10- 148 C.M.R. ch. 37, § 3

Current through 2024-51, December 18, 2024

Section 148-37-3 - PROGRAM ADMINISTRATION

A.GOVERNING AUTHORITY

The Facility's governing authority must comply with program-specific standards set out in this rule and applicable statutes.

1.Responsibility. The governing authority must have ultimate managerial control and legal responsibility for the Facility's operation.

2.Legal authority to operate. The Facility must maintain documentary evidence of its legal authority to operate in the State of Maine, including bylaws, articles of incorporation, charter, partnership agreement, constitution, articles of association or similar documents as applicable. This information must be made available to the Department upon request.

a. A Facility operating as a corporation, partnership, or association, whether for-profit or not-for-profit, must maintain records of the names and current addresses of officers and directors.

b. A Facility operating as a for-profit entity must maintain a current list of the names and addresses of its principal owners.

3.Governance. The governing authority of a Facility may reside in an individual or a board of directors. The composition and structure of the governing authority must be adequate to discharge its responsibilities:

a. Non-profit Facilities must have a board of directors, which must:

i. Include community members who reflect diverse perspectives which may include youth;

ii. Maintain a record of meetings that includes the dates, attendance and topics discussed; records of the board of director meetings must be made available to the Department upon request;

iii. The board of directors must maintain a current record of its membership including the name, address, contact information, position and term of office of each member.

b. For-profit Facilities must have an advisory board, which must:

i. Have a mechanism for obtaining feedback from youth that includes a procedure for direct input to the advisory board, including community members and local public officials who reflect diverse perspectives;

ii. Provide advice to the governing authority;

iii. Maintain a record of meetings that includes the dates, attendance and topics discussed; records must be made available to the Department upon request; and

iv. The governing authority must maintain a current record of the membership of the advisory board including the name, address, and contact information of each member.

4.Prohibited. The following persons are prohibited from serving as the governing authority:

a. An employee of the State or federal government who has regulatory oversight of the Facility.

b. An employee, or a family member of an employee, assigned responsibilities associated with the licensing or regulatory oversight of the Facility, or associated with contracting functions of an agency that purchases the services of the Facility.

5.Valid license. The Facility must have a current, valid license.

6.Responsibilities. The Facility must have a governing authority that is responsible for and has authority over the policies and operations of the Facility. The governing authority's responsibilities include but are not limited to the following provisions:

a. Reviewing written policies and procedures required by this rule annually.;

b. Ensuring that the Facility is adequately funded and fiscally sound;

c. Reviewing and approve the Facility's annual budget;

d. Reviewing and accept the Facility's annual audit and annual financial report;

e. Providing facilities, staff, equipment, supplies and other resources to provide licensed services;

f. Abuse and neglect in the Facility. The Facility must ensure that when the governing authority is made aware that abuse and neglect of a youth has occurred, that these instances are appropriately reported per Section 5(G)(1), and that reporting procedures exist that are transparent and accessible to all youth and employees.

7.Conflict of interest. The governing authority is subject to the Facility's written conflict of interest policy.

B.ORGANIZATIONAL CHART

The Facility must have a written, up-to-date organizational chart and policies governing the line of authority, communication, staff responsibility and staff assignment.

C.PROGRAM ADMINISTRATOR

The Facility must have an administrator or designee who demonstrates the ability to manage the affairs of the Facility. The administrator's duties include but are not limited to the following:

1. Ensuring the Facility's continual compliance and conformity with all relevant laws and regulations, whether federal, State, or local, governing the operation of the Facility, including but not limited to those set out in this rule;

2. Ensuring that reportable events are reported to the Department within the required timeframes;

3. Ensuring notification to the Department within 24 hours after receiving notice or learning of an arrest or indictment of any personnel related to criminal activity that is alleged to have occurred on the grounds of the Facility or any location where services are provided;

4. Providing written notification to the Department within two weeks after the facility receives notice of any legal proceedings related to the provision of services or the continued operation of the facility, whether brought against the facility or against the facility's personnel. Legal proceedings, including but not limited to, bankruptcy, civil rights complaints, professional licensing body sanctions, lawsuits, alleged criminal activities by personnel that have implications for the programmatic or fiscal integrity of the Facility or the safety of its youth.

5. Providing written notification upon any change of administrator. The licensed Facility must notify the Department at least 30 calendar days prior to a planned change or within 10 calendar days of an unplanned change in the Facility's administrator; and

6. Must have the authority to cooperate with Department inspections and investigations.

D.ANNUAL PROGRAM EVALUATION

The Facility must complete an annual program evaluation. The process must include family and youth interviews, as appropriate. The written program evaluation must be available to the Department upon request and must address at least the following:

1. General program effectiveness in relation to stated goals and community needs;

2. General staff effectiveness and staffing patterns;

3. Staff turnover rate;

4. Review of grievances and complaints, responses and outcomes;

5. Emergency and safety procedures;

6. Frequency of unplanned discharges of youth in care (not applicable for Shelters for Homeless Youth).

E.FINANCIAL

1.Financial accountability and viability. The Facility's financial accountability and viability must be achieved through the application of sound financial management practices that are consistent with legal and regulatory requirements.

2.Management systems. The Facility must maintain a business management system, including written policies and procedures to assure maintenance of complete and accurate accounts, books, and records.

3.Budget. The Facility must develop a formal, annualized line-item budget approved by the governing authority, indicating revenues and expenses for the current fiscal year.

10- 148 C.M.R. ch. 37, § 3