Section 164.040 - Written Policies(A) Each Licensed or Approved Provider shall have written policies and procedures consistent with and implemented in accordance with the requirements established in 105 CMR 164.000, Department administrative guidelines, accepted standards of care for substance use disorder treatment services and applicable laws. All policies required under 105 CMR 164.000 shall be in writing, and available to staff, patients, residents and Department inspectors, and shall at a minimum address the following areas: (1) organizational structure including lines of authority, responsibility, communication, personnel practices, supervisory mechanisms for staff, and staff assignment;(2) statement of goals and objectives of the program;(3) types of services offered;(4) fiscal management including establishment and collection of fees;(5) criteria for admission, treatment, termination and discharge planning, involuntary termination, aftercare, post-discharge and follow-up, including for patients or residents who leave the program without notice;(7) prohibition of alcohol and drugs, other than those medications properly prescribed or ordered by a patient's practitioner, are prohibited on the premises.(8) confidentiality in accordance with 105 CMR 164.084;(9) security of and access to patient and resident records, and patient and resident information;(10) personnel policies, including: (a) the criteria and procedures for hiring, assigning, promoting, and suspending or dismissing a staff member;(b) the procedure for handling staff complaints and grievances;(c) prohibition of sexual harassment and procedures for handling and investigating sexual harassment complaints;(d) prohibited interactions between staff and patients or residents, and between patients or residents;(e) provisions for vacations, holidays, paternity and maternity leave, educational leave, sick leave, other leaves of absence, and fringe benefits;(f) staff member accident and safety procedures;(g) employee assistance plan;(h) restrictions on the use of tobacco products and vaping;(i) requirements of 42 CFR Part 2 (federal confidentiality regulations) and 45 CFR Parts 160, 162 and 164 (Health Insurance Portability and Accountability Act, HIPAA), where applicable;(j) annual tuberculosis screening, and testing as indicated by the results of the screening; and(k) provision of employee assistance, which shall include the following provided directly or through QSOAs:1. Confidential assessment and referral for services related to personal or professional difficulties which affect the employee's ability to perform assigned duties, including substance use disorders, gambling or other addictive behaviors, and domestic violence.2. Response for employees who experience injury or stress related to workplace incidents.3. Information about tobacco treatment programs, and encouragement of staff to utilize resources.(11) development and implementation of policies to ensure equitable access to services on a non-discriminatory basis in accordance with state and federal law;(12) when providing 24-hour diversionary services and residential services: care of patient and resident possessions, safe storage, administration and disposal of medication, handling of patient and resident mail, visits and communication;(13) transfer or referral of a patient or resident to another program or for additional services not provided by the Licensed or Approved Provider directly or through a QSOA;(14) ensuring patient safety, including adequate patient and resident oversight and periodic patient and resident safety checks;(15) behavior management;(17) staff response to patient and resident threats to harm self or others;(18) submission of mandated reports of child abuse or neglect under M.G.L. c. 119, § 51A, elder abuse under M.G.L. c. 19A, § 15, and abuse of a disabled person under M.G.L. c. 19C, § 4 and maintenance of records of any such reports made by staff;(19) staff response and reporting requirements in accordance with 105 CMR 164.035;(20) procedures for conducting internal investigations for any alleged or suspected serious incident at or under circumstances connected with the program involving the health, safety, or well-being of the patients or residents.(21) all-hazard and emergency planning and procedures;(22) employee assistance;(23) orientation and supervision of staff from contract or temporary agencies;(24) for Licensed or Approved Providers providing opioid treatment services, severe weather;(25) controlling access to records and to information pertaining to HIV/AIDS testing pursuant to M.G.L. c. 111, §70F;(26) care and treatment protocols developed in accordance with all applicable federal regulation;(27) clinical supervision of direct care staff by appropriately licensed staff qualified to deliver supervision;(28) storing, prescribing, and administering medications including methadone and buprenorphine take home medication; and(29) monitoring safe sleep conditions in client rooms as well as conducting periodic safety checks with parents and children overnight and during any napping times.(B) Standards for the content of required policies may be set by administrative requirements issued from time to time by the Department.(C) Each Licensed or Approved Provider shall ensure all policies and procedures are complied with.Amended by Mass Register Issue 1305, eff. 1/29/2016.Amended by Mass Register Issue 1482, eff. 11/11/2022.