10 Colo. Code Regs. § 2505-10-8.7408

Current through Register Vol. 47, No. 24, December 25, 2024

Section 10 CCR 2505-10-8.7408 - Policies and Procedures

A. Provider Agencies shall establish and maintain policies and procedures for each of the items below.

1. Staffing and employment

a. Provider Agencies shall have written policies and procedures for recruiting, selecting, orienting, training, and terminating employees and Contractors. Such policies shall include procedures for conducting criminal background checks, a Colorado Adult Protection Services (CAPS) check, and reference checks prior to employing staff or Contractors providing supports and services, and mitigation procedures to be used if the Provider Agency becomes aware of information that indicates a staff Member or volunteer could pose a risk to the health, safety, and welfare of the Members served.

b. Provider Agencies shall have written policies and procedures to establish qualifications for employees and Contractors. Such policies shall include:

i. Responsibilities assigned to each employee job description.

ii. Procedures for initial and continuing training of staff to ensure all duties and responsibilities are accomplished in a competent manner.

iii. Supervision and management of staff and oversight of contractors.

iv. Restrictions prohibiting staff on-site access if they are under the influence of alcohol or illicit drugs.

2. Medication Administration

a. Provider Agencies shall establish and maintain policies and procedures for the administration of medication including administration by gastrostomy as part of gastrostomy services described at Section 8.7416

b. Provider Agencies shall establish and maintain written policies and procedures for the appropriate procurement, storage, distribution, and disposal of medications.

i. All medications shall be stored under proper conditions of temperature and light, and with regard for safety.

ii. Discontinued and outdated medications, and medication containers with worn, illegible, or missing labels shall be promptly disposed of in a safe manner.

iii. A record shall be maintained of missing, destroyed, or contaminated medications.

c. Medication reminder boxes shall be used in accordance with Section 25-1.5-303(1), C.R.S.

3. Protected Health Information (PHI)

a. Provider Agencies shall have written policies governing access to duplication and dissemination of information from the Member's records in accordance with Section 26-1-114(3), C.R.S. and 42 C.F.R. § 164.502 . Within the Agency policies for protection of confidentiality, Provider Agencies shall have written policies and procedures for confidential access to Member information by employees as needed to provide the assigned services.

4. Mistreatment, Abuse, Neglect, and Exploitation (MANE)

a. Pursuant to Section 25.5-10-221, C.R.S., Provider Agencies shall prohibit MANE of any Member.

b. Provider Agencies shall have written policies and procedures for thoroughly investigating cases of alleged or suspected MANE of any Member.

c. MANE policies and procedures shall be consistent with state law and provide a mechanism for monitoring to detect instances of MANE. Monitoring is to include, at a minimum, the review of:

i. Incident reports;

ii. Verbal and written reports of unusual or dramatic changes in behavior(s) of Members; and,

iii. Verbal and written reports from Members, advocates, families, Guardians, and friends of Members.

d. Provider Agencies shall establish and maintain procedures for identifying, reporting, reviewing, and investigating all allegations of MANE. Documentation of all investigations shall be maintained. Documentation shall include:

i. The Incident report and preliminary results of the investigation;

ii. A summary of the investigative procedures utilized;

iii. The full investigative finding(s); and

iv. The actions taken.

e. Provider Agencies shall

i. Ensure that appropriate disciplinary actions up to and including termination, and appropriate legal recourse are taken against employees and Contractors who have engaged in MANE.

ii. Ensure that employees and Contractors are made aware of applicable state law and Agency policies and procedures related to MANE.

iii. Require immediate reporting when observed by employees and Contractors according to Agency policy and procedures and to the Agency administrator or his/her designee;

f. Require reporting of allegations within 24 hours to a Legally Authorized Representative and Case Management Agency.

5. Protection of individual rights

a. All Provider Agencies shall have written policies and procedures concerning the exercise and protection of individual rights pursuant to Sections 25.5-10-218 through 231, C.R.S. and Section 8.7001.

b. Provider Agencies shall supply Members with a Plain Language explanation of their rights.

6. Non-discrimination policies

a. Provider Agencies shall have policies in place that prohibit Discrimination on the basis of race, religious or political affiliation, gender, national origin, age, or disability and outline the Agency's follow up procedures to address any discriminatory acts.

7. Dispute resolution

a. Provider Agencies shall have procedures for resolution of disputes involving Members:

i. Who are found ineligible to receive the service(s) from the Provider Agency;

ii. Whose services or supports are to be terminated; or,

iii. Whose services set forth in the Person-Centered Support Plan are to be changed, reduced, or denied.

b. The procedure shall contain an explanation of the process to be used by Members, prospective Members, or Legally Authorized Representatives if they are dissatisfied with the decision or action of the Provider Agency.

c. The dispute resolution procedures of the Provider Agency shall, at a minimum, provide the parties the opportunity to present information and evidence in support of their positions to an impartial decision maker. The impartial decision maker may be the director of the Agency taking the action or their designee. The impartial decision maker shall not have been directly involved in the specific decision at issue.

d. Provider Agencies shall supply Members with a Plain Language explanation of available dispute resolution procedures, along with outside Agency contact information, including phone numbers, for assistance.

e. Provider Agencies must provide Members with 15 days advance notice of any change to or termination of services.

8. Grievances and Complaints

a. Provider Agencies shall have procedures setting forth a process for the timely resolution of Grievances or Complaints of Members, prospective Members, or Legally Authorized Representatives, as appropriate. Use of the Grievance/Complaint procedure shall not prejudice the future provision of appropriate services or supports. No individual shall be coerced, intimidated, threatened, or retaliated against because the individual has exercised his or her right to file a Grievance/Complaint or participate in the Grievance process.

b. The Grievance/Complaint procedure shall, at a minimum, include:

i. Identification of the staff Member responsible to receive Grievances/Complaints;

ii. A mechanism to receive Grievances/Complaints verbally and/or in writing that requires staff receiving a verbal Grievance/Complaint to record any verbal Grievances and/or Complaints;

iii. Identification of a support person(s) to assist a Member to submit a Grievance/Complaint;

iv. An opportunity for individuals to meet and attempt to reach a mutually acceptable solution;

v. Timelines for the resolution of the Grievance/Complaint;

vi. Consideration by the Agency director or designee if the Grievance/Complaint cannot be resolved at a lower level; and,

c. Provider Agencies shall supply Members with a Plain Language explanation of available Grievance/Complaint procedures, along with outside Agency contact information, including phone numbers, for assistance.

d. Provider Agencies shall allow Grievances/Complaints to be submitted anonymously.

9. Independent Contractors

a. Provider Agencies may utilize the services of independent Contractors at their discretion. If an Agency does utilize independent Contractors, it shall conduct the vetting, training, and monitoring of, and take corrective action against Contractors.

b. Nothing in these regulations shall create any contractual relationship between any independent Contractor of the Provider Agency and the Department.

10. Contingency planning

a. Provider Agency shall have a documented contingency plan for providing services if a Member's caregiver or direct service provider are unavailable due to an emergency or unforeseen circumstances.

11. Telehealth

a. Provider Agencies that provide HCBS Telehealth services shall establish and maintain documented policies on the use of Telehealth services that comply with Section 8.7562.

12. Written Plans to Address Emergencies

a. An emergency can be defined as an unforeseen situation that may endanger the lives of Members and/or staff, as well as disrupt for a short time the normal operations within a setting or Agency.

b. Emergencies can include, but are not limited to:

i. Medical Emergencies

ii. Public Health Emergencies

iii. Fire

iv. Natural Disasters

c. Each HCBS Provider Agency shall have written policies and procedures to address emergencies, unless otherwise specified within service regulations.

i. Plans should include how the agency prepares for loss of staff, various emergencies, back up plans, protocols, etc. should any staff be affected.

ii. Day Habilitation services shall have written plans to address emergencies regardless of service location or type of program.

10 CCR 2505-10-8.7408

47 CR 03, February 10, 2024, effective 3/16/2024

47 CR 21, November 10, 2024, effective 11/30/2024