This
rule was files as 7 NMAC 20.3.
TITLE 7 HEALTH
CHAPTER 20 MENTAL HEALTH
PART 3 REQUIREMENTS FOR COMMUNITY
MENTAL HEALTH CENTERS
7.20.3.1 ISSUING
AGENCY: New Mexico Department of Health - Division of Health Improvement
- Health Facility Licensing and Certification Bureau.
[01/01/00; Recompiled 10/31/01]
7.20.3.2 SCOPE:
A. These
regulations apply to the following:
(1)
outpatient facilities which are certified by the behavioral health
services division of the department to provide psychosocial rehabilitation services
to adults with priority given to individuals with severe disabling mental
illness (SDMI); and
(2)
any facility providing services as outlined by these regulations which
by federal regulation must be certified by the behavioral health services
division of the department to obtain or maintain full or partial, permanent or
temporary federal funding.
B. These
regulations do not apply to offices and treatment facilities of licensed
private practitioners.
[01/01/00; Recompiled 10/31/01]
7.20.3.3 STATUTORY
AUTHORITY: The regulations set forth herein are promulgated by the secretary
of the New Mexico department of health, pursuant to the general authority
granted under Section 9-7-6 (E) of the Department of Health Act, NMSA 1978, as
amended; and the authority granted under Sections 24-1-2 (D), 24-1-3 (I) and
24-1-5 of the Public Health Act, NMSA 1978, as amended.
[01/01/00; Recompiled
10/31/01]
7.20.3.4 DURATION: Permanent.
[01/01/00; Recompiled
10/31/01]
7.20.3.5 EFFECTIVE
DATE: January 1,
2000, unless a later date is cited at the end of a Section or Paragraph.
[01/01/00; Recompiled
10/31/01]
[Compiler’s note: The words or paragraph, above, are no longer applicable. Later dates are now cited only at the end of
sections, in the history notes appearing in brackets.]
7.20.3.6 OBJECTIVE:
A. to
establish minimum standards for licensing of community mental health centers;
B. to
monitor community mental health centers through surveys to identify any areas
which could be dangerous or harmful to the clients or staff; and
C. to
ensure the provision of quality services which maintain or improve the health
and quality of life to the clients.
[01/01/00; Recompiled
10/31/01]
7.20.3.7 DEFINITIONS:
A. “Applicant”
means the organization that applies for a license. The individual signing the application on behalf of the
organization must have authority from the organization.
B. “Branch”
means a part of the certified community mental health center, which is part of
the corporation or campus that is certified by DOH, where client care takes
place. Branches of facilities must meet
the intent of these regulations. The
parent facility is responsible for their branches’ compliance. A separate state license is required for
separate geographic locations under each certified facility.
C. “Client”
means any individual who is requesting or receiving
mental health services from a community mental health center as defined in this
regulation.
D. “Community-based crisis intervention” means, at a minimum, twenty-four (24) hour telephone
crisis services, initial face-to-face crisis intervention and follow-up crisis
support services.
E. “Community mental health center” means a facility certified by the department of health
to provide and manage a comprehensive array of mental health services with
priority given to serving adults with severe disabling mental illness (SDMI) in
a community-based setting. At a
minimum, the following core services must be available and accessible:
(1)
professional consultation;
(2)
community-based crisis intervention;
(3)
therapeutic interventions;
(4)
medication services; and
(5)
psychosocial interventions.
F. “Deficiency” means a violation of or failure to comply with a
provision(s) of these regulations
G. “Department” means the New
Mexico department of health.
H. “Facility”
means a building or buildings, including all branches, in which outpatient
mental health services are provided to the public and which is licensed
pursuant to these regulations.
I. “Governing body” means the governing authority of a facility, which has the ultimate
responsibility for all planning, direction, control, and management of the
activities and functions of a facility licensed pursuant to these regulations.
J. “License” means the document issued by the licensing authority
pursuant to these regulations granting the legal right to operate for a
specified period of time, not to exceed one (1) year.
K. “Licensee”
means the organization which has an ownership, leasehold, or similar interest
in the facility and in whose name a license for a facility has been issued and
who is legally responsible for compliance with these regulations.
L. “Licensing authority” means the agency within the New Mexico department of
health vested with the authority by DOH to regulate and enforce these
regulations.
M. “Medication services” means assessing the need for psychoactive medications
and management of pharmacological treatments.
N. “NMSA”
means the New Mexico Statutes Annotated, 1978 compilation, and all the
revisions and compilations thereof.
O. “Plan of
correction” means the plan submitted by
the licensee or representative of the licensee addressing how and when
deficiencies identified at the time of a survey will be corrected.
P. “Policy” means a statement of principle that guides and
determines present and future decisions and actions.
Q. “Premises” means buildings, grounds, and equipment of a
facility.
R. “Procedure” means the action(s) that must be taken in order to
implement a policy.
S. “Professional consultation” means the initial assessment of the client’s needs and
resources, the development of the patient’s treatment plan, its monitoring and
review and the access of specialized expertise to provide tests.
T. “Psychosocial interventions” means an array of services designed to help an
individual capitalize on his personal strengths, develop coping strategies, and
to develop a supportive environment in which to function as independently as
possible. This array must include, at a
minimum:
(1)
basic living skills;
(2)
psychosocial skills training; and
(3)
therapeutic socialization.
U. “Psychosocial
rehabilitation services” means
a set of treatment strategies which help persons with mental disorders,
including those with co-occurring substance abuse issues, achieve optimum
functioning in the personal and social dimensions of their lives. The treatment strategies must be
rehabilitative in nature and create, sustain, and encourage empowerment through
a recovery process.
V. “Therapeutic interventions” means interactive
therapies which, when used in conjunction with other treatment strategies,
assist persons with severe disabling mental illness to achieve optimum
functioning in the personal and social dimensions of their lives.
W. “U/L approved” means approved for safety by the national
underwriters laboratory.
X. “Variance” means to refrain from pressing or enforcing
compliance with a portion or portions of these regulations for an unspecified
period of time where the granting of a variance will not create a danger to the
health, safety, or welfare of clients or staff of a facility, and is issued at
the sole discretion of the licensing authority.
Y. “Waive/waiver” means to refrain from pressing or enforcing compliance
with a portion or portions of these regulations for a limited period of time
provided the health, safety, or welfare of the clients and staff are not in
danger. Waivers are issued at the sole discretion of the licensing authority.
[01/01/00; Recompiled
10/31/01]
7.20.3.8 STANDARD OF
COMPLIANCE: The degree of compliance required throughout these regulations is
designated by the use of the words “shall” or “must” or “may.” “Shall” or “must” means mandatory. “May” means permissive. The use of the words
“adequate,” “proper,” and other similar words means the degree of compliance
that is generally accepted throughout the professional field by those who
provide outpatient mental health services to the public in facilities governed
by these regulations.
[01/01/00; Recompiled
10/31/01]
7.20.3.9 PROHIBITION ON UNLICENSED OPERATION: These
regulations apply to all community mental health centers operating within New
Mexico as set out in Section 2 [now 7.20.3.2 NMAC] above. No community mental health center, or branch
thereof, may operate in New Mexico without being duly licensed according to
these regulations.
[01/01/00; Recompiled
10/31/01]
7.20.3.10 INITIAL LICENSURE PROCEDURES: To obtain an
initial license for a facility pursuant to these regulations the following
procedures must be followed by the applicant.
A. Application phase: These
regulations apply to the design of a new building or renovation or addition to
an existing building for licensure as a facility pursuant to these
regulations. Prior to starting
construction, renovations or additions to an existing building the applicant of
the proposed facility shall:
(1)
advise the licensing authority
in writing of intention to open a facility pursuant to these regulations.
(2)
submit a set of floor plans for the building which must be of
professional quality, be on substantial paper of at least 18" x 24",
and be drawn to an accurate scale of ¼ inch to 1 foot. These plans must
include:
(a) proposed use of each room e.g., waiting
room, counseling/therapy room, office, et cetera;
(b) interior dimensions of all rooms;
(c) one building or wall section showing exterior and interior
wall construction. Section must include floor, wall, ceiling, and the finishes,
e.g., carpet, tile, gyp board with paint, wood paneling;
(d) door types, swing, and sizes of all doors, e.g. solid core,
hollow core, 3'0' x 6'8", 1 3/4" thick;
(e) if the building is air-conditioned;
(f) all sinks;
(g) furnaces and hot water heaters, and if gas or electric;
(h) windows including
size and type;
(i) any level changes within the building, e.g., steps or ramps;
(j) fire extinguishers, heat and smoke detectors and alarm
systems;
(k)
location of the building on a site/plot plan to determine surrounding
conditions, include all steps, ramps,
parking areas, walks, and any permanent structures; and
(l) plans if the building is new construction, remodeled or
alteration, or an addition. If
remodeled or an addition, indicate existing and new construction on the plans.
(3)
Blueprints or floor plans must be reviewed by the licensing authority
for compliance with current licensing regulations, building and fire codes.
(4)
If blueprints or plans are approved, the licensing authority will advise
the applicant that construction may begin.
B. Construction phase: During the construction
of a new building or renovations or additions to an existing building, the
applicant must coordinate with the licensing authority and submit any changes
to the blueprints or plans for approval before making such changes.
C. Licensing phase: Prior to
completion of construction, renovation or addition to an existing building, the
applicant will submit to the licensing authority the following:
(1) application forms:
appropriately completed and notarized.
(2) fees:
(a) Current fee schedules must be provided by the licensing
authority.
(b) Fees must be in the form of a certified
check, money order, personal, or business check made payable to the state of
New Mexico.
(c) Fees are non-refundable.
(3) Zoning and building approval:
(a) All initial applications must be
accompanied with written zoning approval from the appropriate authority (city,
county or municipality).
(b) Prior to
licensure, initial applicants must submit written building approval
(certificate of occupancy) from the appropriate authority (city, county, or
municipality).
(4) Fire authority approval:
Prior to licensure, initial applicants must submit written approval of
the fire authority having jurisdiction.
(5) New Mexico environment department approval: Prior to
licensure, initial applicants are responsible for submission of the written
approval of the New Mexico environment department for the following:
(a) private water supply, if applicable;
(b) private
waste or sewage disposal, if applicable; and
(c) kitchen, if meals are prepared on site.
(6) Copy of appropriate drug permit issued by the state board of pharmacy, if applicable.
D. Initial survey: Upon receipt
of a properly completed application with all supporting documentation as
outlined above, an initial Life Safety Code on-site survey and an on-site
health survey of the proposed facility will be scheduled by the licensing
authority.
E. Issuance of license: Upon completion of the initial survey and
determination that the facility is in compliance with these regulations, the
licensing authority will issue a license.
[01/01/00; Recompiled
10/31/01]
7.20.3.11 LICENSES:
A. Annual license: An annual license is issued for a one (1)
year period to a facility which has met all requirements of these regulations.
B. Temporary license: The licensing authority may, at its sole
discretion, issue a temporary license prior to the initial survey or when it
finds partial compliance with these regulations.
(1)
A temporary license shall cover a period of time not to exceed one
hundred twenty (120) days, during which the facility must correct all specified
deficiencies.
(2)
In accordance with Section 24-1-5 (D) NMSA 1978, no more than two (2)
consecutive temporary licenses shall be issued.
C. Amended license: A licensee must apply to the licensing
authority for an amended license when there is a change of
administrator/director or when there is a change of name for the facility.
(1)
Application must be on a form provided by the licensing authority.
(2)
Application must be
accompanied by the required fee for amended license.
(3)
Application must be submitted within ten (10) working days of the
change.
[01/01/00; Recompiled
10/31/01]
7.20.3.12 LICENSE
RENEWAL:
A. Licensee
must submit a renewal application on forms provided by the licensing authority,
along with the required fee at least thirty (30) days prior to expiration of
the current license.
B. Upon receipt of renewal application
and required fee prior to expiration of their current license, the licensing
authority will issue a new license effective the day following the date of
expiration of the current license if the facility is in compliance with these
regulations.
C. If a licensee fails to submit a renewal application with the required
fee and the current license expires, the facility shall cease operations until
it obtains a new license through the initial licensure procedures. Section 24-1-5 (A) NMSA 1978, as amended,
provides that no health facility shall be operated without a license.
[01/01/00; Recompiled
10/31/01]
7.20.3.13 POSTING
OF LICENSE: The facility's license must be posted on the licensed premises in
an area visible to the public.
[01/01/00; Recompiled
10/31/01]
7.20.3.14 NON-TRANSFERABLE
RESTRICTION OF LICENSE: A license shall not be transferred by
assignment, or otherwise, to other persons or locations. The license shall be
void and must be returned to the licensing authority when any one of the
following situations occur:
A. ownership
of the facility changes;
B. the
facility changes location;
C. licensee
of the facility changes;
D. the facility
discontinues operation; or
E. a
facility wishing to continue operation as a licensed facility under
circumstances 14.1 - 14.4 [now Subsections A - D of 7.20.3.14 NMAC] above must
submit an application for initial licensure in accordance with Section 10 [now
7.20.3.10 NMAC] of these regulations at least thirty (30) days prior to the
anticipated change.
[01/01/00; Recompiled
10/31/01]
7.20.3.15 AUTOMATIC
EXPIRATION OF LICENSE: A license will automatically expire at
midnight on the day indicated on the license as the expiration date, unless
renewed, suspended, or revoked, or
A. on
the day a facility discontinues operation;
B. on
the day a facility is sold, leased, or otherwise changes ownership and/or
licensee; or
C. on
the day a facility changes location.
[01/01/00; Recompiled
10/31/01]
7.20.3.16 SUSPENSION
OF LICENSE WITHOUT PRIOR HEARING: In accordance with Section 24-1-5 (H), NMSA
1978, if immediate action is required to protect human health and safety, the
licensing authority may suspend a license pending a hearing, provided such
hearing is held within five (5) working days of the suspension, unless waived
by the licensee
[01/01/00; Recompiled 10/31/01]
7.20.3.17 GROUNDS
FOR REVOCATION OR SUSPENSION OF LICENSE, DENIAL OF INITIAL OR RENEWAL
APPLICATION FOR LICENSE, OR IMPOSITION OF INTERMEDIATE ACTIONS OR CIVIL
MONETARY PENALTIES: A license may be revoked or suspended, an
initial or renewal application for license may be denied, or intermediate
sanctions or civil monetary penalties may be imposed after notice and
opportunity for a hearing, for any of the following:
A. failure
to comply with any provision of these regulations;
B. failure
to allow survey by authorized representatives of the licensing authority;
C. allowing
any person active in the operation of a facility licensed pursuant to these
regulations to be under the influence of, or impaired by, alcohol or other
behavior altering substances;
D. misrepresentation
or falsification of any information on application forms or other documents
provided to the licensing authority;
E. repeated
violations of these regulations; or
F. failure
to provide the required care and services as outlined by these regulations for
the clients receiving care at the facility.
[01/01/00; Recompiled
10/31/01]
7.20.3.18 HEARING
PROCEDURES:
A. Hearing
procedures for an administrative appeal of an adverse action taken by the
licensing authority against a facility's license as outlined in Section 16 and
17 [now Sections 16 and 17 of 7.20.3 NMAC] above will be held in accordance
with Adjudicatory Hearings, New Mexico department of health, 7 NMAC 1.2 [7.1.2
NMAC].
B. A
copy of the above regulations will be furnished to a facility at the time an
adverse action is taken against its license by the licensing authority. A copy
may be requested at any time by contacting the licensing authority.
[01/01/00; Recompiled
10/31/01]
7.20.3.19 LICENSED
FACILITIES:
A. Any
community mental health center, currently licensed as a limited diagnostic and
treatment center on the date these regulations are promulgated and which
provides the services prescribed under these regulations, may continue to be
licensed as such until that license expires and renewal is required. At that time, the facility must seek
licensure as a community mental health center.
B. Any community mental health center,
not currently licensed on the date these regulations are promulgated and which
provides the services prescribed under these regulations, must seek licensure
as a community mental health center.
(1) Community mental health centers may seek
variances for those building requirements the facility cannot meet under the
criteria outlined in these regulations if not in conflict with existing
building and fire codes.
(2)
Variances or waivers may be considered for circumstances where the
facility demonstrates an extreme financial hardship to comply with requirements
outlined in these regulations.
[01/01/00; Recompiled
10/31/01]
7.20.3.20 NEW
FACILITY: A new facility may be opened in an existing building or a newly
constructed building.
A. If
opened in an existing building, a variance may be granted for those building
requirements the facility cannot meet under the criteria outlined in these
regulations if not in conflict with existing building and fire codes. This is
at the sole discretion of the licensing authority.
B. A
new facility opened in a newly constructed building must meet all requirements
of these regulations.
[01/01/00; Recompiled
10/31/01]
7.20.3.21 FACILITY
SURVEYS:
A. Application
for licensure, whether initial or renewal, shall constitute permission for entry
into, and survey of, a facility by authorized licensing authority
representatives at reasonable times during the status of the application and,
if licensed, during the licensure period.
B. Surveys
may be announced or unannounced at the sole discretion of the licensing
authority.
C. Upon
receipt of a written notice of deficiency from the licensing authority, the
licensee, or their representative, will be required to submit a plan of
correction to the licensing authority within ten (10) working days stating how
the facility intends to correct each violation noted and the expected date of
correction.
D. The
licensing authority may at its sole discretion accept the plan of correction as
written or require modifications of the plan by the licensee.
[01/01/00; Recompiled
10/31/01]
7.20.3.22 REPORTING
OF INCIDENTS: All facilities licensed pursuant to these
regulations must report incidents in accordance with the policies established
by the division of health improvement of the department.
[01/01/00; Recompiled
10/31/01]
7.20.3.23 QUALITY
ASSURANCE: All facilities licensed pursuant to these regulations must be in
compliance with the quality assurance standards established by the division of
health improvement of the department.
[01/01/00; Recompiled 10/31/01]
7.20.3.24 CLIENT
RECORDS: Each facility licensed pursuant to these regulations must
maintain a record for each client in accordance with the client record
standards set forth by the division of health improvement of the department.
[01/01/00; Recompiled
10/31/01]
7.20.3.25 REPORTS
AND RECORDS REQUIRED TO BE ON FILE IN THE FACILITY: Each facility
licensed pursuant to these regulations must keep the following reports and
records on file and make them available for review upon request of the
licensing authority:
A. a
copy of the latest fire inspection report by the fire authority having
jurisdiction;
B. a
copy of the last survey conducted by the licensing authority and any variances
granted;
C. record
of fire and emergency evacuation drills conducted by the facility;
D. licensing
regulations: A copy of these regulations;
E. a
copy of the current license, registration or certificate, of each staff member
for which a license, registration, or certification is required by the state of
New Mexico; Facilities with satellite
or branch locations that maintain personnel records in a central location may
make arrangements with licensing authority inspectors for viewing such records.
F. valid
drug permit as required by the state board of pharmacy; and
G. New
Mexico environment department approval of private water system and private
waste or sewage disposal, if applicable.
[01/01/00; Recompiled
10/31/01]
7.20.3.26 CLIENT
RIGHTS: All facilities licensed pursuant to these regulations shall
support, protect and enhance the rights of clients in accordance with the
standards set forth by the division of health improvement of the department.
[01/01/00; Recompiled
10/31/01]
7.20.3.27 STAFF
RECORDS: Each facility licensed pursuant to these regulations must maintain
a complete record on file for each staff member or volunteer working more than
half-time. Staff records will be made available for review upon request of the
licensing authority.
A. Staff
records will contain at least the following:
(1) name;
(2)
address and telephone number;
(3)
position for which employed;
(4)
date of employment; and
(5)
health certificate stating that the employee is free from tuberculosis
in a transmissible form as required by New Mexico department of health
regulations, Control of Communicable Disease in Health Facility Personnel, 7
NMAC 4.4 [now 7.4.4 NMAC].
B. A
daily attendance record of all staff must be kept in the facility.
C. The
facility must keep weekly or monthly schedules of all staff. These schedules must be kept on file for at
least six (6) months.
[01/01/00; Recompiled
10/31/01]
7.20.3.28 POLICIES
AND PROCEDURES: All community mental health centers licensed
pursuant to these regulations must have written policies and procedures in
accordance with the standards set forth by the division of health improvement
of the department.
[01/01/00; Recompiled
10/31/01]
7.20.3.29 GENERAL
BUILDING REQUIREMENTS:
A. New construction, additions and alterations: When construction of new buildings,
additions, or alterations to existing buildings are contemplated, plans and
specifications covering all portions of the work must be submitted to the
licensing authority for plan review and approval prior to beginning actual
construction. When an addition or
alteration is contemplated, plans for the entire facility must be submitted.
B. Access to the disabled: Community
mental health centers licensed pursuant to these regulations must be accessible
to and useable by disabled employees, staff, visitors, and clients.
C. Extent of a facility: All buildings of the premises providing
client care and services will be considered part of the facility and must meet
all requirements of these regulations. Where a part of the facility services
are contained in another facility, separation and access shall be maintained as
described in current building and fire codes.
D. Additional requirements: A facility
applying for licensure pursuant to these regulations may have additional
requirements not contained herein. The complexity of building and fire codes
and requirements of city, county, or municipal governments may stipulate these
additional requirements. Any additional requirements will be outlined by the
appropriate building and fire authorities, and by the licensing authority
through plan review, consultation and on-site surveys during the licensing
process.
[01/01/00; Recompiled
10/31/01]
7.20.3.30 MAINTENANCE
OF BUILDING AND GROUNDS: Facilities must maintain the building(s) in
good repair at all times. Such maintenance shall include, but is not limited
to, the following:
A. All
electrical, mechanical, water supply, heating, fire protection, and sewage
disposal systems must be maintained in a safe and functioning condition,
including regular inspections of these systems;
B. All equipment and materials used for client care shall
be maintained clean and in good repair;
C. All
furniture and furnishings must be kept clean and in good repair; and
D. The grounds of the facility must
be maintained in a safe and sanitary condition at all times.
[01/01/00; Recompiled
10/31/01]
7.20.3.31 HOUSEKEEPING:
A. The
facility must be kept free from offensive odors and accumulations of dirt,
rubbish, dust, and safety hazards.
B. Counseling/therapy rooms, waiting
areas and other areas of daily usage must be cleaned as needed to maintain a clean
and safe environment for the clients.
C. Floors
and walls must be constructed of a finish that can be easily cleaned. Floor
polishes shall provide a slip resistant finish.
D. Deodorizers must not
be used to mask odors caused by unsanitary conditions or poor housekeeping
practices.
E. Storage
areas must be kept free from accumulation of refuse, discarded equipment,
furniture, paper, et cetera.
[01/01/00; Recompiled
10/31/01]
7.20.3.32 WATER:
A. A facility licensed pursuant to these
regulations must be provided with an adequate supply of water that is of a safe
and sanitary quality suitable for domestic use.
B. If the
water supply is not obtained from an approved public system, the private water
system must be inspected, tested, and approved by the New Mexico environment
department prior to licensure. It is the facility's responsibility to insure
that subsequent periodic testing or inspection of such private water systems be
made at intervals prescribed by the New Mexico environment department or recognized
authority.
C. Hot
and cold running water under pressure must be distributed at sufficient
pressure to operate all fixtures and equipment during maximum demand periods
D. Back
flow preventers (vacuum breakers) must be installed on hose bibbs, laboratory
sinks, janitor's sinks, and on all other water fixtures to which hoses or
tubing can be attached.
E. Water
distribution systems are arranged to provide hot water at each hot water outlet
at all times. Hot water to hand washing facilities must not exceed 120 degrees
F.
[01/01/00; Recompiled
10/31/01]
7.20.3.33 SEWAGE
AND WASTE DISPOSAL:
A. All
sewage and liquid wastes must be disposed of into a municipal sewage system
where such facilities are available.
B. Where
a municipal sewage system is not available, the system used must be inspected
and approved by the New Mexico environment department or recognized local
authority.
C. Where
municipal or community garbage collection and disposal service are not
available, the method of collection and disposal of solid wastes generated by
the facility must be inspected and approved by the New Mexico environment
department or recognized local authority.
D. All
garbage and refuse receptacles must be durable, have tight fitting lids, must
be insect and rodent proof, washable, leak proof and constructed of materials
which will not absorb liquids. Receptacles must be kept clean.
[01/01/00; Recompiled
10/31/01]
7.20.3.34 FIRE
SAFETY COMPLIANCE: All current applicable requirement of state
and local codes for fire prevention and safety must be met by the facility.
[01/01/00; Recompiled
10/31/01]
7.20.3.35 FIRE
CLEARANCE AND INSPECTIONS: Each facility must request from the fire
authority having jurisdiction an annual fire inspection. If the policy of the
fire authority having jurisdiction does not provide for annual inspection of
the facility, the facility must document the date the request was made and to
whom. If the fire authorities do make annual inspections, a copy of the latest
inspection must be kept on file in the facility.
[01/01/00; Recompiled
10/31/01]
7.20.3.36 STAFF
FIRE AND SAFETY TRAINING:
A. All
staff of the facility must know the location of, and be instructed in, proper
use of fire extinguishers and other procedures to be observed in case of fire
or other emergencies. The facility
should request the fire authority having jurisdiction to give periodic
instruction in fire prevention and techniques of evacuation.
B. Facility
staff must be instructed as part of their duties to constantly strive to detect
and eliminate potential safety hazards such as frayed electrical cords, faulty
equipment, blocked exits or exit pathways and any other condition which could
cause burns, falls, or other personal injury to the clients or staff.
[01/01/00; Recompiled 10/31/01]
7.20.3.37 EVACUATION
PLAN: Each facility must have a fire evacuation plan posted in each
separate area of the building showing routes of evacuation in case of fire or
other emergency.
[01/01/00; Recompiled
10/31/01]
7.20.3.38 PROVISIONS
FOR EMERGENCY CALLS: An easily accessible telephone for summoning
help, in case of emergency, must be available in the facility.
[01/01/00; Recompiled
10/31/01]
7.20.3.39 FIRE
EXTINGUISHERS:
A. Fire
extinguishers as approved by the state fire marshal or fire prevention
authority having jurisdiction must be located in the facility.
B. Fire
extinguishers must be properly maintained as recommended by the manufacturer,
state fire marshal or fire authority having jurisdiction.
C. All
fire extinguishers must be inspected yearly and recharged as specified by the
manufacturer, state fire marshal, or fire authority having jurisdiction. All
fire extinguishers must be tagged, noting the date of inspection.
[01/01/00; Recompiled
10/31/01]
7.20.3.40 ALARM
SYSTEM: A manually operated, electrically supervised fire alarm system
shall be installed in each facility only as required by national fire
protection association (NFPA) 101 (Life Safety Code). Multiple story facilities do require manual alarm systems.
[01/01/00; Recompiled
10/31/01]
7.20.3.41 FIRE
DETECTION SYSTEM: The facility must be equipped with smoke
detectors as required by the NFPA 101 (Life Safety Code) and approved in
writing by the fire authority having jurisdiction as to number, type and
placement
[01/01/00; Recompiled
10/31/01]
7.20.3.42 JANITOR’S
CLOSET(S):
A. Each
facility shall have at least one (1) janitor's closet.
B. Each
janitor's closet shall contain:
(1)
a service sink; and
(2)
storage for housekeeping supplies and equipment.
C. Each
janitor's closet must be vented.
D. Janitor
closets are hazardous areas and must be provided with one-hour fire separation
and one and three quarters (1¾) inch solid core doors which are rated at a 20 minute
fire protection rating.
[01/01/00; Recompiled
10/31/01]
7.20.3.43 EMERGENCY
LIGHTING:
A. A facility must be
provided with emergency lighting that will activate automatically upon
disruption of electrical service.
B. The
emergency lighting must be sufficient to illuminate paths of egress and exits
of the facility.
[01/01/00; Recompiled
10/31/01]
7.20.3.44 ELECTRICAL
STANDARDS:
A. All
electrical installation and equipment must comply with all current state and
local codes.
B. Circuit breakers or fused
switches that provide electrical disconnection and over current protection
shall be:
(1)
enclosed or guarded to provide a dead front assembly;
(2)
readily accessible for use and maintenance;
(3) set apart from traffic lanes;
(4)
located in a dry, ventilated space, free of corrosive fumes or gases;
(5)
able to operate properly in all temperature conditions.
(6)
Panel boards servicing lighting
and appliance circuits shall be on the same floor and in the same facility area
as the circuits they serve.
(7)
each panel board will be marked showing the services; and
(8)
the use of jumpers or devices to bypass circuit breakers or fused
switches is prohibited.
[01/01/00; Recompiled
10/31/01]
7.20.3.45 LIGHTING:
A. All
spaces occupied by people, machinery, or equipment within buildings, approaches
to buildings, and parking lots shall have lighting.
B. Lighting
will be sufficient to make all parts of the area clearly visible.
C. All
lighting fixtures must be shielded.
D. Lighting
fixtures must be selected and located with the comfort and convenience of the
staff and clients in mind.
[01/01/00; Recompiled
10/31/01]
7.20.3.46 ELECTRICAL
CORDS AND RECEPTACLES:
A. Electrical cords and extension cords:
(1)
Electrical cords and extension cords must be U/L approved.
(2)
Electrical cords and extension cords must be replaced as soon as they
show wear.
(3)
Under no circumstances shall extension cords be used as a general wiring
method.
(4)
Extension cords must be plugged into an electrical receptacle within the
room where used and must not be connected in one room and extended to some
other room.
(5)
Extension cords must not be used in series.
B. Electrical receptacles:
(1)
Duplex-grounded type electrical receptacles (convenience outlets) must
be installed in all areas in sufficient quantities for tasks to be performed as
needed. Each examination must have access to a minimum of two duplex
receptacles.
(2)
The use of multiple sockets (gang plugs) in electrical receptacles is
strictly prohibited.
[01/01/00; Recompiled
10/31/01]
7.20.3.47 HEATING,
VENTILATION, AND AIR-CONDITIONING:
A. Heating,
air-conditioning, piping, boilers, and ventilation equipment must be furnished,
installed and maintained to meet all requirements of current state and local
mechanical, electrical, and construction codes.
B. The
heating method used by the facility must have a minimum
indoor-winter-design-capacity of seventy five (75) degrees F. with controls
provided for adjusting temperature as appropriate for client and staff comfort.
C. The
use of non-vented heaters, open flame heaters or portable heaters is
prohibited.
D. An
ample supply of outside air must be provided in all spaces where fuel fired
boilers, furnaces, or heaters are located to assure proper combustion.
E. All fuel fired
boilers, furnaces, or heaters must be connected to an approved venting system
to take the products of combustion directly to the outside air.
F. A facility must be adequately
ventilated at all times to provide fresh air and the control of unpleasant
odors.
G. All
gas-fired heating equipment must be provided with a one hundred (100) percent
automatic cutoff control valve in event of pilot failure.
H. The
facility must be provided with a system for maintaining clients and staff's
comfort during periods of hot weather.
I. All boiler, furnace
or heater rooms shall be protected from other parts of the building by
construction having a fire resistance rating of not less than one hour. Door
must be self-closing with 3/4 hour fire resistance.
[01/01/00; Recompiled
10/31/01]
7.20.3.48 WATER
HEATERS:
A. Must
be able to supply hot water to all hot water taps within the facility at full
pressure during peak demand periods and maintain a maximum temperature of one
hundred and twenty (120) degrees F.
B. Fuel
fired hot water heaters must be enclosed and separated from other parts of the
building by construction as required by current state and local building codes.
C. All water heaters must be equipped with a pressure
relief valve (pop-off valve).
[01/01/00; Recompiled
10/31/01]
7.20.3.49 TOILETS
AND LAVATORIES:
A. All fixtures and
plumbing must be installed in accordance with current state and local plumbing
codes.
B. All
toilets must be enclosed and vented.
C. All
toilet rooms must be provided with a lavatory for hand washing.
D. All
toilets must be kept supplied with toilet paper.
E. All
lavatories for hand washing must be kept supplied with disposable towels for
hand drying or provided with mechanical blower
F. The
number of and location of toilets and lavatories will be mandated by
requirements for each type facility.
Such factors as extent of services provided and size of facility will
also dictate requirements.
[01/01/00; Recompiled
10/31/01]
7.20.3.50 EXITS:
A. Each
facility and each floor of a facility shall have exits as required by national
fire protection association 101 (Life Safety Code).
B. Each exit must be marked by illuminated signs having
letters at least six (6) inches high whose principle strokes are at least three
quarters (3/4) inch wide.
C. Illuminated exit
signs must be maintained in operable condition at all times.
D. Exit
ways must be kept free from obstructions at all times.
E. Exit
doors to exit or exit access doors must be at least thirty six (36) inches
wide.
[01/01/00; Recompiled
10/31/01]
7.20.3.51 CORRIDORS:
A. Minimum
corridor width shall be five (5) feet except work corridors less than six (6) feet
in length may be four (4) feet in width.
B. Facilities
will often be contained within existing commercial or residential buildings and
less stringent corridor widths may be allowed other than those contained in
Section 51.1 [now Subsection A of 7.20.3.51 NMAC] above if not in conflict with
building or fire codes and approved by the licensing authority prior to
occupying the licensed part of the building.
[01/01/00; Recompiled
10/31/01]
7.20.3.52 DOORS:
A. The
minimum door width for client's use shall be thirty four (34) inches in width.
B. Rooms where client
treatment takes place shall have a minimum door width of thirty six (36)
inches.
[01/01/00; Recompiled
10/31/01]
7.20.3.53 COMMON
ELEMENTS FOR FACILITIES:
A. Entrance
shall be able to accommodate wheelchairs.
B. Public
services shall include:
(1)
conveniently accessible wheelchair storage;
(2)
a reception and information counter or desk;
(3)
waiting areas;
(4)
conveniently accessible public toilets; and
(5)
drinking fountain(s) easily accessible to clients or other visitors.
C. Interview
space(s) for private interviews related to mental health, medical information,
etc., shall be provided.
D. General or individual office(s) for business
transactions, records, administrative, and professional staff shall be
provided. These areas shall be
separated from public areas for confidentiality.
E. Special
storage for staff personal effects with locking drawers or cabinets shall be
provided.
F. General
storage facilities for supplies and equipment shall be provided.
G. Drug distribution stations shall be in accordance with
standards set forth by the New Mexico board of pharmacy.
[01/01/00; Recompiled
10/31/01]
7.20.3.54 FLOORS
AND WALLS:
A. Floor
and wall areas penetrated by pipes, ducts, and conduits shall be tightly sealed
to minimize entry of rodents and insects.
Joints of structural elements shall be similarly sealed
B. Threshold
and expansion joint covers shall be flush with the floor surface to facilitate
use of wheelchairs and carts.
[01/01/00; Recompiled
10/31/01]
7.20.3.55 GOVERNING
BODY: All facilities licensed pursuant to these regulations must have a
governing body that assumes full legal responsibility for determining,
implementing, and monitoring policies governing the total operation of the
facility. The governing body must
ensure that these policies are administered so as to provide quality health
care in a safe environment. When
services are provided through a contract with an outside resource, the
governing body is responsible for assuring that these services are provided in
a safe and effective manner.
[01/01/00; Recompiled
10/31/01]
7.20.3.56 ADMINISTRATOR/DIRECTOR/MANAGER: Each facility
must have an administrator, director or manager hired or appointed by the
governing body to whom authority has been delegated to manage the daily
operation of the facility and implement the policies and procedures adopted by
the governing body.
[01/01/00; Recompiled
10/31/01]
7.20.3.57 STAFF
EVALUATION AND DEVELOPMENT: A facility licensed pursuant to these
regulations must be in compliance with staff evaluation and development
standards set forth by the division of health improvement of the department.
[01/01/00; Recompiled
10/31/01]
7.20.3.58 DIRECT
SERVICE STAFF: A facility licensed pursuant to these
regulations must be in compliance with direct service staff standards set forth
by the division of health improvement of the eepartment.
[01/01/00; Recompiled
10/31/01]
7.20.3.59 EMERGENCY
MEDICAL SERVICES: Each facility licensed pursuant to these
regulations must maintain a list of emergency phone numbers co-located with
telephones in the facility. This list
must include fire and police departments, ambulance or EMS crew numbers, the
New Mexico poison control center and the nearest hospital.
[01/01/00; Recompiled
10/31/01]
7.20.3.60 HOURS
OF OPERATION: Each facility licensed pursuant to these
regulations must post its hours of operation where it can clearly seen [sic] by
clients and visitors.
[01/01/00; Recompiled
10/31/01]
7.20.3.61 PHARMACEUTICAL
SERVICES:
A. Drugs must be stored, prepared and administered in
accordance to acceptable standards of practice and in compliance with the New
Mexico state board of pharmacy.
B. Outdated drugs and biologicals must be disposed of in
accordance with methods outlined by the New Mexico state board of pharmacy.
C. One individual shall be designated responsibility for
pharmaceutical services to include accountability and safeguarding.
D. Keys to the drug
room or pharmacy must be made available only to personnel authorized by the
individual having responsibility for pharmaceutical services.
E. Adverse reactions to medications must be reported to
the physician responsible for the client and must be documented in the client's
record.
[01/01/00; Recompiled
10/31/01]
7.20.3.62 LABORATORY
SERVICES:
A. All lab test results
performed either at the facility or by contract or arrangement with another
entity must be entered into the client’s record.
B. All laboratory procedures including specimen
collection will be conducted in accordance with acceptable standards of
practice. A CLIA certificate will be
appropriately maintained if so required by federal CLIA standards.
[01/01/00; Recompiled
10/31/01]
7.20.3.63 RELATED
REGULATIONS AND CODES: Facilities or agencies subject to these
regulations are also subject to other regulations, codes and standards as the
same may from time to time be amended as follows.
A. Health Facility
Licensure Fees and Procedures, New Mexico department of health, 7 NMAC 1.7 [now
7.1.7 NMAC];
B. Health Facility Sanctions and Civil Monetary
Penalties, 7 NMAC 1.8 [now 7.1.8 NMAC]; and
C. Adjudicatory Hearings, New Mexico
department of health, 7 NMAC 1.2 [now 7.1.2 NMAC].
[01/01/00;
Recompiled 10/31/01]
HISTORY OF 7.20.3 NMAC: [RESERVED]