130 CMR 417.438
Written Policies and Procedures
A psychiatric day treatment program must have and observe written policies and
procedures that include:
(A) a statement of program philosophy and objectives;
(B) admission procedures, including criteria and procedures for multidisciplinary review of
each individual referral;
(C) treatment procedures, including development of the treatment plan, case assignment,
periodic review, and follow-up on drop-outs;
(D) discharge criteria and procedures;
(E) medication policy;
(F) referral policy, including procedures for ensuring uninterrupted and coordinated patient
care upon transfer;
(G) procedures for clinical emergencies that occur both during and outside the program's
operating hours;
(H) recordkeeping policy;
(I) personnel and management policies, including policies for hiring, discharging, and
supervision protocol for all staff;
(J) a policy for proper food preparation, cleanliness, and storage, including designation of a
staff person to take responsibility for supervision of the member’s food preparation at each
meal;
(K) explicit fee policies for billing third-party payers and patients, along with procedures for
cancellation and fee reductions;
(L) procedures for fire and other nonclinical emergencies; and
(M) staff training and evaluation.