Okla. Admin. Code § 450:1-9-5.4

Current through Vol. 41, No. 16, May 1, 2024

Section 450:1-9-5.4 - Core organizational standards for facilities and programs

(a)Governing Authority. With the exception of facilities certified under Chapter 16 of this Title, all facilities and programs shall have documents of authority, which shall be available to the public and ODMHSAS upon request. Documents of authority shall identify the duly constituted authority and governance structure for assuring legal responsibility and for requiring accountability for performance and operation of the facility (including all components and satellites). The documents of authority shall indicate:

(1) Eligibility criteria for governing body membership;

(2) The number and types of membership;

(3) The method of selecting members;

(4) The number of members necessary for a quorum;

(5) Attendance requirements for governing body membership;

(6) The duration of appointment or election for governing body members and officers; and

(7) The powers and duties of the governing body and its officers and committees or the authority and responsibilities of any person legally designated to function as the governing body.

(b)Organizational Description. All facilities and programs shall have a written organizational description which is approved by its governing authority. The facility or program shall make the organizational description available to staff and, upon request, to the public. The organizational description shall minimally include descriptions of:

(1) Population(s) to be served;

(2) The overall program mission statement;

(3) The goals and objectives for the program, including the goal of continued progress in providing evidence-based practices; and

(4) The specific geographic area in which services are provided for programs certified under Chapter 55 of this Title.

(c)Personnel Policies and Procedures.

(1) All facilities and programs shall have written personnel policies and procedures. With the exception of facilities certified under Chapter 16 of this Title, these policies and procedures shall be approved by the governing authority.

(2) All employees shall have access to personnel policies and procedures, as well as other rules and regulations governing the conditions of their employment.

(3) The facility or program shall develop, adopt, and maintain policies and procedures at each provider location to provide for qualified personnel during all hours of operation.

(4) There shall be job descriptions for all positions setting forth minimum qualifications and duties of each position.

(d)Utilization of Volunteers.

(1) In facilities and programs where volunteers are utilized, specific policies and procedures shall be in place to define the purpose, scope, training, supervision and operations related to the use of volunteers.

(2) There shall be documentation to verify orientation of each volunteer which shall enable him or her to have knowledge of program goals, and familiarity with routine procedures.

(3) All volunteers must receive in-service training pursuant to OAC 450:1-9-5.6(b).

(e)Information Analysis and Performance Improvement.

(1) With the exception of facilities certified under Chapter 16 of this Title, all facilities and programs shall have an ongoing information analysis and performance improvement system in order to objectively and systematically monitor, evaluate, and improve consumer outcomes and organizational performance.

(2) The system shall also address the fiscal management of the facility or program.

(3) Each facility and program shall prepare a year-end management report annually which shall include, at a minimum:

(A) An analysis of consumer outcomes and organizational processes, including:

(i) A quarterly quality consumer record review to evaluate the quality of service delivery, including:

(I) Appropriateness of services;

(II) Patterns of service utilization;

(III) Consumer involvement in service planning;

(IV) Assessment processes;

(V) Service planning procedures and compliance;

(VI) Alignment between services provided and treatment goals;

(VII) Service documentation procedures and compliance; and

(VIII) Alignment between services provided and billed service encounters.

(ii) A review of staff privileging processes;

(iii) A review of critical incidents and consumer grievances and complaints;

(iv) An assessment of service provision, including the provision of trauma-informed, co-occurring capable, culturally competent, and consumer-driven services; and

(v) Consumer satisfaction.

(B) Identified areas of improvement; and

(C) Strategies that will be implemented to address areas of improvement.

(4) The management report shall be made available to consumers, staff, the governing authority and ODMHSAS upon request.

(f)Special Populations.

(1) Under Titles 11 and 111 of the Americans with Disabilities Act of 1990, all facilities shall comply with the "Accessibility Guidelines for Buildings and Facilities (ADAAG) for alterations and new construction." State and local standards for accessibility and usability may be more stringent. Facilities shall assume responsibility for verification of all applicable requirements and comply with the most stringent standards.

(2) All facilities and programs shall have written policy and procedures for providing or arranging for services for persons who fall under the protection of the Americans with Disabilities Act of 1990 and provide documentation of compliance with applicable Federal, state, and local requirements. A recommended reference is the "Americans with Disabilities Handbook" published the in U.S. Equal Employment Opportunities Commission and the U.S. Department of Justice.

(3) All facilities shall have a policy of non-discrimination against persons with Human Immunodeficiency Virus (HIV) and persons with Acquired Immunodeficiency Syndrome (AIDS).

Okla. Admin. Code § 450:1-9-5.4

Adopted by Oklahoma Register, Volume 38, Issue 23, August 16, 2021, eff. 9/15/2021

Amended by Oklahoma Register, Volume 39, Issue 24, September 1, 2022, eff. 9/15/2022