Written Policies

(A) Licensed or Approved Providers that directly provide services shall have written policies and procedures consistent with and implemented in accordance with the applicable requirements established in 105 CMR 164.100 through 164.500, Department administrative guidelines, accepted standards of care for substance use disorder treatment services and applicable laws. All policies required under 105 CMR 164.000 shall be in writing, and available to staff, patients, residents and Department inspectors, and shall at a minimum address the following areas: (1) program rules; (2) confidentiality in accordance with 105 CMR 164.584; (3) security of and access to patient and resident records, and patient and resident information; (4) personnel policies, including: (a) prohibition of sexual harassment and procedures for handling and investigating sexual harassment complaints; (b) prohibited interactions between staff and patients or residents, and between or among patients and/or residents; and (c) requirements of 42 CFR Part 2 (federal confidentiality regulations) and 45 CFR Parts 160, 162 and 164 (Health Insurance Portability and Accountability Act, HIPAA), where applicable. (5) ensuring patient safety, including adequate patient and resident oversight and periodic patient and resident safety checks; (6) responses to and reports of death, accident, injury, fire and alleged assault, and responses to and reports of safety and health conditions at the program; (7) all-hazard and emergency planning and procedures; (8) orientation and supervision of staff from contract or temporary agencies; and care and treatment protocols developed in accordance with all applicable federal regulations. (B) Standards for the content of required policies may be set by administrative requirements issued from time to time by the Department.