6 Colo. Code Regs. § 1011-1-2.4

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

Section 6 CCR 1011-1-2.4 - Personnel and Contracted Services

2.4.1 The BHE shall ensure appropriate administrative and clinical oversight of endorsement(s), service(s), and physical location(s), in accordance with policies and procedures adopted by the governing body under Part 2.3.4(A) of these rules, including, as appropriate:

(A) An Administrator, responsible for implementing appropriate endorsement and service policies and procedures as adopted by the governing body and the day-to-day operation of the endorsement, services, or location, including, but not limited to:

(1) Management of business and financial operations.

(2) Ensuring standards in Part 2 of this Chapter are met in the endorsement, services, or location, including, but not limited to the standards in Part 2.9, Medication Administration, Storage, Handling, and Disposal.

(3) Ensuring buildings are properly maintained and building safety/security needs are met.

(4) Implementing infection control and emergency preparedness policies and procedures, in accordance with governing body policies.

(5) Establishing and maintaining relationships with agencies, services, and behavioral health resources within the community.

(6) Identifying an individual to whom administrator responsibilities are delegated during periods when the Administrator is neither on-site nor available through interactive means in a timely manner.

(B) A Clinical Director, responsible for the overall services provided to clients, including, but not limited to:

(1) Ensuring appropriate training and continuing education for BHE personnel, relevant to the services provided.

(2) Ensuring appropriate supervision and clinical oversight of BHE personnel.

(a) The BHE shall have a method to provide appropriate clinical supervision and oversight during periods when the Clinical Director is unable to fulfill their duties in a timely manner.

(3) Appropriateness of client services provided, including assessment, service planning, and provision of services.

(C) The minimum qualifications for the Administrator and Clinical Director shall be set by the BHE's governing body's policies and procedures, and shall be appropriate for the services provided by the BHE.

(D) An Administrator or Clinical Director may be specific to a physical location or may be shared among locations, as appropriate for the services, size, and geographic dispersion of the services.

(E) A single individual may serve as both the Administrator and the Clinical Director, if qualifications are met, it is appropriate for the BHE, and it is consistent with policies adopted by the governing body.

2.4.2 The BHE shall provide a sufficient number of qualified personnel for each endorsement and at each physical location to effectively provide the endorsed services, meet the clinical needs of the clients, and comply with state and federal requirements, and shall ensure personnel are assigned only duties they are able to adequately and safely perform.

2.4.3 All personnel assigned to direct client care shall be qualified through professional credentials, education, training, and experience in the principles, policies, procedures, and appropriate techniques necessary for providing client services.

(A) Personnel providing client services shall be legally authorized to provide the service in accordance with applicable federal, state, and local laws.

(B) Licensed, certified, and/or registered personnel shall have an active license, certification, or registration in the state of Colorado and shall provide services within their scope of practice.

(C) The BHE shall verify the license, certification, or registration, and check for disciplinary action for each individual providing client services through the Colorado Department of Regulatory Agencies or other agency as appropriate, prior to hire.

2.4.4 The BHE shall request, prior to hire or acceptance for volunteer service, a name-based criminal history record check for each prospective individual providing client services.

(A) If the applicant has lived in Colorado for more than three (3) years at the time of application, the BHE shall obtain a name-based criminal history report conducted by CBI.

(B) If the applicant has lived in Colorado for three (3) years or less at the time of application, the BHE shall obtain a name-based criminal history report for each state in which the applicant has lived during the past three (3) years, conducted by the respective states' bureaus of investigation or equivalent state-level law enforcement agency or other name-based report as determined appropriate by the Department.

(C) The cost of obtaining such information shall be borne by the BHE.

(D) If a BHE contracts with a staffing agency for the provision of BHE services, it shall require the staffing agency meet the requirements of this Part 2.4.4.

(E) When determining whether an applicant is eligible for hire if the criminal history record check reveals the applicant has a conviction or plea of guilty or nolo contendere, the BHE shall follow its policy developed in accordance with Part 2.4.5(C) of these rules.

2.4.5 The BHE shall have written personnel policies developed in accordance with Part 2.3.4(C)(5), including, but not limited to:

(A) Line of authority/management of personnel.

(B) Job descriptions/responsibilities.

(C) Written criteria and procedures for evaluating which convictions or complaints make prospective personnel unacceptable for hire, or for existing personnel unacceptable for retention, including:

(1) Factors to be considered when determining whether a job applicant is eligible for hire when their criminal history record check reveals a conviction or plea of guilty or nolo contendre, including, but not limited to:

(a) The nature and seriousness of the offense;

(b) The nature of the position and how the offense relates to the duties of the position;

(c) The length of time since the conviction or plea;

(d) Whether such conviction is isolated or part of a pattern; and

(e) Whether there are mitigating or aggravating circumstances involved.

(D) Conditions of employment, including but not limited to:

(1) Conflicts of interest.

(2) Maintenance of appropriate relationships between personnel and clients, including a prohibition against sexual relationships with clients.

(E) Position qualifications and required credentials.

(F) Orientation, training, and continuing education requirements, appropriate for the populations served and services provided.

(G) Routine monitoring of individual credentials and disciplinary actions.

(H) Self-reporting of investigations, indictments, or convictions that may affect the individual's ability to carry out their duties or functions of the job.

(I) Policies requiring all personnel to be free of communicable disease that can be readily transmitted in the BHE.

(1) All staff shall be required to have a tuberculin skin test prior to direct contact with clients. In the event of a positive reaction to the skin test, evidence of a chest x-ray and other appropriate follow-up shall be required in accordance with community standards of practice.

2.4.6 The BHE shall ensure that all personnel have access to and be knowledgeable about the BHE's policies, procedures, and state and federal laws and regulations relevant to their respective duties.

2.4.7 The BHE shall maintain records on all personnel, including, but not limited to:

(A) Date of hire;

(B) Job description;

(C) Results of criminal history record checks, and Colorado Adult Protective Data System (CAPS) checks performed in accordance with Part 2.3.6 of 6 CCR 1011-1, Chapter 2, General Licensure Standards;

(D) Documentation of professional credentials, education, and training;

(E) Documentation of any disciplinary action taken against the individual by a credentialing body;

(F) Documentation of orientation and training;

(G) Evidence of review of the BHE's policies, procedures, and state and federal laws and regulations relevant to their respective duties; and

(H) Documentation of tuberculosis testing and results, for individuals who have direct contact with clients.

2.4.8 The BHE shall ensure that all personnel complete an initial orientation on basic infection prevention and control, safety, and emergency preparedness procedures.

2.4.9 The BHE shall ensure that all personnel receive the following training prior to working independently with clients, and on a periodic basis consistent with policies developed in accordance with Part 2.4.5(F), above:

(A) Training specific to the particular needs of the populations served;

(B) Infection control;

(C) Emergency preparedness;

(D) Occurrence reporting;

(E) Suicide prevention;

(F) Individual rights of the population served;

(G) Confidentiality, including individual privacy and records privacy and security;

(H) BHE policies and procedures;

(I) Seclusion and restraint procedures in compliance with 6 CCR 1011-1, Chapter 2, Part 8.5, for all individuals involved in utilizing restraint and seclusion within the BHE; and

(1) If the BHE does not use seclusion or restraint, and has a documented statement to that effect in compliance with 6 CCR 1011-1, Chapter 2, Part 8.8.2, this training requirement does not apply.

(J) Training required for the 24-hour/Overnight Endorsement, as found in Part 4.1.3 of these rules, as applicable.

6 CCR 1011-1-2.4