Required Policies and Procedures

Section 380.500  Required Policies and Procedures a)         The licensee shall be responsible for compliance with licensing requirements and for the organization, management, operation and control of the facility.  The delegation of any authority by the licensee shall not diminish the responsibilities of the licensee. b) A facility shall establish written policies and procedures to implement the responsibilities and rights provided under the Act and this Part . The policies shall include the procedure for the investigation and resolution of consumer complaints. The policies and procedures shall be clear and unambiguous and shall be available for inspection by any person. A summary of the policies and procedures, printed in not less than 12-point font, shall be distributed to each consumer and representative. (Section 3-208 of the Act) Written policies and procedures also shall be established and implemented for each of the following: 1)         The administration and management of the facility; 2)         Personnel policies and procedures, which shall include: A)        Job descriptions detailing qualifications and essential duties of each classification of employee, available to all personnel; B)        Employee orientation to the facility, job, consumer population, policies, procedures and staff; C)        Employee benefits; D)        Employee health and grooming; and E)        Verification of licensure, credentials, certification, education, training and references; 3)         Policies and procedures for consumer admission, transfer, day passes and weekend passes, discharge and other care transitions; charge for services included in the basic rate; charges for other services and causes for termination of services. The facility shall comply with the rules of the State-designated assessment and authorization entity; 4)         Policies and procedures governing consumer records, including, but not limited to: A)        Access to, duplication of, and dissemination of information from consumer records, with a specific policy and procedure for sharing information with behavioral health providers and consumers pursuant to applicable federal and State laws; and B)        Ensuring confidentiality of consumer information, pursuant to applicable federal and State laws and this Part; 5)         Policies and procedures for reporting incidents and accidents, the abuse and neglect of consumers, and the theft of consumers' property and other data as required in Section 380.530; 6)         A written organizational chart showing each program, the person in charge of each program, the lines of authority, including responsibility and communication, and the staff assignments, including information on the governing structure; 7)         Policies concerning the use of restraints only with informed consent, and other restraint and therapeutic separation policies and procedures pursuant to the Act and to Section 380.160; 8)         Policies concerning the administration of psychotropic medication only with informed consent, and other informed consent to medical and psychiatric treatment policies and procedures pursuant to the requirements in Section 380.150 of this Part and Section 3-106(b) of the Act; 9)         Policies and procedures to ensure that experimental research and treatment on consumers is conducted only in accordance with the oversight of an Institutional Review Board, pursuant to the requirements in Section 380.580; 10)       Dietary services, policies and procedures; and 11)       Environmental services policies and procedures, including provision for the housekeeping and maintenance of a safe, clean environment for consumers, employees and the public. c)         Each facility shall employ or otherwise provide an executive director, delegated by the licensee to be responsible for the administration and management of the facility.  The executive director shall be responsible for the administration and management of only one facility. If these responsibilities are delegated to the executive director, liability shall remain with the licensee or the facility's governing body.