La. Admin. Code tit. 48 § I-8531

Current through Register Vol. 50, No. 9, September 20, 2024

Section I-8531 - Governing Body

A. An ICF/DD shall have an owner or identifiable governing body with responsibility for, and authority over, the policies and activities of the ICF/DD and ultimate authority for:

1. the overall operation of the facility;

2. the adequacy and quality of care;

3. the financial solvency of the facility and the appropriate use of its funds;

4. the implementation of the standards set forth in these regulations; and

5. the adoption, implementation, and maintenance, in accordance with the requirements of state and federal laws and regulations and these licensing standards, of ICFs/DD and administrative policies governing the operation of the facility.

B. An ICF/DD shall have documents identifying the names and addresses of its owners. When an ICF/DD is owned by any type of corporation, partnership, or association it shall identify the names and address of its members and officers and shall have, where applicable, a charter, partnership agreement, articles of association, by laws, or other organizational documents.

C. An ICF/DD shall have documents identifying all members of the governing body; their addresses; their terms of membership; officers of the governing body, and terms of office of all officers, if applicable.

D. When the governing body of an ICF/DD is composed of more than one person, the governing body shall hold formal meetings at least twice a year.

E. When the governing body is composed of more than one person, an ICF/DD shall have written minutes of all formal meetings of the governing body and by-laws specifying the frequency of meetings and the quorum requirements.

F. Responsibilities of a Governing Body. The governing body of an ICF/DD shall:

1. ensure the ICF/DD's continual compliance and conformity with the ICF/DD's charter, bylaws or other organizational documents;

2. ensure the ICF/DD's continual compliance and conformity with all relevant federal, state, local and municipal laws and regulations;

3. ensure that the ICF/DD is adequately funded and fiscally sound;

4. review and approve the ICF/DD's annual budget;

5. ensure the review and approval of an annual external audit;

6. ensure that the ICF/DD is housed, maintained, staffed, and equipped appropriately considering the nature of the ICF/DD's program;

7. designate a person to act as administrator and delegate sufficient authority to this person to manage the ICF/DD;

8. formulate and annually review, in consultation with the administrator, written policies concerning the ICF/DD's philosophy, goals, current services, personnel practices, and fiscal management;

9. annually evaluate the administrator's performance;

10. have the authority to dismiss the administrator;

11. meet with designated representatives of the department whenever required to do so;

12. inform designated representatives of DHH prior to initiating any substantial changes in the program, services or physical plant of the ICF/DD; and

13. ensure statewide criminal background check on all unlicensed persons.

G. The administrator or a person authorized to act on behalf of the administrator shall be accessible to the ICF/DD staff and designated representatives of DHH at all times.

H. An ICF/DD shall have a written statement describing its philosophy and describing both long-term and short-term goals. An ICF/DD shall have a written program plan describing the services and programs offered by the ICF/DD.

I. Administrative File. An ICF/DD shall have an administrative file including:

1. articles of incorporation or certified copies thereof, if incorporated, bylaws, operating agreements, or partnership documents, if applicable;

2. documents identifying the governing body;

3. a list of members and officers of the governing body and their addresses and terms of membership, if applicable;

4. minutes of formal meetings, if applicable;

5. documentation of the ICF/DD's authority to operate under state law;

6. an organizational chart of the ICF/DD, which clearly delineates the line of authority;

7. all leases, contracts and purchase-of-service agreements to which the ICF/DD is a party;

8. insurance policies;

9. annual budgets and audit reports; and

10. copies of all Incident/Accident Reports.

J. The ICF/DD is not required to admit registered sex offenders; however, if the ICF/DD admits a registered sex offender, as described in R.S. 15:542, or current law, then the ICF/DD shall develop policies and procedures to ensure that residents, their family members, including at a minimum, their primary and secondary contact, and/or their responsible parties, any authorized representative or guardians are notified upon admission of sex offenders living in the facilities. Such policies and procedures must include provisions for addressing the safety and well-being of other residents, staff, and visitors, subject to 42 C.F.R. § 483.420, or current law. The requirement of notification shall continue for as long as the information is considered a public record.

La. Admin. Code tit. 48, § I-8531

Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 38:3190 (December 2012), Amended by the Department of Health, Bureau of Health Services Financing, LR 50397 (3/1/2024), Amended LR 50523 (4/1/2024).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and R.S. 40:2180-2180.5.