HAR §11-98-10. Minimum standards for licensure; administrative and organizational plan

(a) Every facility shall have and maintain a current written plan describing the philosophy, goals, and objectives of its program. This program shall be reviewed and evaluated periodically or at least annually. (b) The plan shall also include a statement of the geographic area to be served, ages and kinds of residents to be served, anticipated average length of stay of its residents, and the limitations and scope of service for which the facility is established. (c) A policy of nondiscrimination based on age, race, color, creed, or national origin relating to admission of residents shall be established. (d) A policy of nondiscrimination based on sex, age, race, color, creed, national origin, or physical handicap relative to the personnel policies and practices governing the hiring, promotion and dismissal of its staff shall be established. (e) Each facility shall develop written policies and procedures, and criteria governing its management and operations. These shall include but are not limited to the following: (1) Personnel policies, procedures and practices including the qualifications, duties and responsibilities for each staff position, hiring, suspension, dismissal, assignment, promotion, grievance procedures and other related personnel matters; (2) Policies and procedures, and criteria relative to admission of residents to the program, dismissal and discharge; (3) Policies and procedures governing the rights (legal, civil, and human) and responsibilities of the residents and the confidential nature of resident information; (4) Procedures for handling complaints and grievances expressed by residents, persons, or agencies responsible for residents, and the public; (5) A description of the facility's services available to residents and responsible parties or agencies and the public. It shall include services directly provided or contracted for by the facility. It shall also include arrangements for emergency medical transportation on a twenty-four hour basis; (6) Terms of contractual agreements entered into with out side providers of services required in this chapter including the description of roles, responsibilities and authority of all parties involved; (7) Policies and procedures and copies of written agreements for coordination and liaison between the facility and relevant community agencies, concerning the admission, treatment, discharge and follow up of residents; (8) A description o£ the provisions for rendering emergency medical and psychiatric care, including the name, address, and telephone number of the physician; (9) The facility shall submit a copy of its policy and procedures regarding the use of physical or chemical restraints. No physical or chemical restraints shall be used except as outlined in the policy and procedures and only following the approval of the policy and procedures by the director; (10) Policies and procedures relative to general rules regarding residents' records, including: (A) All entries shall be made in ink, be legible, dated and signed with first initial and last name; (B) Symbols and abbreviations shall be explained in a legend; (C) An area shall be provided for safe and easy access to residents' records; (D) Residents' records shall be retained for five years after discharge or, if s state-owned facility, a period to comply with state law; (E) Policies governing access by the resident and others, duplication of, and dissemination of information from the record; (F) Policies protecting the confidentiality of resident information; (G) Policies requiring written consent of the resident, if competent, or the resident's guardian for the release of information to persons and agencies not otherwise authorized to receive it; (H) The facility's responsibility to secure the information under lock against loss, distribution, defacement, tampering, or use by unauthorized persons; (f) Every facility shall maintain financial records, include an annual budget and its income and expenditures. (g) New facilities shall document in writing assurances of funding sufficient to meet projected program costs, plus sufficient funds to cover the initial implementation costs. (h) Each facility shall maintain statistical and other administrative records as provided in section 11-98-04. [Eff MAR 10 1986] (Auth: HRS §§321-9, 321-10) (Imp: HRS §§321-10, 92E-2, 92E-4, 92E-5, 378-2, 622-57, Pub. L. 88-352 (1964) , Pub. L. 95-555 (1978) )