10.22.02.10

.10 Policies and Procedures.

A. A licensee shall develop and adopt written policies and procedures for ensuring:

(1) That each individual's health and safety needs, as identified in the individual plan (IP), are being met;

(2) Fundamental rights in accordance with Health-General Article, §7-1002, Annotated Code of Maryland;

(3) That services are provided in a manner which promotes individual choice and the exercise of individual rights;

(4) Confidentiality for each individual in accordance with Health-General Article, §7-1010, Annotated Code of Maryland;

(5) The implementation of a grievance process with safeguards which protect against retaliatory actions for the filing of any grievance;

(6) That services are provided without discrimination;

(7) That all incidents, including those involving life-threatening conditions, are reported and investigated in accordance with the Administration's procedures on reportable incidents;

(8) That medications are administered in accordance with the practices established by the Administration's curriculum on medication training;

(9) Compliance with COMAR 10.27.11;

(10) That an individual whose behavior requires intervention receives the safeguards required by this regulation;

(11) That in order for an individual to be required to pay for property damage caused by the individual's actions, the individual's IP shall show evidence that the:

(a) Individual has a history of destructive behavior that has been documented in the behavior plan (BP),

(b) Individual has a BP that addresses the destructive behavior,

(c) Individual has the ability to pay for damages,

(d) Licensee's standing committee, as described in Regulation .08 of this chapter, has reviewed and approved the damage payment, and

(e) Licensee has reported this approval to the regional director;

(12) Compliance with Health-General Article, §5-605, Annotated Code of Maryland;

(13) That there is no financial or personal conflict of interest for members of the governing body, staff, care providers, volunteers, and standing committee members;

(14) That the fiscal affairs of the licensee are conducted in accordance with generally accepted accounting practices;

(15) That there is adequate protection for the finances and property of each individual, including:

(a) A system to ensure that each individual's funds are used in an appropriate manner consistent with the individual's needs and preferences,

(b) A system to keep personal funds separate from the funds of the licensee and to ensure that funds are transferred to the individual in a timely manner when services are no longer being provided,

(c) Timely access for the individual to the funds,

(d) An accounting of the individual's funds, on request, and

(e) The accrual of any interest into the individual's account from an interest-bearing account;

(16) That State and federally required safety precautions, infection control, and standard precautions are implemented;

(17) That an effective disaster and emergency evacuation plan, with sufficient evacuation drills is in place;

(18) That an individual may not perform the duties of a paid staff person; and

(19) That an individual only perform those duties and tasks that are shared by the household or included as an activity documented in the individual's IP or remunerated as part of a training program as required by federal or State law.

B. A licensed community residential service provider offering services in alternative living units or group homes shall develop an emergency plan for all types of emergencies and disasters that shall include:

(1) Procedures that will be followed before, during, and after an emergency to address the following:

(a) The evacuation, transportation, or 72 hour shelter-in-place of individuals and staff served;

(b) Holding an annual practice drill coordinated with local emergency planners for sheltering in place or evacuating;

(c) Preparing an after action report and improvement plan after drills that evaluates the plan and takes corrective actions;

(d) Ensuring that individuals served and staff have identification with current health, contact, and other important information that is immediately accessible in the event of evacuation;

(e) The role of the resident, family member, or legal representative in the event of evacuation;

(f) Arranging for medical needs and other accommodations for individuals served and staff at alternative facilities or shelters; and

(g) Establishing a communication protocol among all appropriate parties that includes redundant communication means;

(2) The notification to families, staff, and the respective DDA regional office (licensing authority) regarding the action that will be taken concerning the safety and well-being of the individuals served;

(3) The staff coverage, organization, and assignment of responsibilities that includes:

(a) Planning staff coverage needs for ongoing shelter in place or evacuations;

(b) Identifying staff members available to report for work or remain during extended periods; and

(c) Establishing staff notification and recall contingency plans and procedures;

(4) The continuity of operations, including, but not limited to, redundant communications systems, preservation of records and electronic data, the procurement of essential goods, equipment, and services, plans to secure vacated facilities, and the relocation to alternate facilities;

(5) Procedures to:

(a) Backup and electronically store off-site, appropriate records and data of consumers and staff and facility documents, for access under emergency conditions;

(b) Ensure access to an electronic copy of the emergency plans when requested by local, State, or federal emergency management organizations;

(6) Provisions to ensure that the facility's emergency and disaster plans are shared with local emergency management organizations for the purpose of coordinating local emergency planning; and

(7) An executive summary of the evacuation procedures that shall be provided to the family member of a resident on request.

C. The licensee shall ensure that all staff, care providers, consultants, and volunteers are aware of the policies required by this chapter and that all staff, care providers, consultants, and volunteers implement each policy as adopted.

D. The licensee shall ensure that it provides sufficient information about its grievance process to each individual it serves and, when appropriate, to the individual's proponent, to enable the individual or proponent to use the process effectively.