10-144-129 Me. Code R. § 5

Current through 2024-51, December 18, 2024

Section 144-129-5 - QUALITY MEASURES

A.OPERATIONS MANUAL.

1. The agency must have a manual that includes, at a minimum, the following:

a. An organizational diagram delineating the lines of responsibility and accountability;

b. Job descriptions for all positions within the agency;

c. A description of the orientation program, including but not limited to mandated reporting requirements;

d. Policies and procedures on topics, including but not limited to those in subsections (i)-(xvii) below. Policies and procedures on topics that are addressed by this rule or by statutes applicable to the agency must comply with the relevant law.

i. Infection control in the office and in private homes;

ii. A policy for seeking a referral/reassessment when a client may require higher level of care;

iii. Verification of qualifications prior to employment;

iv. Confidentiality of records and services, including transportation and storage of records;

v. Completion of screening of owners and employees, including determination of eligibility for employment;

vi. In-service training, including confidentiality and service planning for clients;

vii. Performance management, including disciplinary measures and annual performance reviews;

viii. Supervision of staff, including staff absences/call outs and smoking, alcohol, or illegal drug use while providing client care;

ix. Ethical business relationships with clients, including a restriction on the acceptance of gratuities, loans, and/or gifts from clients and family members;

x. Client referrals;

xi. Client service plans, including documentation of services provided and emergency procedures related to the client;

xii. Grievance procedures;

xiii. Reporting and investigation of allegations of abuse, neglect, or misappropriation of client property;

xiv. Discontinuing of services, including involuntary discharge;

xv. Contingency planning, including agency closure;

xvi. Client and business record retention while operating and after closure; and

xvii. Communicating new policies and policy changes with all employees.

2. Agency policies and procedures must be implemented and followed by the agency, including the plan for communicating policy changes with all employees.

B.STAFF ORIENTATION.

1. All employees providing direct care to clients must receive agency orientation prior to working independently with any client.

2. The agency orientation program must include, at a minimum, the following topics:

a. Mandated reporting requirements as stated in 22 MRS §3477 and 22 MRS §4011-A;

b. Agency policy related to abuse, neglect, and misappropriation of client property;

c. The agency expectations enumerated in Section 7 (A) of this rule;

d. Grievance policy;

e. Job duties and responsibilities;

f. Agency policies on performance management, including disciplinary measures and annual performance reviews;

g. Client service plans;

h. Documentation requirements;

i. Contingency planning practices;

j. Infection control;

k. Training requirements;

l. Emergency procedures related to the client; and

m. Confidentiality requirements in accordance with state and federal rules and laws.

C.ANNUAL STAFF TRAINING.

1. Each employee must receive annual training, including but not limited to:

a. Maine's mandated reporting statutes;

b. Agency policy related to abuse, neglect, and misappropriation of client property;

c. Grievance policy;

d. The agency expectations enumerated in Section 7 (A) of this rule;

e. Infection control;

f. Emergency and disaster policies; and

g. Confidentiality requirements in accordance with state and federal rules and laws.

D.SUPERVISION.

1. The agency must designate one or more individuals who will be responsible for supervision of employees providing direct care.

a. To be a supervisor, an individual must:

i. Hold a license in good standing as a Licensed Practical Nurse or Registered Nurse;

ii. Have completed the Department-approved course in personal care services and have at least one year's experience providing personal care services;

iii. Be registered as a CNA; or

iv. Have a combination of at least five years of education and/or experience in a related field.

b. The supervisor must provide on-site supervision at least once every 30 days to each employee assigned direct care duties, for the first three months of employment. The on-site supervision must occur while the employee is providing personal care services.

c. The on-site supervisory visit must be documented. This documentation must include, at a minimum, the following:

i. The services that the supervisor observed;

ii. Any competency issues noted;

iii. The action plan to resolve any issues; and

iv. An interview with the client and/or legal representative regarding his/her satisfaction with the services the staff is providing to the client and whether the service plan is being followed.

d. The supervisor must complete an annual performance review, based on the employee's date of hire. The evaluation must be maintained in the employee's personnel record.

E.QUALITY IMPROVEMENT MEASURES. The agency must develop, implement, and maintain a data-driven Quality Improvement Plan that focuses on indicators of the outcomes of care and quality of life.

1. The plan shall include how data and information collected from systems and/or reports will be used to develop, investigate or identify trends related to service delivery, client care and quality of life/service provided.

2. Agencies shall use information to develop strategies to mitigate or prevent adverse event(s) and improve quality of service.

3. The agency shall have documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities.

10-144 C.M.R. ch. 129, § 5