La. Admin. Code tit. 48 § I-8905

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

Section I-8905 - Organization and Administration

A. General Requirements

1. A provider shall allow designated representatives of DSS in the performance of their mandated duties to inspect all aspects of a provider's functioning which impact on clients and to interview any staff member or client (if the client agrees to said interview).

2. A provider shall make any information which the Provider is required to have under the present requirements and any information reasonably related to assessment of compliance with these requirements available to DSS.

B. Governing Body

1. A provider shall have an identifiable governing body with responsibility for and authority over the policies and activities of the program/agency.

2. A provider shall have documents identifying all officers and members of the governing body, their addresses, and terms of membership.

3. When the governing body of a provider is comprised of more than one person, the governing body shall hold formal meetings at least twice a year.

4. When the governing body is composed of more than one person, a provider shall have written minutes of all formal meetings of the governing body and by-laws specifying frequency of meetings and quorum requirements.

C. Responsibilities of a Governing Body. The governing body of a provider shall:

1. ensure the provider's compliance and conformity with the provider's charter;

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

3. ensure that the provider is adequately funded and fiscally sound;

4. review and approve the provider's annual budget;

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

6. designate a person to act as chief administrator and delegate sufficient authority to this person to manage the provider agency;

7. formulate and annually review, in consultation with the chief administrator, written policies concerning the provider's philosophy, goals, current services, personnel practices, job descriptions and fiscal management;

8. annually evaluate the chief administrator's performance;

9. have the authority to dismiss the chief administrator;

10. meet with designated representatives of DSS whenever required to do so;

11. inform designated representatives of DSS prior to initiating any substantial changes in the services provided by the provider.

D. Accessibility of Executive. The chief administrator or a person authorized to act on behalf of the chief administrator shall be accessible to staff and designated representatives of DSS at all times.

E. Documentation of Authority to Operate. A private provider shall have documentation of its authority to operate under state law.

F. Administrative File. A provider shall have an administrative file including:

1. documents identifying the governing body;

2. list of members and officers of the governing body and their addresses and terms of membership;

3. minutes of formal meetings and by-laws of the governing body, if applicable;

4. documentation of the provider's authority to operate under state law;

5. organizational chart of the provider;

6. all leases, contracts and purchase-of-service agreements to which the provider is a party;

7. insurance policies: every provider shall maintain in force at all times a comprehensive general liability insurance policy. this policy shall be in addition to any professional liability policies maintained by the provider and shall extend coverage to any staff member who provides transportation for any client in the course and scope of his/her employment;

8. annual budgets and audit reports;

9. master list of all contractors used by the provider.

G. Accounting

1. A provider shall establish a system of business management and staffing to assure maintenance of complete and accurate accounts, books and records, in keeping with generally accepted accounting principles.

2. A provider shall demonstrate fiscal accountability through regular recording of its finances and annual external audit.

3. A provider shall not permit public funds to be paid, or committed to be paid, to any person or organization to which any of the members of the governing body, administrative personnel, or members of the immediate families of members of the governing body or administrative personnel have any direct or indirect financial relationship or interest, or in which any of these persons serve as an officer or employee, unless the services or goods involved are provided at a competitive cost or under terms favorable to the provider. The provider shall have a written disclosure of any financial transaction between the provider and other business entities in which a member of the governing body, administrative personnel, or his/her immediate family is involved.

H. Confidentiality and Security of Files

1. A provider shall have written procedures for the maintenance, security, and confidentiality of records. This shall include specifying who shall supervise the maintenance of records, and who shall have custody of records. This procedure shall also state to whom records can be released and the procedure for doing so. Records, including client as well as administrative, shall be the property of the provider and the provider, as custodian, shall secure records against loss, tampering, or unauthorized use.

2. Staff members of the provider shall not disclose or knowingly permit the disclosure of any information concerning the agency, the clients or his/her family, directly or indirectly, to any unauthorized person.

3. When the client is of majority age and noninterdicted, a Provider shall obtain the client's written, informed permission prior to releasing any information from which the client or his/her family might be identified.

4. When a client is a minor or is interdicted, a provider shall obtain written, informed consent from the legally responsible person prior to releasing any information from which the client or his/her family might be identified.

5. A provider shall, upon written authorization from the client or his legal representative, make available information in the case record to the client, his counsel, or the client's legally responsible person. If, the provider reasonably concludes that knowledge of the information contained in the record would be injurious to the health or welfare of the client, or could reasonably be expected to endanger the life or safety of any other person, that provider may deny access to the record. The provider may charge a reasonable fee for copying the records.

6. A provider may use material from case records for teaching or research purposes, development of the governing body's understanding and knowledge of the provider's services, or similar educational purposes, provided that names are deleted and other similar identifying information is disguised or deleted.

7. A provider shall not release a personnel file without the staff member's written permission except in accordance with state law.

I. Records - Administrative and Client

1. A provider shall ensure that all entries in records are legible, signed by the person making the entry and accompanied by the date on which the entry was made.

2. All records shall be maintained in an accessible, standardized order and format and shall be retained and disposed of in accordance with state laws and requirements of the funding sources.

3. A provider shall have sufficient space, facilities and supplies for providing effective record keeping services.

4. A provider shall have a written record for each client which shall include:

a. The name, sex, race, birth date of the client, home address, address of crisis location.

b. Other identification data including court status and/or legal status, name of parent or legal guardian, as appropriate.

c. The names, addresses and phone numbers of other persons or providers involved with the client's plan/case. This shall include the client's physician.

d. A provider shall document:

i. client's presenting problem, any known DSM IV diagnosis and medications;

ii. any other known serious health condition and medication.

e. information and documentation of interventions used and case disposition, including progress notes as required in 8907.D.1.b.

f. information and documentation concerning any injuries (regardless of cause), any violations of client safeguards, any suspected incidents of abuse/mistreatment/neglect, or any client grievances.

5. A provider shall have a written record for each staff member which includes:

a. the application for employment and/or resume's;

b. references (three);

c. any required medical examinations;

d. all required documentation of appropriate status which includes:

i. valid driver's license for operating provider vehicles or transporting clients;

ii. professional credentials/certification required to hold the position.

e. periodic, at least annual, performance evaluations;

f. staff member's starting and termination dates along with salary paid;

g. staff member shall have reasonable access to his/her file and shall be allowed to add any written statement he/she wishes to make to the file at any time;

h. documentation of criminal records check;

i. any reports or internal investigations concerning the staff member's involvement in any suspected abuse/mistreatment/neglect, violation of client safeguards, or violation of client rights.

La. Admin. Code tit. 48, § I-8905

Promulgated by Department of Social Services, Office of the Secretary, LR 21:1262 (November 1995).

AUTHORITY NOTE: Promulgated in accordance with R.S. 46:51.