6 Colo. Code Regs. § 1011-1-2.3

Current through Register Vol. 47, No. 11, June 10, 2024

Section 6 CCR 1011-1-2.3 - Governing Body

2.3.1 The BHE shall have an organized governing body suitable for the size and complexity of the organization consisting of members who singularly or collectively have business and behavioral health experience sufficient to oversee the types of endorsements, services, and number of physical locations included in the BHE's license.

2.3.2 The governing body shall meet at regularly stated intervals, and maintain records of the meetings.

2.3.3 The governing body shall be responsible for:

(A) Planning, organizing, developing, and controlling BHE operations.

(B) Defining, in writing, the scope of preventive, diagnostic, and treatment services provided by the BHE, including services provided through arrangements with, or referrals to, other health care service providers.

(C) Providing facilities, personnel, and services in compliance with applicable endorsement-specific standards.

(D) Establishing organizational structures that clearly delineate personnel positions, lines of authority, and supervision.

(E) Ensuring all services and locations operate in compliance with applicable federal, state, and local laws and regulations.

(F) Ensuring professionally ethical conduct on the part of all individuals providing BHE services, whether paid, contracted, or volunteer, and initiating corrective measures as required.

(G) Developing and implementing a Quality Management Program in compliance with the requirements of 6 CCR 1011-1, Chapter 2, Part 4.1, taking into account each endorsement's services and any significant differences in client populations. Quality Management Program information shall be confidential in accordance with 6 CCR 1011-1, Chapter 2, Part 4.1.5, and Section 25-3-109(3), C.R.S.

(H) Ensuring emergency preparedness for the BHE, in accordance with Part 2.3.6 of this Chapter.

(I) Establishing and maintaining a system of financial management and accountability for the BHE.

(J) Developing, implementing, and annually reviewing policies in accordance with Part 2.3.4 of this Chapter.

(K) Maintaining relationships and agreements with health care facilities, organizations, and services to ensure appropriate client transfers, referrals, and transitions of care.

(L) Ensuring all marketing, advertising, or promotional information published or otherwise distributed by the BHE accurately represents the BHE and the care, treatment, and services that it provides.

(M) Considering and documenting the use of client input in decision-making processes in accordance with Part 2.3.4(C)(9) of this Chapter.

2.3.4 The governing body shall develop, implement, and annually review policies and procedures for the BHE, and shall comply with the policy requirements in this subpart and as found elsewhere in this Chapter.

(A) The governing body shall have policies regarding administrative and clinical oversight of the BHE's endorsements, services, and/or physical locations, as appropriate. Such policies shall meet oversight requirements included in Part 2.4.1 of this Chapter, and shall include, but not be limited to:

(1) Oversight positions within the BHE, such as an Administrator or Clinical Director, and whether each position is for the endorsement, specific services, specific locations, or a combination thereof.

(2) The authority and responsibilities for each oversight position.

(3) The minimum qualifications, including minimum education, experience, training, and/or licenses/certifications, to be met by individuals in each oversight position, including, but not limited to:

(a) When an Administrator is needed for an endorsement, service(s), or location(s), whether the Administrator:

(i) Is required to have a particular license or credential, and/or

(ii) The extent of the Administrator's clinical responsibilities, if any.

(b) When a Clinical Director is needed for an endorsement, service(s), or location(s), the Clinical Director shall have experience in clinical supervision and meet one of the following:

(i) Be a licensed mental health professional in Colorado, or

(ii) Hold a license as a mental health professional from another state, and be eligible for, and in the process of, obtaining a Colorado license as a mental health professional, and expecting to receive such license within six (6) months.

(4) The model or framework for clinical supervision. Such model or framework may be different by endorsement, service, or setting, as appropriate.

(5) A requirement for identifying an individual that will be delegated responsibilities of the oversight position during periods when the individual holding the oversight position is not on-site and is not readily available through other means.

(6) The procedure for accessing oversight personnel or their delegate when the oversight personnel are not on-site, including, but not limited to, methods of contact, on-call or other procedures, and required response times.

(B) If the governing body has delegated the responsibility for development, implementation, and/or annual review of policies to leadership at the endorsement level, the governing body shall approve such policies and ensure their implementation and review.

(C) At a minimum, the BHE shall have policies and procedures that address the following items:

(1) Occurrence reporting in accordance with 6 CCR 1011-1, Chapter 2, Part 4.2.

(2) Client rights policies in accordance with Part 2.5.1 of this Chapter.

(3) Client complaint policies, including complaint resolution procedures.

(4) Infection prevention and control policies in accordance with Part 2.3.5 of this Chapter.

(5) Personnel policies and procedures, including those required by Part 2.4, and as required by the endorsements of the BHE license as described by this Chapter.

(6) Admission, assessment/discharge, service plan, and care policies as required by Part 2.6 of this Chapter.

(7) Medication administration, storage, handling, destruction, and disposal policies and procedures in accordance with Part 2.9.2 of this Chapter.

(8) Defining and preventing conflicts of interest to the extent possible, and where such conflicts exist, developing and implementing controls to minimize such conflict and ensure decisions are made for the best interest of the client.

(9) The use of client input and feedback in governing body decisions, including, but not limited to:

(a) The formal or informal processes, appropriate for the clients served and the size and complexity of services offered, to be used for collection of client input and feedback.

(b) How the governing body will document that client input and feedback has been considered.

(10) Individual client records policies, including but not limited to confidentiality, access, and disposal/destruction.

(11) Building safety and security policies, procedures, and practices.

(a) Such policies may be for the BHE, an endorsement, or physical location, as appropriate.

(b) Policies shall address the needs of the client population being served and/or the services being provided.

(c) Policies may include, but not be limited to, electronic surveillance, delayed egress, and/or locked settings as appropriate.

2.3.5 Infection prevention and control. The governing body shall be responsible for developing and implementing infection prevention and control policies and procedures reflecting the scope and complexity of the services provided across the BHE, including but not limited to:

(A) A requirement that at least one individual trained in infection control shall be employed by or regularly available to the BHE.

(B) Endorsement-specific requirements included in Part 4 of these rules, as applicable.

(C) Maintenance of a sanitary environment.

(D) Mitigation of risks associated with infections and the prevention of the spread of communicable disease, including, but not limited to, hand hygiene, bloodborne and airborne pathogens, and respiratory hygiene and cough etiquette for clients and BHE personnel.

(E) Coordination with other federal, state, and local agencies, including but not limited to a method for when to seek assistance from a medical professional and/or the local health department.

2.3.6 Emergency Preparedness. The governing body shall be responsible for emergency preparedness for the BHE, including the following:

(A) The governing body shall be responsible for completing a risk assessment of all hazards and preparedness measures to address natural and human-caused crises including, but not limited to, fire, gas leaks/explosions, power outages, tornados, flooding, threatened or actual acts of violence, and bioterror, pandemic, or disease outbreak events. Such risk assessment shall be reviewed when BHE operations are modified through the addition or discontinuation of a physical location, services, or endorsement, and no less than annually.

(B) The governing body shall develop and implement a written Emergency Management Plan addressing the hazards identified in Part 2.3.6(A), above, and meeting, at a minimum, the following requirements:

(1) The plan shall differentiate between endorsements, physical locations, and client populations served, as appropriate, and shall meet the requirements as applicable for the endorsements held by the BHE.

(2) The plan shall be updated based on changes in the risk assessment conducted in accordance with Part 2.3.6(A), above.

(3) The plan shall address interruptions in the normal supply of essentials, including, but not limited to water, food, pharmaceuticals, and personal protective equipment (PPE).

(4) The plan shall ensure continuation of necessary care to all clients immediately following any emergency.

(5) The plan shall address the protection and transfer of client information, as needed.

(6) The plan shall address the methods and frequency of holding routine drills to ensure BHE personnel familiarity with emergency procedures, in compliance with requirements established by the Department of Public Safety, Division of Fire Prevention and Control, in 8 CCR 1507-31.

(C) BHEs with an endorsement under Part 4, 24-hour/Overnight services, shall maintain enough food and water on hand to provide all clients with three (3) nutritionally balanced meals for four (4) days.

6 CCR 1011-1-2.3