10.47.01.03

.03 Governance.

A. The program shall:

(1) Have a governing body legally responsible for overseeing the management and operation of the program and for ensuring compliance with applicable laws and regulations by:

(a) Approving the program's:

(i) Mission;

(ii) Goals;

(iii) Policies and procedures;

(iv) Budget; and

(v) Program service plan;

(b) Adopting written bylaws;

(c) Overseeing the operation of the program, according to the stated purposes of the program;

(d) Ensuring proper management of the program by developing a job description for the administrator, and hiring, supervising, and providing for periodic performance evaluation of the administrator; and

(e) Ensuring sound fiscal operation;

(2) Implement fiscal policies and procedure which include:

(a) The maintenance of fiscal records according to generally accepted accounting principles in Article 19, §28A, Annotated Code of Maryland, and COMAR 10.02.01 and 10.04.04;

(b) Appropriate fire, casualty, liability, unemployment, and workers' compensation insurance;

(c) In the event of fiscal instability, immediately notifying the Office of Health Care Quality;

(d) Maintaining and posting a list of services and associated charges; and

(e) Maintaining an annual program budget reflecting anticipated expenditures and sources of income;

(3) Implement personnel policies and procedures that include:

(a) Personnel policies and procedures that promote the objectives of the program;

(b) Personnel policies that include:

(i) The qualifications required for each position;

(ii) An employee assistance policy and procedure;

(iii) A policy to prevent discrimination prohibited by Article 49B, Annotated Code of Maryland, and federal law;

(iv) A policy designed to prevent sexual harassment of staff and patients and appropriately manage complaints of sexual harassment;

(v) A staff grievance procedure;

(vi) A mechanism for assuring annual employee tuberculosis testing;

(vii) Before employment, applying for national and State criminal history records checks;

(viii) As part of the employment or volunteer application process, requiring the applicant to complete and sign a sworn statement or written affirmation disclosing the existence of a criminal conviction, probation before judgment disposition, not criminally responsible disposition, or pending charges without a final disposition;

(ix) Requiring the employee to comply with §A(3)(b)(viii) of this regulation annually; and

(x) Providing information to the employee so the employee may determine whether he or she needs testing or vaccination or both for hepatitis;

(c) Maintaining a personnel file, in accordance with State and federal confidentiality requirements, for each employee, contractual staff, intern, or volunteer, that includes the individualís:

(i) Written application or resume including, name, home address, current telephone number, educational and training background, and employment history;

(ii) Emergency contact information;

(iii) Copies of required credentials;

(iv) Current job title and description;

(v) Current wage and salary information;

(vi) Annual performance evaluation;

(vii) Contracts, if applicable;

(viii) Results of a criminal background check;

(ix) Results of tuberculosis tests; and

(x) Documentation of attendance at continuing education courses or other training; and

(d) Not permitting any individual with a documented history of physical, mental, or sexual abuse or neglect of adolescents or children to work with children and adolescents;

(4) Manage the program by:

(a) Implementing a policy and procedure manual that contains:

(i) An all hazards emergency protocol plan, approved by the Administration and updated at the time of recertification, that includes the name of the contact person for access to medical and clinical records, the written agreement or agreements with another facility to provide services in case of an emergency, notification procedures for the State Methadone Authority, program staff, and patients, a policy regarding patient access to emergency mental health services necessitated by a hazardous event, and a policy assuring that correctional levels of care comply with the institutionís all hazards emergency plan;

(ii) The program's mission and goals;

(iii) A description of the organizational structure of the program;

(iv) Identification of the duties of the administrator and, if applicable, the medical director or clinical director;

(v) Admission, transition, discharge, and termination procedures;

(vi) Procedures governing patient rights and grievances;

(vii) If applicable, a procedure for storing, handling, prescribing, dispensing, administering, and disposing of medications;

(viii) Procedures for assisting program enrollees with access to entitlements, insurance benefits, and reimbursements for which the individual is eligible, if the program provides case management services; and

(ix) Procedures for staff orientation, supervision, training, and education that include, but are not limited to, ethics and State and federal laws regarding confidentiality including, but not limited to, Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland, 42 CFR Part 2, The Health Insurance Portability Assurance and Accountability Act (HIPAA), and 45 CFR Parts 160 and 164; and

(b) Implementing a program service plan, approved by the Administration, that is based on the levels of treatment to be provided as defined in COMAR 10.47.02.03—.11 and describes how the program shall comply with the regulatory requirements, is updated annually, and includes:

(i) A description of medical staff, if required by the level of treatment;

(ii) A description of the program's scope that includes target populations and other program characteristics;

(iii) Staff positions, their job descriptions, and educational and clinical training requirements, including an organizational chart detailing lines of authority and responsibility;

(iv) A list of services to be delivered, including the types of medication and controlled dangerous substances to be prescribed, the types of group sessions, including education, the types of individual sessions and a complete family services plan;

(v) Names of clinical supervisors and the number of alcohol and drug counselors supervised;

(vi) Types of services that are available by referral; and

(vii) Planning protocol for transfer or discharge of patients;

(5) Implement a continuous quality review process that includes:

(a) Designated teams responsible for implementation;

(b) An ongoing procedure for utilization review;

(c) A plan to identify problems and initiate actions to correct deviations from the programís established standards, which includes:

(i) Data collection;

(ii) Current information regarding efficient and effective service delivery;

(iii) Indicators relevant to the needs of the population served; and

(iv) Ongoing internal review of the program, including monitoring for effectiveness of changes incorporated; and

(d) An opportunity for all staff to participate on the teams described in §E of this regulation; and

(6) Report critical incidents to the Administration within 5 business days of the incident;

(7) Limit an individualís role on the governing body to being a nonvoting member if the individual has an immediate family member who:

(a) Is employed by the program;

(b) Consults on behalf of the program;

(c) Owns the program; or

(d) Sits on an advisory committee for the program; and

(8) Refuse to allow an individual to serve on the programís governing body if the individual receives any monetary benefit from the program.

B. The program may not allow:

(1) An immediate family member of an employee of an organization to serve as a voting member of the governing body, board of directors, or advisory committee; or

(2) An individual who is compensated for providing goods or services to the program to serve on the governing body, board of directors, or advisory committee.