Governing Authority and Program Administration

PURPOSE: This rule describes requirements for and responsibilities of the governing body in Opioid Treatment Programs, Substance Use Disorder Treatment Programs, Comprehensive Substance Treatment and Rehabilitation Programs (CSTAR), Gambling Disorder Treatment Programs, Recovery Support Programs, Substance Awareness Traffic Offender Programs (SATOP), Required Education Assessment and Community Treatment Programs (REACT), Community Psychiatric Rehabilitation Programs (CPRP), and Outpatient Mental Health Treatment Programs. (1) Governing Body. The organization shall have a designated governing body with legal authority and responsibility over its policies and operations. The governing authority ensures the organization complies with all federal, state, local, and municipal laws and regulations, as applicable. The chief executive officer is responsible to the governing body for the overall day-to-day operations of the organization, including the control, utilization, and conservation of its physical and financial assets and the recruitment and direction of the staff. (A) The governing body has written documents of its source of authority that are available to the public upon request. The source of authority document includes, but is not limited to— 1. The eligibility criteria for governing body membership; 2. The number and types of membership; 3. The method of selecting members; 4. The number of members necessary for a quorum; 5. Attendance requirements for governing body membership; 6. The duration of appointment or election for governing body members and officers; and 7. The powers and duties of the governing body and its officers and committees, or the authority and responsibilities of any person legally designated to function as the governing body. (B) The requirements of section (1) are not applicable to state-operated programs except such programs must have an administrative structure with identified lines of authority to ensure responsibility and accountability for the successful operation of its behavioral health services. (2) Composition of the Governing Body and Meetings. Members of the governing body shall have a demonstrated interest in the area(s) and/or region(s) served by the organization. A current roster of the governing body members shall be maintained and available to the public upon request. (A) Members of the governing body shall represent the demographics of the population served including, but not limited to, geographic area, race, ethnicity, gender identity, disability, age, and sexual orientation. Individuals living with mental illness and/or a substance use disorder and family members/natural supports, and parents/legal guardians of children, adolescents, and adults receiving services shall have meaningful input to the governing body. (B) The governing body shall meet at least quarterly and maintain an accurate record of meetings including dates, attendance, discussion items, and actions taken. (3) Functions of the Governing Body. Duties of the governing body shall include, but are not limited to— (A) Providing fiscal planning and oversight; (B) Ensuring implementation of an organizational performance improvement and measurement process; (C) Approving policies to guide administrative operations and service delivery; (D) Ensuring responsiveness to the communities and individuals served; (E) Delegating operational management to a chief executive officer and, as necessary, to program managers to effectively operate its services; and (F) Designating contractual authority. (4) Policy and Procedure Manual. The organization shall maintain a policy and procedure manual which accurately describes and guides the operation of its services and promotes compliance with applicable regulations. Additional policies and procedures for specialized programs/services may be specified in department contracts. The policy and procedure manual shall be readily available to staff and the public upon request and shall include, but is not limited to: (A) Mission, goals, and objectives of the organization; (B) Organization of the agency; (C) Rights, responsibilities, and grievance procedures in accordance with 9 CSR 10-7.020; (D) Service delivery process, documentation, and individual records in accordance with 9 CSR 10-7.030; (E) Service array including, but not limited to: 1. Description of all services available, including crisis assistance; 2. Outreach and education strategy for all services; 3. Location of service sites, hours, and days of operation for each site; 4. Accessibility, including provisions for individual choice of services and location; 5. Referral process including follow-up, continuity of care, and timely transfer of records. (F) Performance measurement and improvement in accordance with 9 CSR 10-7.040; (G) Research in accordance with 9 CSR 10-7.050; (H) Emergency safety interventions in accordance with 9 CSR 10-7.060; (I) Medications in accordance with 9 CSR 10-7.070; (J) Dietary services in accordance with 9 CSR 10-7.080; (K) Governing authority and program administration in accordance with 9 CSR 10-7.090; (L) Fiscal management in accordance with 9 CSR 10-7.100; (M) Personnel in accordance with 9 CSR 10-7.110; (N) Physical environment and safety in accordance with 9 CSR 10-7.120; (O) Background screenings in accordance with 9 CSR 105.190; (P) Report of complaints of abuse, neglect, and misuse of funds/property in accordance with 9 CSR 10-5.200 and 9 CSR 10-5.206; (Q) Routine monitoring of individual records for compliance with applicable standards; (R) Commonly occurring issues with individuals served such as missed appointment, accidents on the premises, suicide attempts, threats, loitering, and non-compliance with program policies and procedures; and (S) Relevant information related to services available for children and youth addressing any and all aspects of paragraph (4)(A)–(R) of this rule. (5) Corporate Compliance. Each organization shall have a corporate compliance plan to assure federal and state regulatory, contractual obligations, and requirements are fulfilled and services are provided with integrity and the highest standards of excellence. (A) A staff member of the organization shall serve as the corporate compliance officer and be responsible for coordinating, implementing, and monitoring the corporate compliance plan. (B) The corporate compliance plan shall include education and training of staff and specific oversight activities to monitor and detect potential fraud and abuse. (6) Agency Contracts. The organization shall establish a formal, accountable relationship with any contractor that provides a direct service and is not an employee of the organization. (A) The organization retains full responsibility for all services provided by a contractor. All services must meet the requirements of all laws, rules, regulations, and contracts applicable to the organization. (B) The department reserves the right to approve any contractor utilized by an organization when the services to be provided are certified or deemed by the department. The department, at its sole discretion, may require such approval prior to the utilization of any contractor. (C) The organization retains full responsibility for all legal and financial responsibilities related to execution of the contract. (7) Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Regulatory Compliance. The organization shall comply with applicable requirements as set forth in 9 CSR 105.220. AUTHORITY: sections 630.050 and 630.055, RSMo 2016. 45 CFR parts 160 and 164, the Health Insurance Portability and Accountability Act of 1996.* Original rule filed Feb. 28, 2001, effective Oct. 30, 2001. Emergency amendment filed April 1, 2003, effective April 14, 2003, expired Oct. 14, 2003. Amended: Filed April 1, 2003, effective Oct. 30, 2003. Amended: Filed March 15, 2010, effective Sept. 30, 2010. Amended: Filed Nov. 5, 2018, effective June 30, 2019. *Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 630.055, RSMo 1980.