D.C. Mun. Regs. r. 22-A6308

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

Rule 22-A6308 - GENERAL MANAGEMENT AND ADMINISTRATION STANDARDS

6308.1

Each provider shall be established as a recognized legal entity in the District of Columbia and qualified to conduct business in the District. Evidence of qualification to conduct business includes a certificate of good standing and clean hands, or an equivalent document, issued by the District of Columbia Department of Consumer and Regulatory Affairs (DCRA). Each provider shall maintain the clinical operations, policies, and procedures described in this section. These operations, policies and procedures shall be reviewed and approved by the Department during the certification survey process. Providers certified or accredited by a national body may apply for deemed status. To be considered for deemed status, a prospective provider submitting an application for certification must request "Deemed Status" on the certification application. Providers must also provide a current copy of their national accreditation certificate along with their most recent accreditation report. Deemed Status does not waive the requirement of service specific requirements and/or fiscal responsibility requirements.

6308.2

All providers shall report to the Department in a form and manner prescribed by the Department 's policy on major unusual incidents, including but not limited to abuse or neglect of client or any other event that may compromise the health, safety, or welfare of clients.

6308.3

Each provider shall:

(a) Comply with all applicable Federal and District laws and regulations; and

(b) Participate through a formal agreement with a registered Health Information Exchange ("HIE") entity of the District of Columbia Health Information Exchange ("DC HIE"), defined in Chapter 87 of Title 29 DCMR; and

6308.4

Each provider shall hire Qualified Practitioners and Credentialed Staff with the necessary qualifications to provide SUD treatment and/or RSS that meet the needs of its enrolled clients and in accordance with this chapter: Qualified Practitioners and Credentialed Staff must at all times adhere to the following:

(a) Qualified Practitioners and Credentialed Staff are individuals permitted to provide SUD services or components of SUD services in accordance with applicable service specific standards and any other applicable standards in this chapter;

(b) Qualified Practitioners are behavioral health clinicians appropriately licensed, certified, or registered in the District by the Department of Health. A Qualified Practitioner shall only render those SUD services or components of SUD services that are consistent with the scope of the Qualified Practitioner's license, certification, or registration. Applicable laws and regulations dictate whether and to what extent a Qualified Practitioner:

(1) Is subject to supervision requirements when providing SUD services; and

(2) May supervise other Qualified Practitioners or Credentialed Staff in the provision of SUD services.

(c) Credentialed Staff are non-licensed staff or staff who are not Qualified Practitioners who are permitted to render SUD services or components of SUD services pursuant to any applicable service specific supervision requirements. Credentialed Staff shall only render SUD services or components of SUD services that do not require a license, certification, or registration by the Department of Health

6308.5

Providers shall make services available a minimum five (5) days per week on a regular schedule for at least eight (8) hours per day, in the evening by appointment, and at least once a month on a Saturday for four (4) hours. An independently licensed clinician with the ability to provide and supervise the offered services must be available on-site during regular hours of operation.

6308.6

Each provider shall have a full-time program director with authority and responsibility for the administrative direction and day-to-day operation of the program(s).

6308.7

Each provider shall have a clinical director responsible for the full-time clinical direction and day-to-day delivery of clinical services provided to clients of the program(s). The clinical director must be a clinician who is licensed to practice independently in the District and supervise other clinical staff.

6308.8

The program director and clinical director shall devote adequate time and authority to perform necessary duties to ensure that service delivery is in compliance with applicable standards set forth in this chapter and in applicable policies issued by the Department. The program director and clinical director shall not be the same individual.

6308.9

Each provider shall establish and adhere to policies and procedures for selecting and hiring staff, including but not limited to requiring:

(a) Evidence of licensure, certification, or registration, as applicable and as required by the job being performed;

(b) Evidence of an appropriate degree, training program, or credentials, such as academic transcripts or a copy of degree;

(c) Evidence of all required criminal background checks, and for all non-licensed staff members, application of the criminal background check requirements contained in District Official Code §§ 44- 551et seq., Unlicensed Personnel Criminal Background Check, as well as child abuse registry checks (for both state of residence and employment);

(d) Evidence of quarterly checks that no individual is excluded from participation in a federally funded health care program as listed on the Department of Health and Human Services' "List of Excluded Individuals/Entities" the General Services Administration's "Excluded Parties List System," or any similar succeeding governmental list; and

(e) Evidence of a negative result on a tuberculosis test or medical clearance related to a positive result.

6308.10

Each provider shall establish and adhere to written job descriptions for all positions, including, at a minimum, the role, responsibilities, reporting relationships, and minimum qualifications for each position. The minimum qualifications established for each position shall be appropriate for the scope of responsibility and clinical practice (if any) described for each position.

6308.11

Each provider shall establish and adhere to policies and procedures requiring aperiodic evaluation of clinical and administrative staff performance that requires an assessment of clinical competence (if appropriate), general organizational work requirements, and key functions as described in the job description. The periodic evaluation shall also include an annual individual development plan for each staff member.

6308.12

Each provider shall establish and adhere to a supervision policy to ensure that services are provided according to this chapter and Department policies on supervision and service standards as well as District laws and regulations.

6308.13

Each provider shall establish and adhere to a training policy in accordance with § 6319 of this chapter.

6308.14

Personnel policies and procedures shall apply to all staff and volunteers working for a provider and shall include:

(a) Compliance with Federal and District equal opportunity laws, including the Americans with Disabilities Act and the D.C. Human Rights Act;

(b) A current organizational flow chart reflecting each program position and, where applicable, the relationship to the larger program or provider of which the program is a part;

(c) Written plans for developing, posting, and maintaining files pertaining to work and leave schedules, time logs, and on-call schedules for each functional unit, to ensure adequate coverage during all hours of operation;

(d) A written policy requiring that a designated individual be assigned responsibility for management and oversight of the volunteer program, if volunteers are utilized;

(e) A written policy regarding volunteer recruitment, screening, training, supervision, and dismissal for cause, if volunteers are utilized; and

(f) Provisions through which the program shall make available to staff a copy of the personnel policies and procedures.

6308.15

Providers shall develop and implement procedures that prohibit the possession, use, or distribution of controlled substances or alcohol, or any combination of them, by staff during their duty hours, unless medically prescribed and used accordingly. Staff possession, use, or distribution of controlled substances or alcohol, or any combination of them, during off duty hours that affects job performance shall also be prohibited. These policies and procedures shall ensure that the provider:

(a) Provides information about the adverse effects of the non- medical use and abuse of controlled substances and alcohol to all staff;

(b) Initiates disciplinary action for the possession, use, or distribution of controlled substances or alcohol, which occurs during duty hours or which affects job performance; and

(c) Provides information and assistance to any impaired staff member to facilitate his or her recovery.

6308.16

Individual personnel records shall be maintained for each person employed by a provider and shall include, at a minimum, the following:

(a) A current job description for each person, that is revised as needed;

(b) Evidence of a negative result on a tuberculosis test or medical clearance related to a positive result;

(c) Evidence of the education, training, and experience of the individual, and a copy of the current appropriate license, registration, or certification credentials (if any);

(d) Documentation that written personnel policies were distributed to the employee;

(e) Notices of official tour of duty: day, evening, night, or rotating shifts; payroll information; and disciplinary records;

(f) Documentation that the employee has received all health care worker immunizations recommended by the District of Columbia Department of Health; and

(g) Criminal background checks as required in § 6309.8.

6308.17

All personnel records shall be maintained during the course of an individual's employment with the program and for three (3) years following the individual's separation from the program.

6308.18

All providers shall obtain a National Provider Identification (NPI) number for themselves and all personnel performing Chapter 63 services through the provider. All providers shall register themselves and all personnel performing Chapter 63 services with the Department of Health Care Finance's designated information system prior to billing for services.

D.C. Mun. Regs. r. 22-A6308

Final Rulemaking published at 62 DCR 12056 (9/4/2015); amended by Final Rulemaking published at 67 DCR 11585 ( 10/9/2020); amended by Final Rulemaking published at 68 DCR 012400 (11/26/2021); amended by Final Rulemaking published at 69 DCR 13495 (11/4/2022)