(a) Program Reporting Requirements. - (i) The program shall notify the Division in writing thirty (30) days prior to any proposed change in location, name, ownership, control of the facility, if the director of a program leaves or is put on administrative leave, or closure of a program. If there are circumstances that prevent this notice, notify the Division within one (1) business day of such changes with an explanation of the reason for the change.
- (ii) If there is a change or transfer in ownership, the new owner(s) or controlling parties shall file an application for certification thirty (30) days prior to taking control. The application will be reviewed for completeness. If the application is complete, and a site visit finds that the minimum requirements are met, a six (6) month provisional certificate will be issued. If the application is not complete, it will be returned to the applicant to address such deficiencies noted. A provisional certificate will only be issued once the application is complete and approved and a site visit is conducted verifying minimum standards.
- (iii) Any notice of hearing order or decision, which the Division issues to a facility prior to a transfer of ownership, shall be effective against the former owner or controlling party to such transfer, and, where appropriate, the new owner following such transfer unless said notice, order, or decision is modified or dismissed by the Division.
- (iv) No program certification shall be transferable from one owner to another or from one facility to another. The program shall immediately notify the Division if the program is closing, including a plan to transfer clients to other services as indicated.
- (v) The program shall immediately notify the Division electronically, by email or fax, of a client or staff death where death occurs on-site. The program shall notify the decedent's family or next of kin as soon as possible. The program shall have written policies describing how critical incidents are handled and reviewed, including notification to the Division. The Division shall establish policies and procedures to ensure that in the case of a client or staff death that occurs on-site, the case is properly evaluated, documented, acknowledged, and handled in an appropriate manner.
- (vi) The program shall notify the Division within one (1) business day of a critical fire, accident, or other incident resulting in the interruption of services at the location. The program shall have written policies describing how critical incidents are handled and reviewed, including notification to the Division. The Division shall establish policies and procedures to ensure that in the case of a critical incident that occurs on-site the case is properly evaluated, documented, acknowledged, and handled in an appropriate manner.
- (vii) Legal proceedings. Every program shall report, in writing, to the Division any civil award against a program or any person while employed by the program which relates to the delivery of the service or which may impact the continued operation of the facility. In addition, every program shall report any felony conviction against the program or any person while employed by the program. The report shall be given to the Division within ten (10) calendar days of receipt of the conviction.
(b) Governing Board Protocols. - (i) The governing authority or legal owner of a program has the primary responsibility to create and maintain the organization's core values and mission via a well-defined annual plan. It assumes final authority over and responsibility for the accountability of all programs. The authority ensures compliance with applicable legal and regulatory requirements. It advocates for needed resources to carry out the mission of the organization and provides guidance to the management to ensure the success of day to day operations.
- (ii) Each program shall have a governing body or other responsible person who is accountable for the development of policies and procedures to guide the daily operations. If a program is governed by a board of directors, minutes and records of all board of directors meetings shall be documented in accordance with the organizational by-laws. The governing board shall meet at a minimum quarterly. The program shall document that the program administrator has reported to the governing body or its designated representative at least one (1) time per quarter.
- (iii) Each program shall keep, maintain, and make available to any employee or client an organizational chart and written policies that describe the organizational structure, including lines of authority, responsibility, communication, and staff assignments.
- (iv) Each program will have a plan that monitors operations in the areas of organization, human resource, fiscal and services provided.
(c) Client Rights. - (i) Each program shall establish a written policy stating that the service will comply with the client rights requirements as specified in this section.
- (ii) Each program shall establish written policies and procedures ensuring that services will be available and accessible where no person will be denied service or discriminated against on the basis of sex, race, color, creed, sexual orientation, handicap, or age, in accordance with Title VI of the Civil Rights Act of 1964, as amended, 42 USC 2000 d, Title XI of the Education Amendments of 1972, 20 USC 1681 - 1686 and s. 504 of the Rehabilitation Act of 1973, as amended, 29 USC 794, and the Americans with Disabilities Act of 1990, as amended, 42 USC 12101 - 12213. Each program shall have policies that assure availability and accessibility for all persons regardless of cultural background, criminal history, drug of choice, and medical status among other factors. However, each program may impose reasonable programmatic restrictions that are intended to support therapeutic goals of the program, meet restrictions of government grants or funding, or required by limitations of the program to provide services specific to a person. Program staff shall receive training on these issues and they shall be documented in the personnel record.
(d) Emergency Procedure Requirements. - (i) During the hours services are provided, there shall be a plan for immediate access to first aid and emergency medical services. Residential programs must have at least one (1) trained staff in first aid and Cardio Pulmonary Resuscitation (CPR) on-site twenty four (24) hours, seven (7) days a week.
- (ii) All programs shall have a written plan for emergency services to include potential emergencies, such as: fires, bomb threats, natural disasters, utility failures, medical emergencies, and safety during violent or other threatening situations. The plan will detail the protocols that will be followed in each situation, the chain of command, and the protocols for contacting emergency services. Documentation of staff training in emergency services is required and shall be documented in the personnel record.
(e) Tobacco Free Protocols. - (i) Use of all tobacco products, secondhand smoke, and tobacco litter must be prohibited throughout the entire facility, with no exceptions, including all indoor facilities, building entrances, offices, hallways, waiting rooms, restrooms, elevators, meeting rooms, and community areas under the control of the facility. An ashtray with a sign indicating that this is a no smoking area is permitted to allow for a person to extinguish a tobacco product safely. A treatment facility may designate out-of-doors smoking areas, so long as they are not in building entrances or other areas that permit contamination of occupied areas by secondhand smoke or tobacco litter. This policy applies to all employees, clients, contractors, and visitors.
- (ii) The program shall offer tobacco cessation programs either on-site or through referral, for both clients and staff.
(f) Legal Requirements. - (i) The program shall ensure that all its program(s), facilities, and services comply with all applicable federal, state, and local laws, regulations, codes and ordinances.
- (ii) The program will obtain a local business license from the city or county if required.
- (iii) Each program shall have general liability insurance including, physical, civil and professional insurance in an amount deemed sufficient by its owners or governing body when applicable. Programs providing prevention services do not have to carry liability insurance if no direct services are being provided. Funded providers with Governing Boards must carry governing board insurance in an amount deemed sufficient by its governing body.