DAR File No. 40929

Human Services, Administration, Administrative Services, Licensing

Rule R501-1

General Provisions

Notice of Proposed Rule

(Repeal and Reenact)

DAR File No.: 40929
Filed: 11/01/2016 06:19:42 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rule updates and clarifies the general processes for the Department of Human Services (DHS), Office of Licensing. Some of the updates are related to H.B. 259 passed during the 2016 General Session.

Summary of the rule or change:

This rule updates and clarifies the general processes for the DHS Office of Licensing. Some of the updates are related to H.B. 259 from the 2016 General Session. It adds and changes definitions. It clarifies office processes related to variances, applications, approvals, denials, extensions, investigations of complaints and critical incidents, etc.

Statutory or constitutional authorization for this rule:

• Title 62A, Chapter 2

Anticipated cost or savings to:

the state budget:

The current budget will cover any tasks affected by these changes. It is not anticipated that these rule changes will be either a cost or savings to the state of Utah.

local governments:

It is not anticipated that this will affect local governments financially. Costs to providers will most likely remain constant. Changes are primarily to Office of Licensing processes and philosophy regarding code of conduct and client's rights.

small businesses:

It is not anticipated that this will affect small businesses financially. Costs to providers will most likely remain constant. Changes are primarily to Office of Licensing processes and philosophy regarding code of conduct and client's rights.

persons other than small businesses, businesses, or local governmental entities:

It is not anticipated that this will affect other entities financially. Costs to providers will most likely remain constant. Changes are primarily to Office of Licensing processes and philosophy regarding code of conduct and client's rights.

Compliance costs for affected persons:

No compliance costs are anticipated. Fees remain the same. No significant compliance changes for providers.

Comments by the department head on the fiscal impact the rule may have on businesses:

It is not anticipated that this rule change will have a fiscal impact on business.

Ann Williamson, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Office of Administrative Rules, or at:

Human Services
Administration, Administrative Services, Licensing
195 N 1950 W 1ST FLR
SALT LAKE CITY, UT 84116

Direct questions regarding this rule to:

• Julene Robbins at the above address, by phone at 801-538-4521, by FAX at 801-538-3942, or by Internet E-mail at [email protected]
• Diane Moore at the above address, by phone at 801-538-4235, by FAX at 801-538-4553, or by Internet E-mail at [email protected]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

12/15/2016

This rule may become effective on:

12/22/2016

Authorized by:

Diane Moore, Director

R501. Human Services, Administration, Administrative Services, Licensing.

[R501-1. General Provisions.

R501-1-1. Authority and Purpose.

1. This Rule is authorized by Section 62A-2-101, et seq.

2. This Rule clarifies the standards for:

a. approving or denying a human services program application, or

b. approving, extending, conditioning, denying, suspending, or revoking a human services program license.

3. This Rule clarifies the standards for inspecting, monitoring, and investigating a human services program.

4. This Rule clarifies the standards for approving or denying a variance to the Human Services Administrative Rules, Title R501, regarding the licensing of human services programs.

 

R501-1-2. Definitions.

1. "Applicant" means a person who submits an application to the Office of Licensing to obtain a license to operate a human services program.

2. "Child" is defined in Section 62A-2-101.

3. "Client" is defined in Section 62A-2-101.

4. "Human services program" is defined in Section 62A-2-101.

5. "Initial License" means the license issued to operate a human services program during the program's first year of operation.

6. "Licensee" means a person with a current, valid license to operate a human services program, issued by the Office of Licensing.

7. "Local government" is defined in Section 62A-2-101.

8. "Person" includes an individual, agency, association, partnership, corporation, or governmental entity.

9. "Probationary License" means a temporary initial license issued to operate a new human services program during the period of time that the Office of Licensing designates for the program to transition from substantial compliance to full compliance with licensing requirements.

10. "Regular business hours" is defined in Section 62A-2-101.

11. "Residential Treatment" is defined in Section 62A-2-101.

12. "Renewal License" means the license issued to operate a human services program after the program's first year of operation.

13. "Site" A human services program identified by a single geographic location, including but not limited to a single dwelling, building, facility, or campus.

14. "Substantial compliance" means a human services program presently conforms to all licensing requirements with the exception of minor requirements that do not create a risk of harm to a child or vulnerable adult. Examples of minor requirements that do not create a risk of harm to a child or vulnerable adult include, but are not limited to, individual staff or client files in a residential treatment program that has not yet provided services, individual staff or client files in a child placing agency that has not yet provided services, or completion of training in a kinship foster care placement.

15. "Variance" means a temporary deviation from an administrative rule.

16. "Vulnerable Adult" is defined in Section 62A-2-101.

 

R501-1-3. Licensing Procedure.

1. Application for Initial License.

A person seeking an initial license to operate a human services program shall submit:

a. an application on the forms provided by the Office of Licensing;

b. the licensing fee required for the category of human services program license sought;

c. a completed background screening application and consent form, and all required identifying information, in accordance with R501-14, for each adult associated with the proposed human services program;

d. the applicant's proposed policy and procedure manual;

e. documentation verifying compliance with all local government zoning, health, fire, and business requirements; and

f. for residential treatment programs, a copy of the notice of its intent to operate a residential treatment program and proof of service, in accordance with Section 62A-2-108.2.

2. Application for Renewal License.

A person seeking renewal of a license to operate a human services program shall submit:

a. an application on the form provided by the Office of Licensing;

b. the licensing fee required for the category of human services program;

c. verification of current background screening approval, in accordance with R501-14, for each adult associated with the human services program;

d. a copy of all modifications that have been made to the licensee's policy and procedure manual since the previous year's licensure;

e. documentation verifying current compliance with all local government zoning, health, fire, and business requirements; and

f. for residential treatment programs, a copy of the notice of its intent to operate a residential treatment program and proof of service, in accordance with Section 62A-2-108.2.

g. the application for renewal of a license shall be submitted no less than thirty days and no more than sixty days prior to the expiration date of the current license.

3. An application and required documentation that are not legible, complete, dated and signed shall be returned to the applicant without further action.

4. On-Site Licensing Review

a. An applicant for an initial license shall permit the Office of Licensing to conduct an unlimited on-site evaluation of the physical facility and grounds, and to interview persons associated with the proposed program to verify compliance with all licensing requirements.

i. The Office of Licensing shall approve an application for an initial human services program license only after verifying full compliance with all licensing requirements.

ii. The Office of Licensing may approve a probationary license only after verifying substantial compliance with licensing requirements.

A. The Office of Licensing shall include an expiration date on a probationary license, which shall not exceed 6 months from the date of issue.

B. A probationary licensee that fails to achieve full compliance with licensing requirements prior to the expiration of the probationary license shall not be granted an extension, and shall not accept any fees, entering any agreements to provide client services, or provide any client services.

C. A probationary licensee that is not granted an initial license may submit a new application for an initial license 3 months after the expiration of the probationary license.

iii. The Office of Licensing shall deny an application for an initial human services program license when substantial compliance with all licensing requirements cannot be verified.

iv. The Office of Licensing shall permit an applicant for an initial human services program license to withdraw the application at any time prior to denying the application when an applicant requests additional time to demonstrate compliance with all licensing requirements.

b. The Office of Licensing shall conduct a minimum of one annual on-site review of each human services program site.

i. The Office of Licensing shall approve an application for a human services program license renewal only after verifying full compliance with all licensing requirements.

ii. The Office of Licensing shall deny an application for a human services program license renewal when full compliance with all licensing requirements cannot be verified.

iii. The Office of Licensing may extend the current license of a human services program in accordance with this rule.

A. A renewal license may be extended for up to sixty days past the current license expiration date if the Office of Licensing determines that the human services program is in substantial compliance with licensing requirements.

B. A notice of extension shall identify the extension expiration date and the requirements that the human services program must comply with to achieve full compliance.

C. A human services program that fails to achieve full compliance with licensing requirements prior to the expiration of the extension shall not be granted additional extensions.

D. The Office of Licensing shall deny the renewal application of a human services program that fails to achieve full compliance with licensing requirements prior to the expiration of an extension.

c. The Office of Licensing shall complete a written monitoring report or a checklist identifying areas of compliance and non-compliance with licensing requirements after each on-site review.

5. The license shall state the name and site address of the human service program facility, category of service, maximum consumer capacity, and the start date and expiration date.

6.a. A license that has expired is void.

b. A license expires at midnight one year after the date it was issued, unless:

i. the license states an earlier expiration date;

ii. the license has been extended in accordance with this rule;

iii. the license has been revoked by the Office of Licensing; or

iv. the license has been relinquished to the Office of Licensing by the licensee.

7.a. A licensee shall not exceed the licensed maximum client capacity indicated on the license issued by the Office of Licensing.

b. A licensee seeking to increase the maximum client capacity of a license shall submit an application for a renewal license in accordance with this rule.

8. A person with an expired license wishing to operate a human services program shall submit an application for a new license in accordance with this rule.

9. A license is deemed void when the human services program has a change of location unless the program obtains prior written approval of the relocation of their license:

a. Relocation can only occur when an existing program is moving to a new location with no change of license type, ownership, or substantial policy or service changes. Relocation does not mean adding an additional site to a currently licensed program.

b. A human services program, excluding foster care, that intends to relocate to a new site may have their license transferred to the new site only after:

i. payment of renewal fees;

ii. request to relocate submitted to the Office of Licensing at least 30 days prior to the move;

iii. Office of Licensing inspection and approval of licensure at the new site.

c. A foster home that intends to relocate to a new site may have their license transferred to the new site only after:

i. request to relocate submitted to the Office of Licensing at least 30 days prior to the move;

ii. Office of Licensing inspection and approval of licensure at the new site within two weeks if foster children are placed, and within 30 days if there are no current foster placements. If foster children are placed, it is the responsibility of the licensed foster parent to ensure health and safety of the foster child pending transfer to the new site.

10. No clients may be present and no services may be provided at a relocation site until after all requirements of 9 above have been met, with the exception of currently placed foster children.

11. A human services program that has a change of ownership shall submit to the Office of Licensing updated documentation in advance of the transfer of ownership, including but not limited to proof of continued insurance, updated organization chart, and business license. Failure to do so will result in a revocation of the license/s.

 

R501-1-4. Fees.

1. The Office of Licensing shall assess and collect licensing fees in accordance with Sections 62A-2-106 and 63J-1-504.

a. A fee shall not be transferred, prorated, reduced, waived, or refunded.

b. No licensing fee shall be assessed on a foster home or on a Division of the Department of Human Services.

c. An initial application fee will expire after 12 months if an initial or probationary license has not been issued in that timeframe.

2. The Office of Licensing is not required to perform an on-site review until the applicant pays the assessed licensing fee in full.

3. Separate initial license fees shall be assessed for each initial category of human services program license offered at a program site.

4. Separate renewal license fees, plus any applicable capacity fees, shall be asses for each license category that is renewed at a program site.

a. Renewal fees shall be calculated according to the maximum licensed client capacity of the human services program, and not according to the number of clients served in the program.

b. A human services program with a current license that intends to increase its maximum licensed capacity shall submit an application and fee for a renewal license. The fee shall include the capacity charges for the new total maximum licensed capacity.

5. A human services program with more than one building, unit, or suite at one site may request to have its fees assessed and licenses/s issued:

a. so that each category of license will be issued to include all on-site buildings, units, or suites; or

b. so that each category of license will be issued for each individual on-site building, unit, or suite.

6. A human services program with a current license that intends to provide additional services at the currently licensed site shall submit an application and fee for an initial license.

 

R501-1-5. Monitoring.

1. The Office of Licensing shall investigate reports of unlicensed human services programs.

a. An unlicensed human services program that fails to submit an application and become licensed shall be referred to the Offices of the Attorney General and the appropriate County Attorney for prosecution.

2. The Office of Licensing shall investigate complaints regarding a licensed human services program.

a. A certified local inspector may investigate complaints regarding a residential treatment program in accordance with Section 62A-2-108.3 and R501-4

3. Unannounced administrative inspections may be conducted during regular business hours.

4. The Office of Licensing shall document violations of administrative rules or statutes

5. The Office of Licensing shall provide written notification to the human services program of violations of administrative rules or statutes and any sanctions imposed.

 

R501-1-6. Corrective Action Plans.

1. The Office of Licensing may require a human services program to submit a written corrective action plan in response to a written notification of its violations of administrative rules or statutes.

2. A human services program shall submit a written corrective action plan to the Office of Licensing within ten calendar days of receiving written notification of its violations of administrative rules or statutes.

3. The written corrective action plan shall include the following:

a. a statement of each violation as identified by the Office of Licensing,

b. a detailed description of how the human services program will correct each violation and prevent additional violations of administrative rules or statutes;

c. the date by which the human services program will achieve complete compliance with administrative rules or statutes; and

d. the signature of all owners and managers of the human services program.

4. The Office of Licensing shall issue a Notice of Agency Action imposing sanctions for a human service program's violations of administrative rules or statutes if the program fails to submit a written corrective action plan in compliance with this rule.

5. The Office of Licensing shall review the submitted written corrective action plan and:

a. inform the human services program that the written corrective action plan is approved; or

b. inform the human services program that the written corrective action plan fails to satisfy the requirements of this rule.

i. The Office of Licensing may permit a human services program to amend its written corrective action plan within 5 additional calendar days to satisfy the requirements of this rule.

6. The Office of Licensing shall issue a Notice of Agency Action imposing sanctions for a human services program's violations of administrative rules or statutes if the program fails to comply with a written corrective action plan approved by the Office of Licensing.

7. A human services program shall post each approved corrective action plan and each Notice of Agency Action where it can be easily reviewed by clients, parents or guardians of clients, and visitors.

a. Each approved corrective action plan and each Notice of Agency Action shall remain posted until the Office of Licensing issues written confirmation that the program has achieved compliance with administrative rules and statutes.

 

R501-1-7. License Violation.

1. An applicant shall not accept any fees, enter any agreements to provide client services, or provide any client services until after receiving written confirmation that the Office of Licensing has approved and issued a license to provide those services.

2. The Office of Licensing may exercise its professional judgment and deny, condition, suspend, or revoke a license for any violation of the administrative Rules or local, state, or federal law.

3. The Office of Licensing shall issue a written notice of agency action when a license sanction is imposed. The notice of agency action shall identify each violation and describe the factual basis underlying each violation.

4. The Office of Licensing may place a license on conditional status. A conditional status allows a program that is in the process of correcting administrative rule violations to continue operation subject to conditions established by the Office of Licensing.

5.a. A human services program that has had its license suspended is prohibited from providing any services to clients until after the suspension period has expired.

b. A human services program that has had its license expire during the suspension period shall be required to submit an application for an initial license after the suspension period has expired and obtain a new license prior to providing any services to clients.

6. A human services program that has had its license revoked is prohibited from providing any services to clients until after a new license is issued in accordance with Section 62A-2-113.

 

R501-1-8. Due Process.

1. A notice of agency action shall inform the applicant or licensee of the right to appeal in accordance with Administrative Rule 497-100 and Section 63G-4-101, et seq.

2. A licensee shall not accept any new clients while an appeal is pending.

 

R501-1-9. Variances.

1. A licensee shall not deviate from any administrative rule without first receiving written approval of a specific variance request signed by the Director of the Office of Licensing or the Director's designee.

2. The Director of the Office of Licensing, or the Director's designee, may grant a variance to the administrative rules of the Office of Licensing, if the Director or the Director's designee determines that a variance:

a. is in the best interests of the client; and

b. may be granted without compromising any health and safety requirements.

3. The licensee must submit a written request for a variance to the licensing specialist. A request for a variance shall specifically describe:

a. the rule for which the variance is requested;

b. how the licensee will ensure the best interests of the client will be maintained;

c. what procedures will be implemented to ensure the health and safety of all clients; and

d. the proposed variance expiration date.

4. The licensing specialist shall review the written request for a variance and forward it to the Director or the Director's designee together with the licensing specialist's recommendations to approve, approve with modifications, or deny the request.

5. The Office of Licensing shall notify the licensee of the approval, approval with modifications, or denial of the variance, in writing, within 30 days.

 

R501-1-10. Abuse or Neglect, or Exploitation.

1. The Office of Licensing shall immediately notify the appropriate investigative or law enforcement agency of any allegations or evidence of abuse, neglect, or exploitation of any child or vulnerable adult.

 

R501-1-11. Compliance.

Any licensee that is in operation of the effective date of this rule shall be given 30 days after the effective date to achieve compliance with this rule.]

R501-1. General Provisions for Licensing.

R501-1-1. Authority and Purpose.

(1) This Rule is authorized by Utah Code Title 62A, Chapter 2.

(2) This Rule clarifies the standards for:

(a) approving or denying a human services program license application;

(b) approving, renewing, extending, placing conditions on, restricting admissions, suspending, or revoking a license for a human services program;

(c) inspecting, monitoring, and investigating a prospective or current human services program; and

(d) approving or denying a variance to the Human Services Administrative Rules, Title R501, regarding the licensing of human services programs.

 

R501-1-2. Definitions.

As used in this Title 501:

(1) "Abuse" includes, but is not limited to:

(a) attempting to cause harm;

(b) threatening to cause harm;

(c) causing non-accidental harm;

(d) unreasonable or inappropriate use of a restraint, medication, confinement, seclusion or isolation that causes harm;

(e) sexual exploitation, as defined in 78A-6-105;

(f) sexual abuse, including sexual contact or conduct with a client, or as defined in 78A-6-105;

(g) a sexual offense, as described in Title 76 Chapter 5; or

(h) domestic violence or domestic violence related to child abuse.

(i) "Abuse" does not include the reasonable discipline of a child, or the use of reasonable and necessary force in self-defense or the defense of others, as such force is defined in 76-2-4.

(2) "Applicant" is defined in 62A-2-101.

(3) "Associated with the Licensee" is defined in 62A-2-101.

(4) "Category" means the type of human service license described in 62A-2-101.

(5) "Client" is defined in 62A-2-101.

(6) "Critical Incident" means an occurrence that involves:

(a) abuse;

(b) neglect;

(c) exploitation;

(d) death;

(e) an injury requiring medical attention beyond basic first aid;

(f) an injury that is a result of staff or client assault, restraint or intervention;

(g) the unlawful or unauthorized presence or use of alcohol or substances;

(h) the unauthorized departure of a client from the program;

(i) outbreak of a contagious illness requiring notification of the local health department;

(j) the misuse of dangerous weapons; or

(k) unsafe conditions caused by weather events, mold, infestations, or other conditions that may affect the health, safety or well-being of clients.

(7) "Director(s)" means a person or persons ultimately responsible for day to day operations of a program; and may include medical, clinical, or those directing other aspects of the program.

(8) "Exploitation" includes, but is not limited to:

(a) the use of a client's property, labor, or resources without the client's consent or in a manner that is contrary to the client's best interests, or for the personal gain of someone other than the client; such as expending a client's funds for the benefit of another; or

(b) using the labor of a client without paying the client a fair wage or without providing the client with just or equivalent non-monetary compensation, where such use is consistent with therapeutic practices; or

(c) engaging or involving a client in any sexual conduct; or

(d) any offense described in 76-5-111(4) or Section 76-5b-201 and 202.

(9) "Foster Home" is defined in 62A-2-101 (18).

(10) "Fraud" means a false or deceptive statement, act, or omission that causes, or attempts to cause, property or financial damages, or for personal or licensee gain. Fraud includes the offenses identified as fraud in Utah Code Title 76 Chapter 6.

(11) "Harm" means physical or emotional pain, damage, or injury.

(12) "Human Services Program" is defined in 62A-2-101.

(13) "Initial License means the license issued to operate a human services program during the licensee's first year of licensure. This license is considered provisional and allows for the licensee to demonstrate sustained compliance with licensing rules prior to renewal.

(14) "Inspection" means announced or unannounced visit of the licensed site in accordance with 62A-2-118.

(15) "Licensee" is defined in 62A-2-101 and includes the person or persons responsible for administration and decision making for the licensed site or program. The term licensee may be used to describe a person or entity that has caused any of the violations described in 62A-2-112 that are related to the human services program.

(16) "Local Government" is defined in 62A-2-101.

(17) "Medication-Assisted Treatment" means the use of medications with counseling and behavioral therapies to treat substance use disorders and prevent opioid overdose.

(18) "Mistreatment" means emotional or physical mistreatment:

(a) emotional mistreatment is verbal or non-verbal conduct that results in a client suffering significant mental anguish, emotional distress, fear, humiliation, or degradation; and may include demeaning, threatening, terrorizing, alienating, isolating, intimidating, or harassing a client; and

(b) physical mistreatment includes:

(i) misuse of work, exercise restraint, or seclusion as a means of coercion, punishment, or retaliation against a client, or for the convenience of the licensee, or when inconsistent with the client's treatment or service plan, health or abilities;

(ii) compelling a client to remain in an uncomfortable position or repeating physical movements to coerce, punish, or retaliate against a client, or for the convenience of the licensee;

(iii) physical punishment.

(19) "Neglect" means abandonment or the failure to provide necessary care, which may include nutrition, education, clothing, shelter, sleep, bedding, supervision, health care, hygiene, treatment, or protection from harm.

(20) "Office" means the Utah Department of Human Services Office of Licensing.

(21) "Owner/Ownership" means any licensee, person, or entity that:

(a) is defined as a "member" in 62A-2-108; or

(b) is a person or persons listed on a foster home license; or

(c) possesses the exclusive right to hold, use, benefit-from, enjoy, convey, transfer, and otherwise dispose of a program; or

(d) retains the rights, participates in, or is ultimately responsible for operations and business decisions of program, or

(e) may or may not own the real property or building where the facility operates; or

(f) a property owner is also an owner of the program if they operate or have engaged the services of others to operate the program.

(22) "Parent Program" means an applicant or licensee owning or directing multiple sites under the same general administrative organization.

(23) "Penalty" means the Office's denying, placing conditions on, suspending, or revoking a human services license due to noncompliance with statute or administrative rules, may include penalties outline in 62A-2-112. A penalty does not include corrective action plans as used in this rule.

(24) "Pending Renewal License" means a temporary program license status that is assigned when an expiring license has a corrective action plan, penalty, or pending appeal. Pending renewal licenses may be granted only after submission of fees and application, and are valid for no more than 12 months.

(25) "Program" refers to a Human Services Program as defined herein.

(26) "Person" means an individual, agency, association, partnership, corporation, business entity, or governmental entity.

(27) "Renewal License" means a continuing program license issued based upon ongoing compliance with administrative rules and statues. It is issued annually or biannually in compliance with 62A-2 108(4).

(28) "Restraint" means the involuntary method of physically restricting a person's freedom of movement, physical activity, or normal access to their body.

(29) "Seclusion" means the involuntary confinement of the individual in a room or an area away from the client community, where the individual is physically prevented from leaving.

(30) "Site" means a human services program identified by a single geographic location and must be linked to the parent program, if one exists.

(31) "Staff" means direct care employees, support employees, managers, directors, supervisors, administrators, agents, volunteers, owners, and contractors.

(32) "Variance" means the Office authorized deviation from the administrative rule.

(33) "Violation" means an act or omission by the licensee, or any person associated with the licensee, contrary to any administrative regulation, or local, state, or federal law applicable to the program.

 

R501-1-3. Licensing Application Procedures.

(1) Initial and Renewal Application

(a) An applicant shall not accept any fees, enter any agreements to provide client services, or provide any client services until they have received a license certificate issued by the Office.

(b) Applicants and licensees shall permit the Office to have immediate, unrestricted access to the site, all on and off-site program and client records, and all staff and clients.

(c) An applicant may withdraw their application for a license, in writing, at any time during the application process.

(d) An applicant seeking an initial or renewal license to operate a human services program shall submit:

(i) an application as provided by the Office; a renewal application that is not submitted at least thirty days prior to the expiration date of the current license may result in the license expiring;

(ii) the fee(s) required for each category of human service program license(s); except as excluded in R501-1-7-2;

(iii) a completed background screening application, fees and supporting documentation for each person associated with the human services program in accordance with 62A-2-120 and R501-14, except for those excluded in 62A-2-120(13);

(iv) the applicant's required policies and procedures per R-501-2. Renewal applicants may only submit modifications made to previously submitted policies and procedures;

(v) name and contact information for all owners and directors, as defined in this chapter;

(vi) disclosure of any individual associated with the application who has been a licensee as defined in this rule that had a license revoked by the Office within the five years prior to the date on the application; and;

(vii) documentation verifying compliance with, or exemption from, local government zoning, health, fire, safety, and business license requirements.

(A) For residential treatment programs applying for initial licensure, a copy of its notice of intent to operate a residential treatment program, and proof of service, in accordance with 62A-2-108.2.

(2) Application Expiration

(a) A program initial application, other than an initial foster home application, that remains incomplete shall expire one year from the date it was first submitted to the Office.

(b) A foster home initial application that remains incomplete, or lacks required documentation may expire 90 days from the date is was first submitted to the Office unless the Office determines the applicant to be making active progress toward licensing compliance.

(c) An expired initial application is void and requires a new initial application and applicable fees for each category of license.

(3) Two Year Licenses

(a) A program may apply for a two year license if:

(i) the program has been licensed consecutively without penalty for two years prior to application;

(ii) there are no current corrective action plans, penalties, or pending appeals at the time of application;

(iii) the program submits double the annual fees for their category/categories of licenses; and

(iv) the program submits a plan for maintaining continued compliance with background screenings as described in 62A-2-120.

 

R501-1-4. Licensing Determinations.

(1) Application Approval

(a) The Office shall issue a license for a human service program only after verifying compliance with applicable administrative rules and statues.

(b) The Office may place individualized parameters on a program license in order to promote the health, safety, and welfare of clients. Such parameters may include, but are not limited to:

(i) age restrictions;

(ii) admission or placement restrictions; or

(iii) other parameters specific to individual sites and programs.

(c) A license certificate shall state the name, site address, license category, maximum client capacity if applicable, any specific parameters, and effective dates of the license.

(d) Licensee shall post the license certificate in a conspicuous location at the licensed site.

(e) A program shall not be issued an initial license while any other license within that program or parent program is under penalty, or has a pending appeal.

(2) Application Denial

(a) The Office may deny the application for a human service program if:

(i) the program has failed to achieve and maintain compliance with administrative rules and statues. All inspections, investigations, and other information gathered during the licensed period shall contribute to the renewal determination;

(ii) the Office determines that, the program is not reasonably likely to provide services in accordance with governing rules or statutes. The Office may consider the history of rule violations by the owner, licensee, or persons associated with the program; or

(iii) the Office determines that significant false or misleading information regarding the program has been provided to the Office, program clients, prospective clients, or the public.

(b) Previously denied applicants shall not reapply for at least three months from the date of denial.

(3) Renewing a License with Violations

(a) If a license has a penalty, pending appeal, or corrective action plan at the time of renewal, the license shall not be renewed per 62A-2-108(4), but shall be put in a pending renewal status until compliance or other resolution is achieved. Pending renewal status:

(i) provides an opportunity for the licensee to achieve compliance and qualify for full renewal per 62A-2-108(4);

(ii) is only issued after submission of renewal application and fees;

(iii) is valid for up to 12 months of the requested renewal period, and cannot be extended;

(iv) may be converted to a regular renewal license for the balance of the renewal period once compliance is verified; and

(v) will be designated on the license certificate.

(b) A license that does not achieve compliance or other resolution in that time shall be denied further renewal.

 

R501-1-5. Expiration, Extension, and Relinquishment.

(1) License Expiration

(a) A license that has expired is void and may not be renewed.

(b) A license expires at midnight on the expiration date listed on the license that is issued by the Office, unless:

(i) the license has been revoked by the Office,

(ii) the license has been extended by the Office,

(iii) the license has been placed in pending renewal status by the Office in accordance with 501-1-4-3, or

(iv) the license has been relinquished by the licensee.

(c) A program with an expired license shall not accept any fees, enter any agreements to provide client services, or provide any client services.

(d) A program with an expired license wishing to operate a human services program shall submit an application for an initial license in accordance with this rule.

(2) License Extension

(a) The Office may extend the current license of a human service program only when the renewal application and applicable fee have been submitted.

(b) A license may be extended one time, up to a maximum of 90 days past the current license expiration date, only if the Office determines there is a reasonable likelihood the program will achieve compliance prior to the expiration of the extension, and there are not current penalties or pending appeals.

(c) The application for a license that has been extended, but does not qualify for renewal within the timeframe of the extension, shall be denied.

(3) License Relinquishment; A licensee wishing to voluntarily relinquish its license shall submit a written notice to the Office.

 

R501-1-6. Program Changes.

(1) Name Change

(a) A licensee wishing to change only the name of the program or site does not need to submit an application or fee; they shall submit updated program documentation reflecting the new name to the Office at least ten days prior to the change.

(b) The Office may link the name of the former program to the new name on the licensing database, and on all license certificates and public websites, for two years following the change.

(2) Relocation

(a) A human services program wishing to relocate to a new address may serve clients at the new site, only after:

(i) submission of renewal application and renewal fees at least 30 days prior to the move;

(ii) submission of local government business license and applicable inspections and clearances, including but not limited to:

(A) health;

(B) fire; and/or

(C) as categorically required;

(iii) submission of insurance coverage at the new site, as categorically required;

(iv) inspection by the Office; and

(v) receipt of the updated license certificate for the new site.

(b) A foster home that intends to relocate to a new site may have their license transferred to the new site only after:

(i) a request to relocate has been submitted to the Office at least 30 days prior to the move;

(ii) Office of Licensing inspection and approval of licensure at the new site which shall occur within two weeks, if a foster child is placed, and within 30 days if there are no current foster placements;

(A) if a foster child is placed, it is the responsibility of the licensed foster parent to ensure health and safety of the foster child during the transfer to the new site.

(c) Except for foster homes outlined in subsection (b), no clients may be present and no services may be provided at a relocation address until after the Office issues a new license in accordance with this Rule.

(3) Capacity Change

(a) A licensee seeking to increase the maximum client capacity of a program shall submit an application and renewal fee for a license renewal as categorically required.

(4) Add New License Category

(a) A program may request to add a new category of service to an existing licensed site by submitting application and fees for an initial license. All requirements for initial licensure must be verified.

(5) Add New Location

(a) A program may add an additional site of service by submitting an application and fees for an initial license. All requirements for initial licensure must be verified.

(6) Owner/Ownership Changes

(a) A program anticipating, or undergoing a change of ownership, or change in owner(s), shall submit in writing, prior to the change:

(i) any changes to the programming and services;

(ii) declaration regarding responsibility for records and records retention to include an agreement signed by both current and prospective owners and/or directors, detailing how all program staff and client records will be retained and remain available to the Office;

(iii) names and contact information of any new directors or owners;

(iv) documentation of continuous insurance coverage;

(v) updated business license.

(b) The status of a license at the time of a change of ownership shall continue.

(c) For any substantial change in this section, the Office may require new, initial application and fees for each license category.

(i) Substantial changes include:

(A) those resulting in direct client impact;

(B) changes to programming;

(C) changes in populations served;

(D) severing ties with previous owner or staff affiliations; or

(E) disrupting continuity of record retention, etc.

 

R501-1-7. License Fees.

(1) The Office shall collect licensing fees in accordance with 62A-2-106, and Utah Code Title 63J Chapter 1 Part 5.

(2) No licensing fee shall be required from a foster home, or a Division, or Office, of the Department of Human Services.

(3) The Office is not required to perform an on-site visit, or document review until the applicant pays the licensing fee.

(4) A license application fee will expire after 12 months if a program has been unable to meet the license requirements.

(5) A fee shall not be transferred, prorated, reduced, waived, or refunded. Costs incurred by applicants in preparation for, or maintenance of licensure are the sole responsibility of the applicant.

(6) Separate initial license fees are required for each new category of human services program offered at each program site.

(7) Separate renewal license fees, and applicable capacity fees, are required for each license category that is renewed at each program site.

(a) Capacity fees are calculated according to the maximum licensed client capacity of the human service program, and not according to the number of clients actually served in the program.

(8) A human service program with more than one building, unit, or suite at one site, may choose to have its fees assessed and each category of license issued:

(a) so that each category of license will be issued to include all on-site buildings, units or suites as one; or

(b) so that separate licenses will be issued for each individual on-site building, unit or suite.

 

R501-1-8. Variances.

(1) A licensee shall not deviate from any administrative rule without first receiving written approval of a specific variance request signed by the Director of the Office, or the director's designee.

(2) The director of the Office, or the director's designee, may grant a variance if the director or the Director's designee determines a variance is not likely to compromise client health and safety, or provide opportunity for abuse, neglect, exploitation, harm, mistreatment, or fraud.

(3) A licensee seeking a variance must submit a written request to their licensing specialist, and specifically describe:

(a) the rule for which the variance is requested;

(b) the reason for the request;

(c) how the variance provides for the best interest of the client(s);

(d) what procedures will be implemented to ensure the health and safety of all clients; and

(e) the proposed variance start and expiration dates.

(4) The Office shall review the variance and notify the licensee of the approval, approval with modification, or denial of the variance, in writing, within 30 days.

(5) The licensee shall comply with the terms of a written variance, including any conditions or modifications contained within the approved written variance.

(6) A variance expires on the end date listed on the approval notice and terms of the variance are no longer permitted after that expiration date, unless a renewal of the variance is granted.

(7) A variance may be renewed by the office when the program is able to justify the request, and ensure ongoing health and safety of all clients.

 

R501-1-9. Monitoring.

(1) The Office shall conduct a minimum of one annual on-site inspection, but may conduct as many announced, or unannounced inspections as deemed necessary to monitor compliance, investigate alleged violations, monitor corrective action plans or penalty compliance, or to gather information for license renewal.

(2) On-site inspections shall take place during regular business hours, as defined in 62A-2-101.

(3) Applicants and licensees shall not restrict the Office's access to the site, clients, staff, and all program records.

(4) Licensees and staff shall not compromise the integrity of the Office's information gathering process by withholding or manipulating information, or influencing the specific responses of staff or clients.

(5) All on-site inspections shall contribute toward the renewal or denial of the license application at the end of the license period.

(6) The Office shall provide written findings to the Program identifying areas of non-compliance with licensing requirements after each on-site inspection.

(7) Except for reports made in relation to foster homes, the licensee shall make copies of inspection reports available to the public upon request per 62A-2-118(5).

(8) The Office may adopt a written inspection report from a local government, certifying, contracting, or accrediting entity to assist in a determination whether a licensee has complied with a licensing requirement.

(9) The Office shall be allowed access to all program documentation and staff that may be located at an administrative location, away from the licensed site.

 

R501-1-10. Investigations of Alleged Violations.

(1) Unlicensed Programs

(a) The Office shall investigate reports of unlicensed human service programs.

(b) Investigation of an unlicensed human service program may include interviewing anyone at the site, neighbors, or gathering information from any source that will aid the Office in making a determination as to whether or not the site should be licensed.

(c) An unlicensed human services program that meets licensure definition, but does not submit an application and fee, or fails to become licensed, shall be referred to the Office of the Attorney General, and the appropriate County Attorney.

(d) The Office may penalize a licensed program at all program sites when a program adds or operates an unlicensed site that requires licensure by the Office.

(2) Licensed Program Complaints and Critical Incidents

(a) The Office shall investigate critical incidents and complaints involving alleged licensing violations regarding a licensed human services program.

(b) Complaints about licensees can come to the Office via any means from any source.

(c) The Office retains discretion to decline investigation of a complaint that is anonymous, unrelated to current conditions of the program, or not an alleged violation of a rule or statute.

(d) Critical incidents shall be reported by the program to the Office by the end of the following business day, to legal guardians of involved clients, and to any other agencies as required by law, including:

(i) Child and Adult Protective Services; or

(ii) Law Enforcement.

(e) Pending investigations or those that result in no rule violation findings in regards to the complaints or critical incidents shall be classified as protected and only released in accordance with Utah Code title 63G chapter 2, Utah Government Access and Management Act.

(3) Investigative Process

(a) In-person, or electronic investigations may include, but are not limited to:

(i) a review of on or offsite records;

(ii) interviews of licensee(s), person(s), client(s), or staff;

(iii) the gathering of information from collateral parties; or

(iv) site inspections.

(b) The Office will prioritize investigations of reports of unlicensed programs, complaints regarding licensed programs, and critical incidents following an assessment of risk to client health and safety as follows:

(i) priority allegations, as administratively identified by the Office as a potential imminent risk to the health and safety of clients, will require initial on-site contact by the Office within three business days. The Office may utilize law enforcement, Child or Adult Protective services, or other protection agencies to meet priority in on-site response;

(ii) all other allegations will require that the Office initiate an investigation within ten business days.

(c) Licensees and staff shall cooperate in any investigation.

(d) The Office may report any allegations or evidence of abuse, neglect, exploitation, mistreatment, or fraud to clients, clients' legal guardians, law enforcement, insurance agencies, the insurance department, the Division of Occupational and Professional Licensing, or any other entity determined necessary by the Office.

 

R501-1-11. License Violations.

When the Office finds evidence of violations of statute or rule, the Office shall do one of the following:

(1) provide written notification of the violation requiring the licensee to correct violation(s) with no formal follow-up; or

(2) provide written notification of violation and request a licensee to submit a corrective action plan in response to a written notification of a violation;

(a) a licensee shall submit a written corrective action plan to the Office within ten calendar days of the request from the Office and the corrective action plan shall include:

(b) a statement of each violation identified by the Office;

(c) a detailed description of how the licensee will correct each violation and prevent additional violations;

(d) the date by which the licensee will achieve compliance with administrative rules and statutes; and

(e) the signature of program owners and directors, including each foster parent, if involving a licensed or certified foster home;

(i) the Office shall review the submitted corrective action plan and:

(A) inform the licensee that the corrective action plan is approved; or

(B) inform the licensee that the corrective action plan is not approved and provide explanation;

(ii) the Office may permit a licensee to amend and resubmit its corrective action plan within five additional calendar days;

(f) the Office shall issue a Notice of Agency Action imposing a penalty for violation(s) if the licensee fails to submit and comply with an approved corrective action plan.

(g) A corrective action plan is not a penalty. Programs have the right to refuse the corrective action plan process and may preserve their appeal rights by requesting a penalty through an Office initiated Notice of Agency Action.

(3) provide a written notice of agency action initiating a penalty, as follows:

(a) the Office may place a license on conditional status. Conditional status allows a program that is in the process of correcting violations to continue operation, subject to conditions established by the Office. Failure to meet the terms of the conditions, and time frames outlined on the notice, could result in further penalty;

(b) the Office may suspend a license for up to one year;

(i) a human services program that has had its license suspended is prohibited from accepting new clients, and may only provide the services necessary to maintain client health and safety during their transition; and

(ii) shall have and comply with written policies and procedures to transition clients into equivalent, safe, currently licensed programs or into the custody of their legal guardians;

(c) the Office may revoke a license;

(i) a human services program that has had its license revoked is prohibited from accepting new clients and may only provide the services necessary to maintain client health and safety during their transition, and

(A) shall have and comply with written policies and procedures to transition clients into equivalent, safe, currently licensed program or into the custody of their legal guardians;

(B) Names of licensees and programs who have had their licenses revoked shall be maintained by the Office for a period of five years, and shall not be associated in any way with a licensed program during that five-year period.

(d) A licensee whose license has been suspended or revoked is responsible for the program staffing and health and safety need of all clients while the suspension or revocation is pending.

(e) The Office may place conditions, such as restricted admissions, to be in immediate effect in the Notice of Agency Action, if necessary, to protect the health and safety of clients.

(f) The Office may utilize any other penalties pursuant to 62A-2, Subsections 112, 113 and/or 116.

(g) The Office may consider chronicity, severity, and pervasiveness of violations when determining whether to simply provide notification of violations with no follow-up requirement; to request a corrective action plan; or to apply a formal penalty to the program.

(h) Repeated violations of the same rule or statute, or failure to comply with conditions of a Notice of Agency Action may elevate the penalty level assessed.

(i) A licensee shall post the Notice of Agency Action on-site, and on the homepage of each of its websites, where it can be easily reviewed by all clients, guardians of clients, and visitors within five business days, and shall remain posted for 90 days, unless otherwise noted by the Office.

(j) A licensee shall notify all clients, guardians and prospective clients of a Notice of Agency Action issued by the Office within five business days. Prospective and new clients will be notified for as long as the Notice of Agency Action is in effect.

(k) Pending an appeal of a revocation, suspension or conditional license that restricts admissions, licensee shall not accept any new clients as outlined on the Notice of Agency Action, or while an appeal of a penalty is pending without prior written authorization from the Office.

(l) The Office shall electronically post Notices of Agency Action issued to a human services program, on the Office's website, in accordance with 62A-2-106.

(m) Due Process: A Notice of Agency Action shall inform the applicant or licensee of the right to appeal in accordance with Administrative Rule 497-100.

 

R501-1-12. Licensing Code of Conduct and Client Rights.

(1) Licensees and staff shall:

(a) accurately represent services, policies and procedures to clients, guardians, prospective clients, and the public;

(b) create, maintain, and comply with a written policy that addresses the appropriate treatment of clients, to include the rights of clients as outlined in this section;

(c) not abuse, neglect, harm, exploit, mistreat, or act in a way that compromises the health and safety of clients through acts or omissions, by encouraging others to act, or by failing to deter others from acting;

(d) not use or permit the use of corporal punishment and shall only utilize restraint as described in R501-2;

(e) maintain the health and safety of clients in all program services and activities, whether on or offsite;

(f) not commit fraud;

(g) provide an insurer the licensee's records related to any services or supplies billed, upon request by an insurer or the Office;

(h) require that any licensee or staff member who is aware of, or suspects abuse, neglect, mistreatment, fraud, or exploitation shall ensure that a report is made to the Office and applicable investigative agencies as outlined in R501-1-10-2, and in compliance with mandatory reporting laws, including 62A-4a-403 and 62A-3-305;

(i) any licensee or staff member who is aware of, or suspects a violation of this rule, shall ensure that a report is made to the Office of Licensing at 801-538-4242 or directly to the licensor of the specific program or site; and

(j) provide services and supervision that is commensurate with the skills, abilities, behaviors, and needs of each client.

(2) Clients have the right to:

(a) be treated with dignity;

(b) be free from potential harm or acts of violence;

(c) be free from discrimination;

(d) be free from abuse, neglect, mistreatment, exploitation, and fraud;

(e) privacy of current and closed records;

(f) communicate and visit with family, attorney, clergy, physician, counselor, or case manager, unless therapeutically contraindicated or court restricted;

(g) be informed of agency policies and procedures that affect client or guardian's ability to make informed decisions regarding client care, to include:

(i) program expectations, requirements, mandatory or voluntary aspects of the program;

(ii) consequences for non-compliance;

(iii) reasons for involuntary termination from the program and criteria for re-admission;

(iv) program service fees and billing; and

(v) safety and characteristics of the physical environment where services will be provided.

(3) clients shall be informed of these rights and a copy signed by the client or guardian shall be maintained in the client file.

(4) licensees shall train all staff annually on agency policies and procedures, Licensing rules, and the Licensing Code of Conduct. A document verifying this training shall be signed and dated by the trainer and staff member and maintained in the staff personnel file.

 

R501-1-13. Compliance.

(1) A licensee that is in operation on the effective date of this rule shall be given 60 days to achieve compliance with this rule.

 

KEY: licensing, human services

Date of Enactment or Last Substantive Amendment: [July 1, 2015]2016

Notice of Continuation: October 18, 2012

Authorizing, and Implemented or Interpreted Law: 62A-2-101 et seq.