Section 16. Personnel

A. The agency provides personnel who are trained, supervised and in all respects qualified to perform the functions for which they are responsible. B. Each position, or group of like positions, is detailed in a written job description that clearly states qualifications, responsibilities and requirements. C. Each agency employee meets all state registration, licensing and/or certification requirements applicable to his or her position and/or use of professional title(s) and the agency has copies of such licenses, etc. on file. D. Orientation of personnel: (1) The agency orients its personnel to the agency’s goals, services, policies and procedures, and to the responsibilities of the staff member’s position. Initial and ongoing orientation is documented in the personnel record. (2) Orientation includes training on the establishment and maintenance of appropriate and responsive relationships and boundaries with clients. E. Personnel training, development, responsibilities and supervision: (1) The agency provides a training and development program to allow personnel to improve their knowledge, skills and abilities and to promote awareness and appreciation of the cultural background and need of persons served by the agency. This training will be documented in the personnel file. (2) The agency provides staff development opportunities for personnel, including in-service training. (3) Staff who require training to qualify for a position in which they are responsible for the care of children do not have sole responsibility for the care of children until after the successful completion of the training. (4) Staff designated as direct service staff under service-specific certification requirements receive ongoing training related to the age and/or emotional development of the children for whom they are responsible. (5) All certified services are provided under supervision of a clinical director who provides clinical oversight of the program, by way of documented supervision and consultation to all agency staff ignated as direct service staff under service-specific certification requirements receive ongoing training related to the age and/or emotional development of the children for whom they are responsible. (5) All certified services are provided under supervision of a clinical director who provides clinical oversight of the program, by way of documented supervision and consultation to all agency staff. Supervision may be direct, or may occur through a clinical supervisor who is directly supervised by the clinical director. (6) All clinical supervision/consultation is documented and documentation includes the theme, date, length of time of supervision and signatures of those participating. (7) In the event that the therapist and clinical supervisor are the same person, another properly credentialed clinician, either from within the agency or from outside the agency, provides supervision at least one time per month to the clinical supervisor. (8) The responsibilities of the therapist include providing therapy and participating in the development of a treatment plan. These activities are documented. (9) When the agency utilizes the services of professionals on a per interview, hourly, part-time, or independent contractor basis, the agency documents regular assessment of the quality of services provided. F. Accountability: (1) The agency ensures that the performance of all employees, consultants, contractors, and volunteers is consistent with agency policy and these certification requirements. (2) At least once a year, written performance reviews are conducted jointly between each staff member, including volunteers, and the person’s supervisor. G. Personnel records: 7.20.11 NMAC 17 (1) A personnel record is maintained for each employee and volunteer rformance of all employees, consultants, contractors, and volunteers is consistent with agency policy and these certification requirements. (2) At least once a year, written performance reviews are conducted jointly between each staff member, including volunteers, and the person’s supervisor. G. Personnel records: 7.20.11 NMAC 17 (1) A personnel record is maintained for each employee and volunteer. Each personnel record is readily accessible to the LCA at each site visit, and contains, at a minimum: (a) documentation of all orientation and training, including dates, hours or credits, names of trainer and trainee, and written confirmation by trainer or training organization that the training has occurred; (b) employee’s name, current address, telephone number and emergency contact(s); (c) job title and description; (d) evidence of licensure for those employees required to be licensed; (e) date first employed and dates of transfers or changes in position; (f) documentation of a minimum of three employment reference checks within three weeks prior to employment (if this process yields fewer than three employment reference checks, additional professional and/or personal references are obtained to achieve the required minimum of three references); (g) a copy of the employee’s current CPR and first aid certificates; (h) for cleared staff, the criminal records clearance letter, or for uncleared staff, a signed statement by the administrator, director, or operator attesting to direct supervision of the uncleared employee by a cleared employee until the clearance is received; (i) application for employment or resume consistent with agency policy; (j) performance reviews, as applicable. (2) The agency’s written policies and practices require that an applicant for employment disclose any prior criminal convictions, and employees report any arrests and/or convictions that occur while employed of the uncleared employee by a cleared employee until the clearance is received; (i) application for employment or resume consistent with agency policy; (j) performance reviews, as applicable. (2) The agency’s written policies and practices require that an applicant for employment disclose any prior criminal convictions, and employees report any arrests and/or convictions that occur while employed. (3) The agency’s written policies provide personnel with access to their records and a process to review the record and to make additions and corrections to the record. H. Schedules of direct service staff in day treatment and residential facilities: (1) Each facility or licensed unit maintains a written, legible schedule clearly identifying direct service staff responsible for care of clients. (2) Each uncleared employee is identified on the staff schedule. (3) The staff schedule is updated daily to reflect actual hours staff are present and changes in attendance as they occur. (4) Original updated staff schedules are kept on file for at least 12 months. (5) The updated schedule documents the client census for each unit of a residential treatment services center or group home service on a daily basis. [7.20.11.16 NMAC - Rp 7 NMAC 20.11.16, 03/29/02; A, 10/29/04] 7.20.11.17 ALLEGATIONS OF ABUSE/NEGLECT, COMPLAINTS, AND SERIOUS INCIDENT REPORTING: A. The agency maintains and follows policies and procedures consistent with these certification requirements for timely reporting of any serious incidents and allegations of abuse or neglect. The agency immediately reports allegations of abuse or neglect to all appropriate entities, including but not limited to the protective services division of the department via statewide ventral intake/tribal social services agency, the client’s legal guardian, the jurisdictional law enforcement agency, and the LCA. B. The agency reports all serious incidents to the LCA by fax within 24 hours of any staff member becoming aware of the incident or allegation of incident ppropriate entities, including but not limited to the protective services division of the department via statewide ventral intake/tribal social services agency, the client’s legal guardian, the jurisdictional law enforcement agency, and the LCA. B. The agency reports all serious incidents to the LCA by fax within 24 hours of any staff member becoming aware of the incident or allegation of incident. Incidents involving minor illnesses or injuries not requiring emergency services do not need to be reported to the LCA. Day treatment services, case management services, and behavioral management skills development services are not required to report serious incidents that do not occur during program hours, with the exception that all deaths must be reported. C. Additional reporting requirements for deaths: Deaths are reported to the LCA immediately by telephone and followed by fax within 24 hours, whether or not the death occurs during program hours. Agencies are required to report any client death to the regional office of the federal centers for medicare and medicaid services by no later than by the close of business the next business day after the client’s death, and must document in the client’s record that the death was reported to the centers for medicare and medicaid services. D. Each serious incident report is written by the staff who have personal or firsthand knowledge of the incident/allegation, and is signed and dated by that person(s). Once written, the report is not altered, but may be amended. Any amendment is signed and dated by its author and filed with the original report. The report clearly distinguishes between events witnessed by the reporter and statements made to the reporter nt report is written by the staff who have personal or firsthand knowledge of the incident/allegation, and is signed and dated by that person(s). Once written, the report is not altered, but may be amended. Any amendment is signed and dated by its author and filed with the original report. The report clearly distinguishes between events witnessed by the reporter and statements made to the reporter. The report contains, but is not limited to the following information regarding the incident: date, time, and location of the incident, behavioral description(s) of relevant event(s), descriptions of health/safety risk(s) relevant to the incident, identification of 7.20.11 NMAC 18 person(s) present, birth date(s) of client(s) involved, level of care of the client(s) involved, initial actions in response to the incident, names of persons providing information to the reporter, and identification of other entities receiving the report. E. Each serious incident for which a report to the LCA is required herein and that involves possible criminal activity is reported immediately to the appropriate law enforcement agency. F. The agency responds in a timely manner to protect its clients from physical or psychological risks of which it is or reasonably should be aware, in order to reduce and prevent future risks. G. Outcomes, dispositions, and descriptions of any voluntary corrective action(s) taken by the agency in response to serious incidents are faxed or mailed to the LCA in a timely manner. H. The program will not rely on the fact that it has made a serious incident report to the LCA, or the fact that it may not have received a response from the LCA, to delay appropriate corrective or protective action in response to an incident. I. The agency maintains and follows policies and procedures for investigating and responding to allegations of abuse or neglect in a confidential and timely manner. J. The agency maintains and follows policies and procedures for investigating and responding to complaints in a timely manner. K a response from the LCA, to delay appropriate corrective or protective action in response to an incident. I. The agency maintains and follows policies and procedures for investigating and responding to allegations of abuse or neglect in a confidential and timely manner. J. The agency maintains and follows policies and procedures for investigating and responding to complaints in a timely manner. K. The agency provides a written response, in a timely manner, to the complaining party and, as applicable, the parent, legal or treatment guardian, regarding the resolution of each complaint or allegation.