6 Colo. Code Regs. § 1011-3-3

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

Section 6 CCR 1011-3-3 - REQUIRED POLICIES AND PROCEDURES

All policies and procedures shall be documented in writing and available for Department inspection.

3.1Related to Consumer Rights

3.1.1 The Agency shall develop and implement policies and procedures regarding rights of the consumer. These policies and procedures shall be made available in writing to the consumer at the initiation of community integrated health care services. At a minimum, the policies and procedures shall include:

A) The right of the consumer to participate in the development of the service plan;

B) The right of the consumer and his or her property to be treated with respect;

C) The right of the consumer to be free from discrimination in the provision of services;

D) The right of the consumer to consent to receive and to discontinue Agency services at any time;

E) The right of the consumer to have personally identifying health information protected from unnecessary disclosure;

F) The right of the consumer or his or her representative to file a complaint with the Agency and/or Department concerning services or care that is or is not furnished, and receive documentation of the existence of the investigation and resolution of the complaint, including providing the complainant with the results of the investigation and the Agency's plan to resolve any identified issues;

G) The right of the consumer to file a complaint with the Agency and/or Department without fear of discrimination or retaliation by the CIHCS Agency owner, administrator, or any CIHCS provider or Agency staff; and

H) The right of the consumer to formulate an advanced directive.

3.2Related to Staffing

3.2.1 The Agency shall develop and implement policies and procedures establishing that each employee and contracted staff possesses, at a minimum:

A) The education, experience, and training, including adequate clinical knowledge of and competence in performing medical skills and acts within the CIHCS provider's scope of practice, to provide services in the homes of consumers, in compliance with Sections 5.3.1 through 5.3.5 of these rules; and

B) Good moral character. If the Agency employs or contracts with any individual convicted of a felony or misdemeanor, the Agency shall develop policies and procedures to ensure that the individual does not pose a risk to the health, safety and welfare of the consumer.

3.2.2 The Agency shall also develop and implement policies and procedures:

A) Ensuring adequate staffing and resources to meet each consumer's needs;

B) Concerning the supervision of CIHCS providers, and the evaluation of their performance, to comport with the requirements of Sections 5.1.1(C)(i) and 5.2.3(A)(i) and (ii) of these rules;

C) Establishing that any on-call medical director[s], administrator and/or CIHCS provider[s] will have access to all pertinent current consumer information;

D) Ensuring proper staff utilization and availability, in compliance with these rules;

E) Designating medical direction back-up, in accordance with the requirements of Sections 5.1.1 and 5.2.3 of these rules, for when the Agency medical director is unavailable;

F) Designating administrative back-up when the Agency administrator is unavailable, in accordance with the requirements of Section 5.1.1(B)(iv) of these rules;

G) Ensuring that the Agency complies with the requirements of Section 26-3.1-111, C.R.S, on and after January 1, 2019.

3.2.3 The Agency shall also develop and implement training policies and procedures that:

A) Ensure the Agency's oversight of training is specific to the community integrated health care services provided to the community and to the equipment used by the Agency;

B) Establish the minimum amount of training its providers must receive annually;

C) Promote consumer dignity, independence, self-determination, privacy, choice and rights; and

D) Without limitation, address the following items:

i) Abuse and neglect prevention and reporting requirements;

ii) Behavior management techniques;

iii) Disaster and emergency procedures;

iv) Infection control, including standard universal precautions; and

v) Topics and subject matter that educate providers on community resources and other available services.

3.3Related to Initial and Subsequent Assessments, Service Planning, and Care Coordination

3.3.1 The Agency shall develop and implement policies and procedures concerning the assessment, service planning, and care coordination services it conducts when providing out-of-hospital medical services to the consumer. At a minimum, such policies and procedures shall establish how the Agency will:

A) Secure consent to obtain the consumer's medical records;

B) Determine the consumer's eligibility for recurrent services, in compliance with Section 6.1 of these rules;

C) Comply with the initial and subsequent consumer assessments requirements set forth in Section 8.4 of these rules;

D) Develop and execute consumer service plans in accordance with Sections 8.3 and 8.5 of these rules;

E) Determine and document the appropriate CIHCS provider[s] who are necessary to fulfill the consumer's service plan goals;

F) Coordinate care across multiple providers, as applicable;

G) Require providers to document every consumer visit in compliance with Section 7.1.5 of these rules;

H) Refer consumers to a higher level of medical care and/or to other appropriate resources that may assist in the resolution of other issues identified in the initial and any subsequent assessments, in compliance with Section 7.1.1 of these rules; and

I) Under circumstances in which the Agency has co-medical directors, delineate the line of authority and medical oversight each medical director must exercise with respect to each consumer.

3.4Related to Access to Services and Consumer Records

3.4.1 The Agency shall develop and implement policies and procedures describing, at minimum:

A) How consumers may contact the CIHCS Agency;

B) That the consumer's documentation of diagnostic and therapeutic procedures, treatments, tests and their results, if applicable, are available upon request; and

C) That all releases of personally identifying health information are consistent with applicable state and federal law.

3.5Related to Discharge

3.5.1 The Agency shall develop and implement policies and procedures concerning the consumer's discharge in accordance with Section 8.6 of these rules that, at minimum, shall require that:

A) Discharge planning be initiated in a timely manner to allow for the arrangement of any other appropriate and necessary care;

B) A discharge plan and summary be included in the consumer's CIHCS Agency record; and

C) The Agency solicit consumer input regarding his or her satisfaction with the CIHCS provider and services received for quality management purposes.

3.6Related to Complaints

The CIHCS Agency shall develop and implement policies and procedures that address, at a minimum, the following:

3.6.1 The CIHCS Agency's duty to provide consumers with contact information for the Department and Agency staff responsible for complaint intake and problem resolution;

3.6.2 The process by which consumers or others can submit verbal or written complaints to the Department and/or directly to the Agency about services or care;

3.6.3 How the Agency will document investigation of, and resolution process for, any complaint made concerning Agency services and providers, including the Agency's mandatory notification to the complainant about the results of the investigation and the agency's plan to resolve the identified issue(s);

3.6.4 The Agency's incorporation of the substantiated findings of any complaint into its quality management program for the purpose of evaluating and implementing systematic changes where needed; and

3.6.5 The Agency's explicit statement that it does not discriminate or retaliate against a consumer for expressing a complaint or multiple complaints.

3.7Related to Required Reporting

3.7.1 The Agency shall develop and implement policies and procedures regarding occurrences and other reporting requirements in Sections 10.1 and 10.2 of these rules.

3.7.2 Every CIHCS Agency shall develop and implement a policy and procedure regarding its duty to define deaths reportable to the local county coroner under Section 30-10-606(1), C.R.S., in a manner consistent with the local coroner's reporting policy.

3.8Related to Quality Management Program

3.8.1 The Agency shall develop and implement policies and procedures that require and document that the quality management program complies with Section 7.2 of these rules.

3.9Related to Records

3.9.1 The Agency shall develop and implement policies and procedures that establish and document its record retention requirements, including the length of time the Agency must retain records for Department inspection in compliance with Section 4.6.3 of these rules.

3.9.2 The Agency shall develop and implement policies and procedures that establish and document its personnel file retention requirements for all employees.

A) Personnel records for all employees shall include references, dates of employment and separation from the Agency, and the reason for separation.

B) Personnel records for all employees shall also include:

i) Current documentation of qualifications and any licenses, certifications, endorsements, or registrations. Qualifications include confirmation of type and depth of experience, advanced skills, training and education, and appropriate, detailed and observed competency evaluation and written testing overseen by a person with the same or higher validated qualifications;

ii) Documentation of the employees orientation to the Agency;

iii) Job descriptions for all positions assigned by the Agency; and

iv) Annual performance evaluation for each employee.

6 CCR 1011-3-3

40 CR 21, November 10, 2017, effective 1/1/2018