Rule 111-8-19-.09 - Administration(1) Program Purpose. A licensed program shall develop and implement written policies and procedures that specify its philosophy, purpose, and program orientation. Such policies and procedures shall identify the types of drug abusers and the ages of the clients that it serves, including referral sources. When the program serves persons with special needs, the description shall explain how these special needs will be met.(2) Program Operations. A licensed program shall develop and implement written policies and procedures for operations to include: (a) A description of the range of treatment and services provided by the program to be reviewed annually and updated as needed, specifying which American Society of Addiction Medicine (ASAM) levels of care will be offered, what services will be provided directly by the program, and what services are provided in cooperation with available community or contract resources;(b) The process for intake, assessment, admission, treatment planning, and evaluation of treatment;(c) Discharge summaries and aftercare plans;(d) The protection of client's rights and confidentiality of client records;(e) The appropriate use of behavior management and emergency safety interventions; and(f) When the program administers medications, policies and procedures related to medication administration.(3) Administrator. The governing body of the program shall designate an administrator who shall be authorized to manage the program. The clinical director may serve as the administrator.(4) Clinical Director. The governing body of the program shall designate a clinical director who is responsible for all treatment services provided.(5) Finances. The governing body shall provide for the preparation of an annual budget and approve such budget. Copies of the current year's budget and expenditure records shall be maintained for examination and review by the department.(a) The administrator and all persons authorized to receive and disburse operating funds shall be authorized by the governing body to do so.(b) The program shall develop and implement a written schedule of client fees. The schedule shall identify all fees which are chargeable to clients and a copy of the schedule shall be provided to the client, or parent, or guardian, or responsible party upon request, during the admission process and subsequently upon request.(c) A financial audit shall be completed annually by a certified public accountant or other qualified audit approved by the governing body.(6) Client Records. A written record of each client assessed and each client admitted to the program must be maintained by the program. (a) Contents. Each client record shall include all information necessary to monitor the client's condition and contain at least the following information:1. Basic identifying information including name, address, telephone number, date of birth, sex, and race;2. If applicable, the names, addresses, and telephone numbers of parents, or guardians, or responsible parties;3. Persons to notify in case of an emergency if different from above;4. The name of the client's attending physician, if any;5. All records of screening and assessment, including a comprehensive psychosocial history;6. If applicable, documentation of why the client was not admitted for treatment and suggested referrals given to client;7. Written consent as required in rule .13(c)1.;8. Documentation of orientation as required in rule .13(c)2.;9. Rights of the client (State and Federal) including confidentiality and signed by the client;10. Individualized treatment plan and treatment notes (including drug administration records if applicable);11. Results of laboratory tests, as appropriate;12. Discharge summary and aftercare plan;13. Any other records relating to the client's treatment and stay in the program such as written grievances, reports about discipline to include any use of emergency safety interventions if an incident resulting in injury occurs while the patient is at the program location, observations, etc.(b) Confidentiality and Retention of Client Records. Written policies and procedures shall be established and implemented for the maintenance and security of client records specifying who shall supervise the maintenance of such records, who shall have custody of such records, and to whom records may be released, how they may be released and for what purposes they may be released. The department shall have access to all client clinical records for the purpose of determining compliance with licensure requirements. Confidentiality, release, and retention of client records must comply with 42 CFR, Part 2 Confidentiality of Alcohol and Drug Abuse Patient Records.(7) Personnel Records. A program shall maintain written records for each employee and the administrator. Each individual file shall include:(a) Identifying information such as name, address, telephone number, emergency contact person(s);(b) A ten year employment history or a complete employment history if the person has not worked ten years;(c) Records of applicable licenses, health requirements, and educational qualifications as required by these rules;(e) The person's job description or statements of the person's duties and responsibilities;(f) Documentation of training and orientation required by these rules;(g) Any records relevant to the employee's performance including at least annual performance evaluations; and(h) The results of employment and criminal background checks conducted by the program prior to employment indicating that the employee has no history of violence or abuse which would pose a risk to clients receiving services through the treatment program.(8) Emergency Services. During non-operating hours, the program must make provisions for 24 hour emergency services or a telephone "hot line" to assist a client in a crisis situation. This information must be provided to the client upon admission.(9) HIV/AIDS. A licensed program shall provide HIV/AIDS education, risk assessment and the provision of HIV counseling and testing, either directly or by referral.(10) Priority Access. Written policies and procedures must be developed for providing priority in access to services and admissions to programs for drug dependent pregnant females.(11) Drug-free work place. Written policies and procedures shall be established and implemented to provide for a drug-free work place. Pre-employment and ongoing random urine drug screens shall be utilized for all program employees. Each sample collected shall be screened for opiates, methadone, amphetamines, cocaine, benzodiazepines, THC and other drugs either as indicated by the department or the employer.(12) Referral to Other Programs. Each program shall have a formal plan of cooperation with other programs in the state for referral of clients to allow for continuity of care for drug dependent persons or for emergency hospitalization. The licensed programs must have identified resources that would be available to continue the drug dependent person's care and to have worked out referral/transfer arrangements where appropriate.(13) Reporting. Written summary reports shall be made to the department, in a form acceptable to the department within 24 hours (with a detailed investigative report to follow in five work days if not provided initially) regarding serious occurrences involving clients that happened either at the facility or were connected with the care that the client received at the facility, such as accidents or injuries requiring medical treatment and/or hospitalization; death; emergency safety interventions resulting in any injury requiring medical treatment beyond first aid; or any incident which results in any federal, state, or private legal action by or against the facility which affects any child or the conduct of the facility. However, legal action involving the juvenile justice system is not required to be reported.(14) Child Abuse Reports. Whenever the program has reason to believe that a client who is a minor in care has been subjected to child abuse it shall cause a report of such abuse to be made to the child welfare agency providing protective services as designated by the Department of Human Services (Division of Family and Children Services) or in the absence of such an agency to an appropriate police authority or district attorney in accordance with the requirements of O.C.G.A. Sec. 19-7-5. A copy of such report shall also be filed with the department.Ga. Comp. R. & Regs. R. 111-8-19-.09
O.C.G.A. §§ 19-7-5, 26-5-5, 26-5-6.
Original Rule entitled "Administration" adopted. F. Sep. 9, 2013; eff. Sept. 29, 2013