2 Colo. Code Regs. § 502-1-2.4

Current through Register Vol. 47, No. 10, May 30, 2024

Section 2 CCR 502-1-2.4 - Governance

A. The BHE shall have a governing body consisting of members who singularly or collectively have professional or lived experience sufficient to oversee the types of endorsements, services, and number of physical locations included in the BHE's license.

B. The governing body shall meet at regularly stated intervals at least four (4) times per calendar year and maintain records of the meetings.

C. The governing body shall be responsible for high-level strategy, oversight, and accountability. If the BHE has a board of directors as its governing body, the board of directors may delegate operations and management responsibilities to an executive hired by the board who shall at the executive's discretion delegate specific operations and management responsibilities including those in this part 2.4.C to an executive leadership team. These responsibilities include:

1. Ensuring the planning and organization of day-to-day operations.

2. Defining, in writing, the scope of services provided by the BHE, including services provided through arrangements with, or referrals to, other health care service providers.

3. Ensuring the provision of facilities, personnel, and services in compliance with applicable endorsement-specific standards found in Chapters 3 through 10 of these rules.

4. Establishing organizational structures that clearly delineate personnel positions, lines of authority, and supervision.

5. Ensuring all services and locations operate in compliance with applicable federal, state, and local laws and regulations, including but not limited to the rehabilitation act of 1973, 29 U.S.C. § 794, and the Americans with Disabilities Act, 42 U.S.C. § 12101, et seq.

6. Ensuring professionally ethical conduct on the part of all personnel providing services, whether paid, contracted, or volunteer, and ensuring a system is in place to implement corrective measures when needed and monitor such system.

7. Developing and implementing a quality management program in compliance with the requirements of part 2.17 of this Chapter, taking into account each endorsement's services and any significant differences in individual populations served.

8. Ensuring emergency preparedness for the BHE, in accordance with part 2.4.F of this Chapter.

9. Establishing and maintaining a system of financial management and accountability for the BHE.

10. Developing, implementing, and reviewing policies at a minimum once every three years or as needed in accordance with part 2.4.D of this Chapter.

11. Maintaining relationships and agreements with treatment facilities, organizations, and services to provide individual transfers, referrals, and transitions of care.

12. Ensuring all marketing, advertising, or promotional information published or otherwise distributed by the BHE is accurate, including, the services the BHE provides.

13. Considering and documenting the use of individual input in decision-making processes in accordance with part 2.4.D.3.i of this Chapter.

D. The governing body or executive leadership team if so, delegated as described in part 2.4.C shall be responsible for ensuring the development and implementation of these policies and procedures and must review any changes to policies and procedures for the BHE. The governing body or executive leadership must ensure compliance with the policy requirements in this subpart and as found elsewhere in this Chapter. Every three (3) years, the governing body or executive leadership shall review all policies and procedures.

1. The BHE must have policies regarding administrative and/or clinical oversight of the BHE's endorsements, services, and/or physical locations that meet oversight requirements. Requirements included in part 2.5.A of this Chapter, and shall include, but not be limited to:

a. 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.

b. The authority and responsibilities for each oversight position.

c. The model or framework for clinical supervision. Such model or framework may differ by endorsement, service, or setting.

d. 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.

2. At a minimum, the BHE shall have policies and procedures that address the following items:

a. Critical incident and occurrence reporting in accordance with part 2.16 of this Chapter.

b. Individual rights in accordance with part 2.7 of this Chapter.

c. Individual grievances, including dispute resolution procedures, in accordance with part 2.8 of this Chapter.

d. Infection prevention and control in accordance with part 2.4.E of this Chapter.

e. Personnel, including a code of ethics for all personnel. This also includes those policies and procedures required by part 2.5 of this Chapter, and as required by the endorsements of the BHE license. This code of ethics must be made available to individuals upon request.

f. As applicable, screening, admission, assessment/discharge, service plan, and care policies as required by parts 2.10, 2.12, and 2.13 of this Chapter.

g. As applicable, medication administration in accordance with part 2.15 of this Chapter.

h. Defining and preventing conflicts of interest and dual relationships, and where such conflicts exist, developing and implementing controls to minimize such conflict and ensure decisions are made for the best interest of the individual.

i. The use of individual input and feedback in governing body decisions, including, but not limited to:

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

(2) How the governing body will document individual input and how that feedback has been considered.

j. Individual records, including but not limited to confidentiality, access, and disposal/destruction of records as required by part 2.11 of this Chapter.

k. Building safety and security

(1) Such policies may be for the agency, an endorsement, or physical location.

(2) Policies must address the needs of the individual population being served and/or the services being provided.

(3) policies may include, but are not limited to, electronic surveillance, delayed egress, and/or locked settings as appropriate.

E. The BHE shall have infection prevention and control policies and procedures that reflect the scope and complexity of the services provided across the BHE, including but not limited to:

1. Maintenance of a sanitary environment.

2. 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 individuals and BHE personnel.

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

4. For BHEs that administer medications or injections on-site, as well as all agencies providing overnight or residential services, a requirement that at least one person trained in infection control be employed by or regularly available to the BHE.

F. The BHE shall be responsible for emergency preparedness policies and procedures, including the following:

1. Completing a risk assessment of potential 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. The governing body shall review such risk assessments annually and whenever BHE operations are modified through the addition or discontinuation of a physical location, service, or endorsement.

2. Developing and implementing a written emergency management plan addressing the hazards identified in part 2.4.F.1, above, and meeting, at a minimum, the following requirements:

a. The plan must differentiate between endorsements, physical locations, and individual populations served and meet the requirements applicable to any endorsements held by the BHE.

b. The plan must be updated based on changes in the risk assessment conducted in accordance with part 2.4.F.1 of these rules, above.

c. The plan must address interruptions in the normal supply of essentials, including, but not limited to water, food, pharmaceuticals, and personal protective equipment (PPE), if these are regularly provided or used by BHE personnel or individuals.

d. The plan must ensure continuation of necessary care to all individuals immediately following any emergency.

e. The plan must address the protection and transfer of individual information, as needed.

f. The plan must address the methods and frequency of holding routine drills to ensure BHE personnel's 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 (December 15, 2021), which is hereby incorporated by reference. No later editions or amendments are incorporated. These regulations are available at no cost at https://www.coloradosos.gov/CCR/DisplayRule.do?action=ruleinfo&ruleId=3177&deptID=17&agencyID=43&deptName=Department%20of%20Public%20Safety&agencyName=Division%20of%20Fire%20Prevention%20and%20Control&seriesNum=8%20CCR%20150. These regulations are also available for public inspection and copying at the BHA, 710 S. Ash Street, Unit C140, Denver, CO 80246, during regular business hours.

3. If the BHE has an automated external defibrillator (AED), personnel must be trained in its use, and it must be maintained in accordance with the manufacturer's specifications.

2 CCR 502-1-2.4

46 CR 23, December 10, 2023, effective 1/1/2024