, or ensure the administrator has no contact with the youth in the facility, relatives of the alleged victim, participants in a youth justice program, or individuals under the jurisdiction of the youth court.

vi. Copies of all written reports shall be maintained in a central incident file.

J. Abuse and Neglect

1. Provider shall ensure staff adheres to a code of conduct that prohibits the use of physical abuse, sexual abuse, profanity, threats, or intimidation. Youth shall not be deprived of basic needs, such as food, clothing, shelter, medical care, and/or security.

2. In accordance with article 603 of the Louisiana Childrens Code, all staff employed by a juvenile detention facility are mandatory reporters. In accordance with article 609 of the Louisiana Childrens Code, a mandatory reporter who has cause to believe that a childs physical or mental health or welfare is endangered as a result of abuse or neglect or was a contributing factor in a childs death shall report in accordance with article 610 of the Louisiana Childrens Code.

K. Grievance Procedure

1. The provider shall have a written policy and procedure which establishes the right of every youth and the youth's legal guardian(s) to file grievances without fear of retaliation.

2. The written grievance procedure shall include, but not be limited to:

a. a formal process for the youth and the youth's legal guardian(s) to file grievances that shall include procedures for filing verbal, written, or anonymous grievances. If written, the grievance form shall include the youth's name, date, and all pertinent information relating to the grievance;

b. a formal process for the provider to communicate with the youth about the grievance within 24 hours and to respond to the grievance in writing within five calendar days;

c. a formal appeals process for provider's response to grievance.

3. Assistance by staff not involved in the issue of the grievance shall be provided if the youth requests.

4. Documentation of any youth's or youth's legal guardian(s) grievance and the conclusion or disposition of these grievances shall be maintained in the youth's file. This documentation shall include any action taken by the provider in response to the grievance and any follow up action involving the youth.

5. The provider shall maintain all verbal, written, and/or anonymous grievances filed and the manner in which they were resolved in a central grievance file.

6. A copy of the grievance and the resolution shall be given to the youth, and a copy shall be kept in a central grievance file.

L. Quality Improvement

1. The provider shall have a written policy and procedure for maintaining a quality improvement program to include:

a. systematic data collection and analysis of identified areas that require improvement;

b. objective measures of performance;

c. periodic review of youth files;

d. quarterly review of incidents and the use of personal restraints and seclusion to include documentation of the date, time and identification of youth and staff involved in each incident; and

e. implementation of plans of action to improve in identified areas.

2. Documentation related to the quality improvement program shall be maintained for at least two years.

La. Admin. Code tit. 67, § V-7511

Promulgated by the Department of Children and Family Services, Division of Programs, Licensing Section, LR 38:1565 (July 2012), amended LR 39:1007 (April 2013), effective July 1, 2013, Amended LR 42396 (3/1/2016), Amended by the Department of Children and Family Services, Licensing Section, LR 45657 (5/1/2019), effective 6/1/2019, Amended LR 49849 (5/1/2023), effective 6/1/2023, Amended by the Department of Public Safety and Corrections, Office of Juvenile Justice, LR 50, exp. 1/20/2025 (Emergency).

AUTHORITY NOTE: Promulgated in accordance with R.S. 15:1110.