.08 Administration.

A. Governing Authority.

(1) The agency shall have a governing authority.

(2) The governing authority shall:

(a) Convene at least annually with management staff to review and advise the agency on policies; and

(b) Keep minutes, including:

(i) The participants of any meeting;

(ii) Agenda items considered; and

(iii) Actions taken.

B. Policies and Procedures.

(1) An agency shall develop and implement policies and procedures, including but not limited to:

(a) Administration, including:

(i) Scope of services;

(ii) Delineation of services provided by the agency when the agency coordinates care within the agency or with another provider;

(iii) Notification to the client or client representative with legal authority to make health care decisions of the agency’s responsibilities to coordinate care when appropriate;

(iv) Admission criteria;

(v) Assessment of potential clients before their acceptance into the program;

(vi) Billing and service records, maintenance of charges, and similar items, except for those clients receiving services through a managed-care health benefits plan or third party payor, in which case records are maintained as required by the third party payor;

(vii) Quality assurance program; and

(viii) Clinical management, including assessment, plans, delegation, and supervision;

(b) Personnel, including:

(i) Job descriptions and educational qualifications for all employees and contractors;

(ii) Skill assessments of all employees and contractors; and

(iii) Health requirements for employees and contractors;

(c) Patient care, including:

(i) Provision of home health care services and criteria for determining the need for skilled services;

(ii) Administration of drugs;

(iii) Enteral and parenteral nutrition procedures;

(iv) Frequency of client monitoring; and

(v) Training and retraining of clients or their family members, when indicated;

(d) Informed consent when:

(i) A client or client representative with legal authority to make legal decisions, signs an informed consent form consenting to changes to the agency’s recommended plan of care; or

(ii) A client signs an informed consent form consenting to assistance by a nonlicensed individual with treatments of a routine nature, or with the self-administration of medications; and

(e) Environment and safety, including:

(i) Preparation and storage of enteral formulas, intravenous therapies, other supplies, equipment, and similar items;

(ii) Infection control procedures;

(iii) Disposal of biomedical waste;

(iv) Maintenance of equipment; and

(v) Emergency procedures.

(2) The Department may waive the requirement of a policy and procedure that is required in §B of this regulation upon the agency’s written explanation as to why the policy and procedure is inappropriate or unnecessary to the agency’s specific operation.

(3) An agency that provides invasive equipment or supplies, such as intravenous therapy, shall arrange for 24-hour-a-day equipment maintenance service in case of equipment failure.