16 Del. Admin. Code § 6001-II-5.0

Current through Register Vol. 28, No. 7, January 1, 2025

Section 6001-II-5.0 - Standards Applicable to all Facilities and Programs

5.1 Governance

5.1.1 Governing Body/Advisory Council.

5.1.1.1 Every community-based agency shall have a governing body and/or advisory council that includes representatives of the population it serves.

5.1.1.2 The governing body shall be legally responsible for overseeing all management and operations of the agency and for ensuring compliance with applicable laws and regulations by approving all of the agency's staffing, documentation and overall operations:

5.1.1.2.1 Written by-laws;

5.1.1.2.2 Mission;

5.1.1.2.3 Goals;

5.1.1.2.4 Policies and Procedures; and

5.1.1.2.5 Budget.

5.1.1.3 The authority and duties of the governing body shall include:

5.1.1.3.1 Ensuring that the agency director, program directors, clinical supervisors and Counselors employed by the agency meet the requirements of §6.1 of these regulations.

5.1.1.3.2 Establishing and reviewing:

5.1.1.3.2.1 Policies and procedures governing the overall management of the program including:

5.1.1.3.2.1.1 Policies and procedures manual; (§5.1.4),

5.1.1.3.2.1.2 Fiscal management policies and procedures; (§5.1.5),

5.1.1.3.2.1.3 Personnel policies and procedures; (§5.1.6.2), and

5.1.1.3.2.1.4 Compliance with these regulations.

5.1.1.4 The Governing Body will meet, at a minimum, one (1) time per year. Documentation of its annual review shall be entered into the minutes of its meeting.

5.1.2 Meetings and minutes of meetings.

5.1.2.1 Minutes of all meetings shall include:

5.1.2.1.1 Names of members who attended;

5.1.2.1.2 Names of members absent;

5.1.2.1.3 Date of meeting;

5.1.2.1.4 Topics discussed and decisions reached.

5.1.2.2 The minutes shall be available for review by the Division.

5.1.3 Administrative Staff

5.1.3.1 Administrator

5.1.3.1.1 The governing body shall appoint an agency director.

5.1.3.1.2 The qualifications, authority, and duties of the agency director shall be defined in writing.

5.1.3.1.3 The Governing body shall ensure that, at the time of employment, the agency director is familiar with the job description and job responsibilities of the position, these regulations, and the agency's policies and procedures as maintained in compliance with §5.1.4.

5.1.4 Policies and procedures manual:

5.1.4.1 Each program shall have a manual of written policies from which written procedures have been derived to address operations and services. The program's policies and procedures manual shall be:

5.1.4.1.1 A complete document;

5.1.4.1.2 Readily available to staff.

5.1.4.2 The program's policies and procedures manual shall be reviewed at least annually by the governing body or its designee.

5.1.4.3 The review shall be documented in the meeting minutes.

5.1.4.4 The manual shall include:

5.1.4.4.1 A statement of program philosophy and goals, including:

5.1.4.4.1.1 Geographical area to be served;

5.1.4.4.1.2 Population to be served;

5.1.4.4.1.3 Types of services offered;

5.1.4.4.1.4 Organization chart,

5.1.4.4.1.5 Policies and procedures to ensure compliance with §5.1.5, Fiscal management;

5.1.4.4.1.6 Personnel files

5.1.4.4.1.7 The intake procedures

5.1.4.4.1.8 The diagnostic assessment procedure established program director in compliance with §8.1.2.1.7.

5.1.4.4.1.9 Referral criteria policies and procedures.

5.1.4.4.1.10 Admission criteria policies and procedures;

5.1.4.4.1.11 Discharge criteria policies and procedures that specify conditions under which clients may be involuntarily discharged, including client behavior that constitutes grounds for discharge by the program.

5.1.4.4.1.12 Established procedures consistent with 42 CFR § 2.12(c)(5) and HIPAA 45 CFR parts 160 and 164 that staff shall follow when discharging a client involved in the commission of a crime on the premises of the program or against its staff, including designation of the person who shall make a report to the appropriate law enforcement program;

5.1.4.4.1.13 Established procedures consistent with 42 CFR Part 2 and HIPAA 45 CFR parts 160 and 164 that staff shall follow when a client leaves against medical or staff advice and the client may be dangerous to self or others;

5.1.4.4.1.14 Confidentiality policy and procedures that comply with 42 CFR Part 2 and HIPAA 45 CFR parts 160 and 164;

5.1.4.4.1.15 Policies and procedures in regard to completion and utilization of all forms used by the program;

5.1.4.4.1.16 Policies and procedures for making mandated reports of suspected child abuse or neglect in compliance with 16Del.C.§§ 902 through 904, 3910, 1132, 2224, 5194 and 42 CFR § 2.12(c)(6) (including non-retaliation policies when personnel report abuse and neglect.);

5.1.4.4.1.17 Policies and procedures for communicating with law enforcement personnel when a client commits or threatens to commit a crime on program premises or against program personnel, in compliance with 42 CFR § 2.12(c)(5) and HIPAA 45 CFR parts 160 and 164;

5.1.4.4.1.18 Policies and procedures for mandated reporting of infectious or contagious diseases, in compliance with state law and 42 CFR Part 2 and HIPAA 45 CFR Parts 160 and 164;

5.1.4.4.1.19 Medication policies and procedures, in compliance with the Delaware State Boards of Medical Practice, Nursing, and Pharmacy;

5.1.4.4.1.20 Policies and procedures, as applicable, for the collection of urine specimens;

5.1.4.4.1.21 Policies and procedures for responding to medical emergencies;

5.1.4.4.1.22 Policies and procedures regarding clients' rights

5.1.4.4.1.23 Code of ethics; and

5.1.4.4.1.24 Policies and procedures for reporting any violations of law or codes of ethics to the appropriate certification and/or licensure boards.

5.1.5 Fiscal management policies and procedures and record keeping

5.1.5.1 Each program shall establish written policies and procedures regarding fiscal management that shall be maintained in compliance with generally accepted accounting principles.

5.1.6 Personnel policies and procedures.

5.1.6.1 Each program shall develop and maintain a written personnel manual that shall include:

5.1.6.1.1 Staff rules of conduct consistent with due process including:

5.1.6.1.1.1.1 Examples of conduct that constitute grounds for disciplinary action;

5.1.6.1.1.1.2 Examples of unacceptable performance that constitute grounds for disciplinary action;

5.1.6.1.1.1.3 Policies and procedures on mental health, and alcohol and drug abuse problems of staff (including staff member assistance policies and procedures);

5.1.6.1.2 Safety and health of staff, including:

5.1.6.1.3 Rules about any required medical examinations and rules about communicable diseases that could affect the health or safety of the program's clients or staff.

5.1.6.2 Each agency shall maintain a separate personnel file for each staff member in a manner that ensures the privacy of agency staff.

5.1.6.3 The personnel file shall include at a minimum:

5.1.6.3.1 the name and telephone number of a person the agency can contact in an emergency;

5.1.6.3.2 The current job title and job description signed by the staff member;

5.1.6.3.3 Either:

5.1.6.3.3.1 an application for employment signed by the staff member; or

5.1.6.3.3.2 a resume;

5.1.6.3.4 A copy of the staff member's license and/or current alcohol or other drug cCounselor certification and/or Co-Occurring Counselor's certification.

5.1.6.3.5 The results of reference investigations and verification of experience, training and education, including:

5.1.6.3.5.1 primary source verification of the staff member's educational degree certificate(s), based on job description;

5.1.6.3.5.2 primary source verification of the staff member's license(s), and/or certification(s), as applicable, based on job description;

5.1.6.3.5.3 A statement signed by the staff member acknowledging that s/he understands the requirements of 42 USC § 290dd-2, 42 CFR Part 2 and HIPAA 45 CFR parts 160 and 164;

5.1.6.3.5.4 Documentation of the staff member's annual written performance evaluation;

5.1.6.3.5.4.1 Any disciplinary actions taken against the staff member;

5.1.6.3.5.4.2 Formal corrective action taken, that:

5.1.6.3.5.4.2.1 The staff member has signed;

5.1.6.3.5.4.2.2 His/her immediate supervisor has signed;

5.1.6.3.5.5 A copy of the staff member's training plan, as required in §5.1.7.1;

5.1.6.3.5.6 Documentation of the staff member's abilities to provide culturally competent services; and

5.1.6.3.5.7 Documentation of in-service training and continuing education as required by §5.1.7.

5.1.6.4 Counselor II's personnel files shall also include:

5.1.6.4.1 Documentation that the Counselor II is working toward meeting the requirements of §6.1.5; and

5.1.6.4.2 Documentation of Supervision as required in §12.2.4.

5.1.6.5 Records documenting all required staff member health clearances, including any medical test results required by agency policy shall be made available to the Division upon request.

5.1.7 Staff training and development

5.1.7.1 Each program shall establish a written staff training and development plan. The plan shall include:

5.1.7.1.1 An orientation curriculum, that will ensure that all staff are familiar with the agency policies and procedures, and have a working knowledge of at least the following:

5.1.7.1.1.1 Personnel policies and procedures, regarding the health and safety of staff, established in compliance with §5.1.6.1.2;

5.1.7.1.1.2 Program policies and procedures regarding the reporting of cases of suspected child abuse or neglect in compliance with 16Del.C.§§ 902 through 904, 910, 1132, 2224, 5194 and42 CFR § 2.12(c)(6), including non-retaliation policies when personnel report abuse andneglect;

5.1.7.1.1.3 Program policies and procedures regarding client's rights established in compliance with §7.1, as applicable;

5.1.7.1.1.4 Instruction and training in the elements of the fire plan in compliance with §9.2;

5.1.7.1.1.5 Program policies and procedures regarding the obligation to report violations of law and applicable codes of ethics to the appropriate certification and/or licensure boards, established in compliance with §5.1.4.4.1.24.

5.1.7.1.1.6 Program policies and procedure regarding the training of all staff regarding culturally competent practices.

5.1.7.2 Programs shall annually establish an individual training plan for each staff member based on the staff member's skill level, education, experience, current job functions, and job performance.

5.1.7.3 Programs providing co-occurring services shall include training and education specific to co-occurring disorders in the training plan for each staff member, based on the staff member's skill level, education and experience, job functions and job performance.

5.1.7.4 Clinical supervisors and all staff providing counseling services to clients shall complete at least twenty (20) hours of training annually, including:

5.1.7.4.1 Ten (10) hours specific to training and education in the treatment of alcohol and other drugs of abus.

5.1.7.4.1.1 When providing co-occurring services the ten (10) hours of training will be a combination of substance use disorders as well as mental health disorders.

5.1.7.4.2 Three (3) hours specific to training and education in providing culturally competence services every two years; and

5.1.7.4.3 Three (3) hours of training specific to ethics training and education every two years.

5.1.7.5 Adjunctive and Alternative Therapies

5.1.7.5.1 Every program utilizing any modalities of adjunct or alternative therapy shall ensure:

5.1.7.5.1.1 Adjunctive or alternative therapies are approved by the program director or designee prior to utilization;

5.1.7.5.1.2 iIndividuals providing the services of Adjunctive or alternative therapies have received specific training and/or credentials applicable to each modality.

5.1.7.6 All staff, trainees and volunteers shall receive training within the first year of employment about:

5.1.7.6.1 Hepatitis;

5.1.7.6.2 HIV/AIDS;

5.1.7.6.3 Tuberculosis;

5.1.7.6.4 Other sexually transmitted diseases;

5.1.7.6.5 Infectious Control.

5.1.8 Quality Assurance

5.1.8.1 Every agency shall have a written quality assurance plan.

5.1.8.2 The plan shall be reviewed and revised annually.

5.1.8.3 The quality assurance plan shall provide for the review of:

5.1.8.3.1 Clinical services to include:

5.1.8.3.1.1 The provision of culturally competent services including:

5.1.8.3.1.1.1 An annual self assessment that focuses on the needs of the community which the agency serves;

5.1.8.3.2 Professional services;

5.1.8.3.3 Administrative services;

5.1.8.3.4 Infection Control; and

5.1.8.3.5 Environment of Care.

5.1.8.4 The results of quality assurance review shall document:

5.1.8.4.1 The problem(s) identified;

5.1.8.4.2 The recommendations made;

5.1.8.4.3 The action(s) taken;

5.1.8.4.4 The individual(s) responsible for implementation of actions; and

5.1.8.4.5 Any follow-up.

5.1.8.5 Every agency shall develop and implement performance indicators and assess outcome measures.

5.1.8.6 Every program shall provide a mechanism to collect opinions from service recipients, personne and other stakeholders regarding the quality of service provided. Information shall be submitted to the appropriate committee for quality assurance review.

5.1.8.7 Every program shall conduct a needs assessment at a minimum of every five (5) years. The results of the needs assessment should determine staffing patterns and types of services to be provided with changes and updates recorded as part of the agency's quality assurance plan.

16 Del. Admin. Code § 6001-II-5.0

14 DE Reg. 471 (11/01/10)