D.C. Mun. Regs. r. 22-A3006

Current through Register Vol. 71, No. 25, June 21, 2024

Rule 22-A3006 - PROGRAM MANUAL

3006.1

Each FSMHC shall have a current program manual that outlines all of its policies and procedures.

3006.2

The program manual shall, at a minimum, include, the following:

(a) A mission statement reflecting the goals and mission of the Department;

(b) The range of services to be provided, and a description of the service delivery model;

(c) Fee schedules;

(d) The population to be served;

(e) Operational schedules;

(f) Personnel policies as listed in § 3006.3;

(g) Other policies as listed in § 3006.4;

(h) Financial and record-keeping procedures;

(i) Compliance and integrity program that complies with § 3011; and

(j) Consumer rights statement that complies with the District of Columbia Mental Health Consumer Protection Act, effective December 18, 2001(D.C. Law 14-56; D.C. Official Code § 7-1231.04 ).

3006.3

Minimum personnel administration requirements include the following:

(a) Written job descriptions of all staff positions, procedures for employee hiring, evaluations, grievances, and in-service training;

(b) A minimum of one (1) hour per week of supervision for all behavioral health practitioners who deliver services with supervision, as described in § 3010.9, furnished by an independently licensed behavioral health practitioner designated as the supervisor. Supervision shall cover consumer related and other activities;

(c) An up-to-date listing of professional staff licensure information; and

(d) Written policies and procedures for emergency care.

3006.4 The program manual shall include the following policies:

(a) Admission, Waitlist, Transfer, and Discharge Policy, which describes preadmission, intake, screening, assessment, referral, transfer, and discharge procedures and inform all consumers of the right to freely choose the provider(s) from whom they will receive services;

(b) Training Policy, which incorporates a written plan for staff development and organizational onboarding, including the training and performance improvement needs of all employees working in the FSMHC;

(c) Anti-Discrimination Policy, which complies with the D.C. Human Rights Act;

(d) Billing and Payment Policy, which requires the FSMHC provider to have the necessary operational capacity to verify the eligibility for Medicaid and other third-party payers, submit Medicaid and third-party claims timely and accurately, document information on services provided, and track payments received;

(e) Care Coordination Policy, which establishes the roles and responsibilities of FSMHC staff in the coordination of care across behavioral health treatment and primary care treatment settings, especially in regards to transitions into or from more intensive levels of care or institutional settings;

(f) Clinical Records Maintenance and Storage Policy, which at a minimum meets the requirements in § 3007 of this chapter;

(g) Complaint and Grievance Policy, which establishes a well-publicized complaint and grievance system, including written policies and procedures for handling consumer, family, and practitioner complaints and grievances that conforms to the requirements in 22-A DCMR § 306;

(h) Consent to Treatment Policy, which shall establish and adhere to policies and procedures for obtaining written informed consent to treatment from consumers which comply with applicable Federal and District laws and regulations, including 22-A DCMR Chapter 1;

(i) Cultural Competence Policy, which shall define the set of values, principles, attitudes, policies and demonstrative behaviors that will enable the FSMHC to work effectively cross-culturally;

(j) Disaster Recovery Plan, which shall establish policies and procedures for maintaining the security and privacy of protected health information and data. Each plan shall also stipulate back-up and redundant systems and measures that are designed to prevent the loss of data and information and to enable the recovery of data and information lost due to disastrous events;

(k) Infection Control Policy, which shall establish policies and procedures governing infection control that comply with applicable Federal and District laws and regulations, including, but not limited to, the blood borne pathogens standard set forth in 29 CFR § 1910.1030;

(l) Interpreter Policy, which, at a minimum, requires using a professional interpreter or interpretation service including qualified sign language interpreters in order to effectively communicate with deaf consumers and those with limited English proficiency;

(m) Medication Storage and Administration Policy, which complies with applicable Federal and District laws and regulations regarding the purchasing, receipt, storage, distribution, dispensing, administering, return, and destruction of medications and require the FSMHC to maintain all medications and prescription blanks in a secured and locked area;

(n) Consumer Choice Policy, which shall establish policies and procedures governing the means by which consumers shall be informed of the full choices of FSMHC providers and other mental health service providers available;

(o) On-Call Policy, which shall require the FSMHC to adopt procedures for handling routine, urgent, and emergency situations that include referral procedures to local emergency departments and on-call arrangements for clinical staff and physicians. The policy shall describe the availability of timely access to face-to-face crisis support services, specify how the FSMHC provider will interact and coordinate services with Department-designated crisis and emergency services, and include procedures for triaging consumers who require crisis services or psychiatric hospitalization;

(p) Staff Performance Review Policy, which shall require at a minimum annual evaluations of clinical and administrative staff performance that includes an assessment of clinical competence, as well as general organizational work requirements and an assessment of key functions as described in the job description;

(q) Primary Care Provider Communication Policy, which shall establish policies and procedures governing communication with the consumer's primary care providers, including the FSMHC provider's interface with primary health care providers, managed health care plans, and other providers of mental health services. This policy shall also describe the FSMHC provider's activities which will enhance consumer access to primary health care and the coordination of mental health and primary health care services;

(r) Quality Improvement ("QI") Policy, which shall describe the objectives and scope of its QI program and require provider staff, consumer and family involvement in the QI program. The QI program shall ensure and measure the following: access and availability of services; coordination of care with behavioral health treatment and primary care treatment settings; compliance with FSMHC certification standards; adequacy, appropriateness and quality of care; efficient utilization of resources; and consumer and family satisfaction with services. The FSMHC shall submit a written report to the Department annually on the outcomes identified in the QI program.

(s) Consumer Privacy and Release of Information Policy, which shall outline how the FSMHC will protect consumer's health information and ensure compliance with the HIPAA and the MHIA. The program shall develop policies and procedures to disclose protected behavioral health information to other certified providers, primary health care providers, and other health care organizations when necessary to coordinate the care and treatment of its consumers. These procedures shall include participation in the DC Health Information Exchange (DC HIE) pursuant to the requirements set forth in § 3008.2. The program shall advise each consumer of the program's notice of privacy practices that authorizes this disclosure to other providers and shall afford the consumer the opportunity to opt-out of that disclosure in accord with the MHIA. The program shall document the individual's decision;

(t) Supervision and Peer Review Policy, which shall meet the requirements of § 3006.3(b) and require personnel files of clinical staff working under supervision to contain evidence that the Supervision Policy is observed;

(u) Bullying Prevention Policy, which conforms to the requirements of 4 DCMR Chapter 15; and

(v) Plan of Care Policy, which shall adhere to § 3009 of this chapter and follow best industry practices.

3006.5

The Department shall review and approve each FSMHC provider's policies during the certification process. The FSMHC provider shall submit any policies that have been revised to the Department for review and approval during recertification.

D.C. Mun. Regs. r. 22-A3006

Final Rulemaking published at 67 DCR 11929 (10/16/2020)