14- 197 C.M.R. ch. 10, § IV

Current through 2024-51, December 18, 2024

Section 197-10-IV - AGENCY ORGANIZATION

A.Statement of Ownership

1. Authority. The agency shall maintain documentary evidence of its source(s) of authority to provide services. Such evidence will include articles of incorporation, corporate charter or similar documents.

2. Records. Corporations, partnerships or associations, whether for-profit or not-for-profit, shall maintain records of the names and current addresses of officers and directors, charters, partnership agreements, constitutions, articles of association and/or by-laws, as applicable.

3. For-Profit Organizations. Organizations operating on a for-profit basis shall maintain the names and current addresses of principal owners.

B.Governing Body

1. Membership of the Governing Body

a. Employees of any state or Federal government entity assigned responsibilities associated with the licensing of, purchase of service from, or contracting with the agency, or members of the immediate family of such employees, shall not be members of the Governing Body.

b. The agency shall maintain a record of the membership of the Governing Body, indicating the position and term of office for each member.

2. Nonprofit Organizations

a. If a paid agency staff person or the chief administrative officer of the agency serves as a member of the Governing Body, he or she shall not have a vote.

b. Members of the Governing Body of nonprofit organizations shall number no fewer than three persons.

c. Agencies shall make concerted efforts to include persons who are recipients of agency services or their family members as equal members of the Governing Body. At least one person with a developmental disability or a family member should be a member of the Governing Body. The input of the members of the Governing Body who are recipients or family members shall be solicited in meaningful ways for the full spectrum of the governance activities of the agency. Documentation and adequacy of such efforts shall be subject to the review of the Department.

3. For-Profit Organizations

a. Advisory Board.

i. The Governing Body shall be served by an advisory board.

ii. The advisory board shall be appointed by the governing body from among persons knowledgeable in case management. Members of the advisory board shall not include: members of the Governing Body; officers, directors, partners or owners; relatives or employees of members of the governing body, officers, directors, partners or owners; employees of any government entity assigned responsibilities associated with the licensing of, purchase of service from, or contracting with the agency, or members of the immediate family of such employees; or employees of the agency.

iii. Agencies shall make concerted efforts to include persons who are recipients of agency services or their family members as equal members of the advisory board. At least one person with a developmental disability or a family member should be a member of the advisory board. The input of the members of the advisory board who are recipients or family members shall be solicited in meaningful ways for the full spectrum of the governance activities of the agency. Documentation and adequacy of such efforts shall be subject to the review of the Department.

iv. The agency shall maintain a list of the members of the advisory board which shall indicate the name, current address, professional occupation and term of membership.

v. The agency shall provide to the advisory board the support needed to carry out its duties.

b. Duties of the Advisory Board

i. The advisory board shall provide advice to the Governing Body on matters affecting the provision of services to adults with mental retardation and autism.

ii. The advisory board shall meet at least quarterly.

iii. The advisory board shall develop and maintain by- laws governing its operation, to include but not necessarily be limited to, quorum and selection of the chair.

iv. The advisory board shall maintain records of attendance and minutes of its meetings. Such minutes shall include matters reviewed, the results of any votes, and advisory opinions provided. Minutes shall be forwarded to the Governing Body. Records of attendance and minutes shall be maintained by the agency and made available to the Department.

4. Duties of the Governing Body

a. Meetings. The Governing Body shall

i. meet at least quarterly;

ii. maintain records of attendance and minutes of its meetings. Records of attendance and minutes shall be maintained by the agency and made available to the Department;

iii. adopt a policy regarding conflicts of interest for its members. At minimum, the policy must define a conflict of interest and a matter of self interest, and describe the procedures for resolving those conflicts.

b. Agency Operation and Management. The Governing Body shall

i. develop a mission statement describing the overall philosophy and function of the agency;

ii. be responsible for and have authority over the policies and operations of the agency;

iii. respond in writing to the recommendations of the Advisory Board, if applicable;

iv. designate a person to act as chief administrative officer of the agency and delegate sufficient authority to that person to manage the agency, while retaining responsibility and authority for those areas specifically described in these rules;

v. complete an annual written performance review of the chief administrative officer;

vi. formulate and periodically review, or designate authority to formulate and approve, written policies required by these rules, in consultation with the chief administrative officer;

vii. periodically confer with persons receiving services and members of the communities in which services are provided as to the nature and direction the agency is heading;

viii. make available to the Department any policies or records required by these rules or reasonably related to the assessment of compliance with these rules;

ix. ensure that services are provided in compliance with the ADA, Section 504 of the Rehabilitation Act and the Maine Human Rights Act (MHRA);

xi. be governed in all respects by the laws, statutes, and regulations of the United States of America and of the State of Maine;

xii. certify that it shall provide a workplace free of illegal or illicit drugs,

xiii. ensure there is in place a quality management system that serves as an integral part of providing quality services to the persons served by the agency.

c. Fiscal Management. The Governing Body shall

i. ensure that the agency is adequately funded to provide certified services;

ii. provide physical facilities, staff, equipment, supplies and other needs adequate and sufficient to provide services;

iii. review and approve the agency's annual budget;

iv. provide for an annual report of the agency's financial status, completed by an independent auditor, consistent with these rules, and shall review and accept said report.

d. Communication with the Department. The Governing Body shall ensure written notification to the Department

i. ninety calendar days in advance of any proposed change in location, name or ownership of the agency;

ii. thirty calendar days prior to any planned change or within ten calendar days following any unplanned change of chief administrative officer of the agency;

iii. sixty calendar days in advance of any substantial change in policy or service;

iv. within two working days after the agency receives notice of any legal proceedings arising from circumstances related to the provision of services or the continued operation of the facility and/or program, whether brought against the agency or against any employee;

v. within two calendar days after receiving notice or learning of criminal convictions for events occurring in the agency workplace;

vi. within ten calendar days after receiving notice of significant discrepancies found at audit.

C.Chief Administrative Officer

1. Selection and Appointment

a. The chief administrative officer shall be appointed by the Governing Body from among persons knowledgeable, by training and experience, and capable of managing the affairs of the agency. The chief administrative officer shall possess a baccalaureate degree from an accredited college or university in a field of study applicable to the provisions of human or social services, and shall have had a minimum of five years of progressive responsibility and experience in the provision of human or social services, which included fiscal responsibilities for the day-to-day operation of a program which required an annual audit.

b. Nothing in these rules prohibits the Governing Body from selecting a contracted management company to fulfill the duties of the chief administrative officer, so long as the individual(s) assuming actual duties fulfill those duties in a manner consistent with these rules.

2. Duties of the Chief Administrative Officer. The chief administrative officer shall

a. manage the affairs of the agency in accordance with policies established by the Governing Body and ensure compliance with all rules and regulations applicable to the provision of services and all programs operated by the agency, except those specifically noted to be the responsibility of the Governing Body, and to ensure that the goals and intent of case management for adult with mental retardation and autism as outlined in these rules, applicable standards and policies are adhered to.

b. have directional authority over all operations of the agency;

c. comply with requirements regarding reportable events;

d. ensure timely written notification to the Department in the event of a change in a program director, medical director or clinical director;

e. ensure written notification of arrests or indictments of staff related to drug use on the grounds of any program or location for the provision of services, within 24 hours of learning of the event.

D.Fiscal Management

1. Budget. There shall be a formal, annualized line item budget, approved by the Governing Body, indicating anticipated revenues and expenses for the current fiscal year.

a. Revenue shall be documented by source.

b. Expenses shall be categorized by line item, and shall be specific to each discrete program or other management division.

c. Revisions to the budget shall be clearly documented.

d. Review and approval of the budget by the Governing Body shall be clearly documented, including date of approval.

2. Policies. The agency shall maintain written policies regarding the fiscal management of the agency. These shall include, but not necessarily be limited to,

a. purchasing and inventory control including purchasing authority and procedures, inventory control, product selection and evaluation, and storage and distribution relevant to all materials acquired or retained for the provision of licensed services;

b. accounts receivable, including handling of cash, credit for services, write-offs for free services or bad debts, billing for services;

c. accounts payable, including authority and procedures for making payments and disbursements;

d. setting of fees or charges for services;

e. notification to clients of fee schedules and means to document such notification.

3. Audits. The agency shall have an annual audit or review of financial operation of overall agency operation and of each discrete program or other management division, which shall conform to the requirements of the Maine Accounting and Auditing Practices for Community Agencies, and which shall be conducted by an independent auditor not otherwise receiving remuneration from the agency or the Governing Body.

a. Audits shall be performed in accordance with applicable state and Federal regulations and shall accurately reflect the agency's financial position.

b. Audit reports shall include a review of the system of cost accounting, which reflects the current cost per unit of service for each discrete program or other management division, and which shall include the formulas used to compute the costs.

c. Audit reports shall be reviewed by the Governing Body. Documentation of such review shall be maintained, including the date of the review. Audit reports and the documentation of review shall be subject to the review of the licensing authority.

E.General Policies. The agency shall maintain and follow policies governing essential elements of service provision.

1. Rights. The agency shall maintain policies and procedures guaranteeing the rights of persons receiving services, consistent with applicable rules and law.

2. Records. The agency shall maintain policies and procedures regarding records of services provided, which shall be consistent with applicable law and rule and integrated with the Departments information systems. Policies shall address, but not necessarily be limited to,

a. organization and content of paper records;

b. definition of active records;

c. confidentiality of records, including security of automated record systems and the Department's information system;

d. security of active and inactive records, including access and removal from storage;

e. authorization for release of information. Authorizations for release of information must comply with HIPAA and other applicable law and rules.

f. disposal of inactive records, which shall provide for retention for no fewer than seven years following the date of the last service contact or the age of majority of the person receiving services, whichever is later;

g. legibility and integrity of entries to paper records. At minimum, the policy must address

i. corrections to records, prohibiting the use of correction fluid, tapes, labels and similar techniques and devices;

ii. the prohibition of back-dating entries;

iii. a provision for the use of late entries to records, which must include the use of a phrase identifying the entry as late;

iv. a requirement for an easily recognizable date for every entry;

h. signatures and identification of persons making entries to records, including professional qualifications;

i. discharge summaries, which shall summarize the course of service/treatment and address efficacy of service/ treatment provided as outlined in the plan of care goals, and make recommendations for further services if needed or desired by the person receiving services.

3. Informed consent. The agency shall maintain policies and procedures regarding the acquisition and support of informed consent for services. The policy must address the agency's role in the pursuit of guardianship if necessary to ensure informed consent.

4. Confidentiality.

a. The agency shall maintain policies and procedures regarding the maintenance of confidentiality in the use of facsimile machines, electronic transfer of data, cellular phones, and other technologies used to store or transmit information, and in interpersonal exchanges.

b. Specific policies, consistent with 5 MRSA §19203, shall address the maintenance of confidentiality of results of testing for Human Immunodeficiency Virus (HIV).

c. Policies must comply with HIPAA and other applicable laws and rules.

5. Access by clients. The agency shall maintain policies and procedures regarding the access of persons to their own records.

F. Quality Management

1. Policies. There shall be written policies governing the development and maintenance of an effective quality management program.

2. Plan. The agency shall maintain a plan to monitor, evaluate, document and improve the services provided and the service delivery systems.

a. The plan shall identify areas determined by the agency to be critical to quality service provision.

i. There shall be clearly documented evidence that the plan has been developed with meaningful involvement of persons who are recipients of the services provided by the agency.

ii. The plan shall clearly demonstrate a logical progression of review of elements in areas critical to quality service provision.

b. The plan shall describe goals set by the agency to improve services or service delivery and shall describe indicators to measure achievement of the goals.

c. The plan shall include on-going, year-round, regular activities to measure goal achievement.

3. Quality Management Review. The findings of the quality management process shall be reviewed at least annually.

a. The review process shall include the Governing Body, persons receiving services, family members, guardians, advocates, agency staff, funding agencies and members of the community at large.

b. For-profit agencies shall include representation from their Advisory Board.

c. The findings, and actions taken as a result of findings, shall be documented and the plan shall be revised in accordance with the findings.

4. Reports of Abuse, Neglect or Exploitation. The agency shall maintain a specific policy and procedure governing the reporting, recording and review of allegations of abuse, neglect or exploitation of persons receiving services, in accordance with applicable laws, rules and regulations, including but not necessarily limited to the Adult Protective Services Act, 22 MRSA §3740et seq.; 14-197 CMR 6, Regulations Governing Adult Protective Assessments & Investigations for Persons with Mental Retardation or Autism, and 14-197 CMR 9, Reporting, Investigation and Review of Reportable Events.

5. Grievances. The agency shall maintain a specific policy and procedure in accordance with 14-197 CMR 8, governing the reporting of grievances of persons receiving services, the procedural follow-up and response on the part of the agency to the person making the complaint, and the documentation of the process and outcome.

G.Miscellaneous

1. Insurance. An insurance program shall be in force at all times. Coverage shall include, but not necessarily be limited to,

a. comprehensive liability insurance for the Governing Body, personnel, and property;

b. automobile liability insurance for every vehicle owned or operated by the agency in an amount equal to the limit set by the Maine Torts Claim Act ( 14 MRSA §8101et seq.);

c. automobile liability insurance for any staff-owned vehicle used for transportation of persons receiving services, in an amount equal to the limit set by the Maine Torts Claim Act.

2. Bonding.

a. The agency shall maintain fidelity bonding in an amount equal to the maximum projected monthly cash flow.

b. All persons delegated the authority to disburse, collect or manage funds shall be bonded at the agency's expense.

3. Marketing. Marketing and promotional material distributed by or on behalf of the agency shall accurately portray the scope of services provided.

14- 197 C.M.R. ch. 10, § IV