Patient and Resident Policy Manual

(A) Each Licensed or Approved Provider shall adopt and maintain a current policy manual for patients and residents containing clear and concise statements regarding: (1) Program description, including: (a) goals and objectives, (b) type of services provided, including aftercare and follow-up; (c) qualifications for service delivery staff; (d) restrictive criteria for receipt of specific services, if any; (e) scheduling restrictions; and (f) overall hours of program operation. Orientation materials provided to patients and residents at admission, including information about treatment options, such as medication for addiction treatment, and about family support services; Admission requirements and intake procedures, including a list of the minimum information that is collected at the intake session; (4) Fee policies including: (a) method used to determine fee, including reduced fees for persons of low income; and (b) whether or not the program accepts public or private third-party reimbursement or funding. (5) Procedures regulating access to patient and resident records; (6) Program rules, including: (a) all patient and resident expectations and responsibilities, and process for maintaining safety and accountability; (b) restrictions on use of tobacco and vaping products; (c) prohibition of sexual harassment and procedures for addressing and investigating sexual harassment complaints; (d) prohibited interactions between staff and patients or residents, and among patients or residents; (e) criteria for termination; (f) procedures for involuntary terminations; (g) grievance procedure for the resolution of any other patient or resident related problem or dispute; and (h) visitation and communication policies that encourage and support family visits, mail, telephone calls, and other forms of communication with family, friends, or other persons provided that no such policy authorizes the Licensed or Approved Provider to hold mail or restrict the sending of mail or open patient or residents' mail; however, such policy may require patients or residents to open letters or packages in the presence of staff. (7) Policies, practices, and procedures to ensure compliance with the ADA; (8) Patients' and residents' rights; and Contact information for the Department's Bureau of Substance Addiction Services complaint line. (B) The policy manual and contact information for the Department's Bureau of Substance Addiction Services complaint line shall be: (1) placed visibly in a public area frequented by all patients or residents or kept at a central location, with a notice of its availability conspicuously posted in a public area frequented by all patients or residents; and (2) given to each new patient or resident during the admission process or subsequently upon his or her request, and to any interested party upon request. (C) Whenever the Licensed or Approved Provider makes a change in policy, it shall issue a written change to the policy manual; the change shall not take effect until placed in the manual and distributed as provided for in 105 CMR 164.081(B). (D) When furnishing a patient or resident with a copy of the policy manual or of any changes to the policy manual, the Licensed or Approved Provider shall secure a dated and signed receipt, which shall be placed in the patient or resident record. (E) The Licensed or Approved Provider may charge for the cost of copying and assembling the policy manual for an interested party or for a second copy to a patient or resident.