The Director of each hospital shall be responsible for the development of a manual which shall establish the framework and general operating procedures for behavior therapy programs in the hospital. The manual shall not be overly constraining on the behavior therapy programs but shall serve as a general guide to clinical practice, within the legal and ethical constraints relating to client rights and accepted professional practice. The manual shall be available for information and inspection by hospital clients, staff, and the general public. Each manual shall address the following:

1. (1) definition of key terms employed;

2. (2) patients rights including but need not be limited to:

   1. (a) consent; and
   2. (b) disallowed procedures;
3. (3) staff qualifications;
4. (4) peer review procedures including a time schedule;
5. (5) training for personnel;
6. (6) records and documentation; and

7. (7) use of aversive (i.e., the application of noxious stimuli) and intrusive procedures including specifically:

   1. (a) documentation of alternative, positive approaches attempted, and documentation of consent to the specific program employed;
   2. (b) statement of minimum client rights to be observed for all patients in the program, citing relevant statutes and standards which shall include client rights as set forth in G.S. 122C‑51 through 122C‑58 and 122C‑62 and 10A NCAC 28A, B, C and D, Division publication HUMAN RIGHTS FOR CLIENTS OF STATE OWNED AND OPERATED FACILITIES, APSM 95‑1 (07/01/89), adopted pursuant to G.S. 150B‑14(c).
   3. (c) specific time schedule for peer review; and
   4. (d) approval procedures, to include review by the Human Rights Committee, as provided in 10A NCAC 28A .0207 DUTIES.

History Note: Authority G.S. 143B‑147;
Eff. October 8, 1980;
Amended Eff. March 1, 1990; April 1, 1981;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. August 24, 2019.