Organization and administration

1. Governing body. The applicant must have a governing body that designates or assigns responsibility for the operation, policies, program, and practice of the facility. The governing body shall: a. Define: (1) The facility's philosophy; (2) The facility's purpose; (3) The facility's function; (4) The geographical area served by the facility; (5) The ages and types of children accepted for care by the facility; and (6) The clinical disorders addressed by the facility's program; b. Ensure that all policies and procedures required by this chapter are in writing and on file at the facility and are accessible to all employees, family members, and residents; c. Develop a records retention policy and procedures consistent with state and federal law; d. Assure that all vehicles transporting children are: (1) Subject to routine inspection and maintenance; (2) Licensed by the state motor vehicle department; (3) Equipped with seatbelts for every passenger; (4) Equipped with a first-aid kit and a fire extinguisher; (5) Carrying no more individuals than the manufacturer's recommended maximum capacity; (6) Disability accessible where appropriate; and (7) Driven by an individual who holds a valid driver's license, of a class appropriate to the vehicle driven, issued by the driver's jurisdiction of residence; and e. Obtain sufficient insurance, including: (1) Liability insurance covering bodily injury, property damage, personal injury, professional liability; and (2) Automobile or vehicle insurance covering property damage, comprehensive, collision, uninsured motorist, bodily injury, and no fault. 2. Quality improvement. The applicant and facility shall implement a quality improvement program. The applicant and facility shall submit the quality improvement program and evaluations of the program to the department for review at a minimum of every six months. The applicant shall create policies and procedures and have them in place to implement its facility's quality improvement program. The facility must monitor and evaluate the quality and appropriateness of care of children, and identify performance indicators that will be monitored to assess the program's effectiveness. The quality improvement program must include: a. A plan for child and employee safety and protection; b. A method to evaluate personnel performance and the utilization of personnel; c. A plan to ensure the facility accesses and maintains copies of the current license of all employees, contract workers, and consultants when relevant for that individual's role or function; d. A system of credentialing, granting, and withholding employee privileges; e. A method to review and update policies and procedures assuring the usefulness and appropriateness of policies and procedures; f. A method to review the appropriateness of admissions, care provided, and employee utilization; g. A plan for the review of individual treatment plans that ensures compliance with paragraph 3 of subdivision b of subsection 3 of section 75-03-17-05; h. A plan for program evaluations that includes measurements of progress toward the facility's stated goals and objectives; and i. A method to evaluate and monitor standards of resident care. 3. Outcomes and data collection. The department shall require a facility to engage in data management practices to collect and report outcomes every six months. Data collection efforts will offer facilities a continuous quality improvement process that measures and monitors the safety, wellbeing, and service delivery provided to children in placement. Facilities must have written policy to identify a plan to implement, collect, and measure outcomes data requirements. The policy must also include how a facility will respond to identified data outcomes by utilizing one or more facility improvement plans every six months. 4. Children's case records. The facility shall establish and implement policies and procedures to ensure the facility maintains a confidential record for each child which must be current and reviewed monthly. Each record must contain: a. An application for service; b. A social history; c. A release of information and medical treatment consent form signed by a person who may lawfully act on behalf of the child and any consent for the use of psychotropic medications as required under subdivision d of subsection 10 of section 75-03-17-07; d. The name, address, and telephone number of individuals to be contacted in an emergency; e. Reports on medical examinations, including immunizations, any medications received, allergies, dental examinations, and psychological and psychiatric evaluations which occurred prior to the placement; f. An explanation of custody and legal responsibility for the child and relevant court documents, including custody or guardianship papers; g. Documentation on all medical examinations, including immunizations, all medications received, allergies, dental examinations, and psychological and psychiatric evaluations received during placement; h. Documentation of medical care given during placement as a result of an admission to the hospital or inpatient care, including: (1) Hospitalization admission and discharge records to include history and physical; (2) Medications administered, with the quantity, directions, physician's name, date of issue, and name of the pharmacy indicated; and (3) Significant illnesses or accidents; i. Records of the annual medical examination required under section 75-03-17-07; and j. A written agreement between a person who may lawfully act on behalf of the child and the facility and a record that the person who acted on behalf of the child received a copy. The agreement must include: (1) A statement as to who has financial responsibility; (2) How payments are to be made to cover the cost of care; (3) Which items are covered by the normal or regular facility charges for care; (4) Medical arrangements, including the cost of medical care; (5) Visiting arrangements and expectations; (6) Arrangements for clothing and allowances; (7) Arrangements for therapeutic leave; (8) Regulations about gifts permitted; (9) Arrangements for participation by the person who acted on behalf of the child through regularly scheduled interviews with designated employee; (10) The facility's policy on personal monetary allowance to be provided to the child at the facility; (11) Records of special treatment orders; and (12) Educational arrangements agreed upon discharge.