14- 197 C.M.R. ch. 10, § V

Current through 2024-51, December 18, 2024

Section 197-10-V - PERSONNEL MANAGEMENT

A.Personnel Policies. The agency shall adopt written personnel policies and procedures to address adequately relevant elements of these rules and applicable laws.

1. Access to personnel policies. Employees, persons receiving services, guardians, advocates and representatives of the Department shall have access to personnel policies during regular business hours of the agency, except as provided below.

a. nothing in these rules prohibits restricting access to personnel policies by employees, persons receiving services, families, guardians and advocates to specific locations or circumstances of oversight and supervision, if the restrictions are reasonable, are clearly defined in policy and otherwise comport with applicable laws and regulations.

b. copies of personnel policies shall be promptly provided to persons receiving services, families, guardians and advocates, if requested. However, nothing in these rules requires the agency to provide copies of personnel policies to persons receiving services, guardians and advocates at the agency's expense.

c. copies of policies governing access to personnel policies, and specific job descriptions, orientation and training, shall be provided to employees at the agency's expense. Copies of additional personnel policies shall be promptly provided to employees, if requested. Nothing in these rules requires the agency to provide copies of additional personnel policies to employees at the agency's expense.

d. no restrictions of access may be imposed on authorized representatives of the Department, nor may fees be charged for copies of personnel policies when access and requests for copies of personnel policies are part of the legitimate functions of the Department.

2. Compensation and Benefits. The agency shall adopt policies and procedures that describe the methods used by the agency

a. to set salary and compensation schedules, including premium payments, if applicable;

b. to establish benefit plans and eligibility requirements to participate in benefit plans, if any benefit program is offered to any employee. At minimum, the policy shall address paid and unpaid vacation or other time off, sick leave, leaves of absence, health-related insurance, educational benefits, retirement and deferred compensation plans. Nothing in these rules requires the agency to provide specific benefits to any employee.

3. Collective Bargaining Agreements. The agency shall adopt policies and procedures regarding compliance with collective bargaining agreements, if applicable. Copies of collective bargaining agreements shall be available for review by the licensing authority if requested.

B.Organizational Structure

1. Table of Organization. The agency shall maintain current a table of organization that clearly describes the relationships between

a. overall management, to include the Governing Body, Advisory Board, the Chief Administrative Officer, and administrative and management functions described elsewhere in these rules, as applicable;

b. overall agency management and the management of each discrete program or other management division.

2. Lines of Authority. The table of organization shall clearly describe the functional lines of authority, oversight, management and/or consultative relationships between each and every position, body or board depicted in the table of organization.

3. Contracted Services. Services provided through contracted relationships shall be so identified on the table of organization.

C.Job Descriptions

1. Written Job Descriptions. The agency shall have written job descriptions for all positions within the agency, which include minimum qualifications, responsibilities, positions supervised and position(s) providing supervision.

a. Jobs divided by a "job sharing" or similar program shall further describe the division of tasks agreed upon among the parties.

b. A copy of the relevant job description(s) shall be included in the employee's personnel file.

2. Minimum Standards. The following minimum standards shall apply to all staff providing case management.

a. A case manager must have a minimum of a bachelor's degree from an accredited four (4) year institution of higher learning with a specialization in psychology, behavioral health, social work, special education, counseling, rehabilitation, nursing, or a closely related field and one (1) year experience in one of the areas listed above.

b. A supervisor of case management or a regional supervisor must have a baccalaureate degree plus a minimum of four (4) years experience in the mental retardation or autism field. The supervisor must also have experience supervising staff providing services to persons with mental retardation and/or autism, knowledge of the public education system in Maine, and training in flexible funding and family-focused service provision.

3. Copies to Employees. The agency at its own expense shall provide a copy of the applicable job description to each employee at the time of hire, promotion or orientation.

4. Access by Managers. The agency shall ensure access to job descriptions within the individual's chain of command to every individual who has management or supervisory responsibilities.

5. Development Process. The agency shall maintain an effective method for development, review and revision of job descriptions.

D.Recruitment and Selection of Employees

1. General Criteria

a. The agency shall not hire or retain in any capacity any person who has a prior criminal conviction or disciplinary action by a professional licensing, registration or accrediting body, that pertains to consumer abuse, neglect, or exploitation.

b. For those staff who have other types of criminal convictions or negative work history known to the agency, the agency shall document in the individual's personnel file the crime and/or other sanctions, the agency's assessment of the seriousness of the information provided and the agency's rationale for hiring and/or retaining the individual. The agency shall specifically address issues of professional misfeasance, malfeasance, malpractice or other related misconduct; convictions or findings in which substance use or the use of firearms or other weapons were elements; and criminal convictions in which the actual or threatened infliction of personal injury upon another was an element.

c. The agency shall develop criteria and procedures specifying the conditions under which persons related to members of the Governing Body or other staff serving in an administrative, governing or supervisory capacity are employed.

d. The agency shall ensure that employment is in compliance with the ADA, the Rehabilitation Act, the Civil Rights Act of 1964, the Maine Human Rights Act, and any other federal, state or local laws or regulations. All substantiated complaints of violations of these laws or regulations shall be assessed by the agency and actions shall be taken to achieve compliance. Plans to achieve compliance shall be subject to the review of the Department.

e. Nothing in these rules prohibits an agency from conducting more extensive background checks on staff.

2. Reference and Background Checks

a. The agency shall acquire and retain evidence to demonstrate that all persons engaged in the provision of case management services meets the standards specified at 10-144 CMR 118, Chapter 2, of a Qualified Mental Retardation Professional (QMRP).

b. When the operation of a motor vehicle is expected or reasonably anticipated in the course of the employee's work, the agency shall conduct a check of the employee's driving record. For those staff who have convictions for operating under the influence or any other violations or accidents that indicate an unsafe driving history within the past three (3) years, the agency shall not permit the employee to transport persons.

c. The agency shall acquire and retain evidence that all persons who in the completion of their duties are expected or could be reasonably anticipated to operate a motor vehicle, have valid driver's licenses appropriate to the class of vehicle to be used. If a staff person, in the course of work, is operating a vehicle not provided by the agency, evidence of registration, inspection and insurance shall be maintained. Such evidence shall be acquired at the commencement of the person's employment and shall be maintained current.

d. The agency shall take effective and lawful action to ensure compliance with V.D.1.a-e, above. This shall include, but not necessarily be limited to, background checks through the State Bureau of Identification, Child Protective Services, Adult Protective Services, the Certified Nursing Assistant register and other similar registers, the Bureau of Motor Vehicles, and such other relevant and available registers, sources of information or data bases.

e. Background checks shall be conducted at the agency's expense.

f. Continued employment of any individual shall be contingent upon results of the background checks. Background checks must be completed and the information available to the hiring agency within six (6) months of the date of hire.

E.Training and Orientation

1. Orientation Program. The agency shall provide to all new employees orientation relevant to the organization as a whole and training that relates directly to the provision of case management services for adults with mental retardation and autism. The content of training shall be subject to the review and approval of the Department. This orientation shall include, but not necessarily be limited to,

a. an overview of the service delivery system as a whole;

b. the agency's mission, philosophy, and other related services;

c. the person's right to privacy and confidentiality;

d. safety and emergency procedures;

e. the identification, response and reporting of abuse, neglect, and exploitation, and the consequences of failure;

f. overview of developmental theory, the nature of mental retardation and autism, and other relevant introductory information;

g. overview of abuse and trauma, and the implications for service and treatment programming;

h. cultural competence issues relevant to the populations served, including age, gender, race, religion, culture and sexual orientation;

i. specific job responsibilities. For managers or supervisors, this shall include responsibilities and procedures for management, supervision and discipline of employees;

j. supervisory chain of command;

k. specialized techniques of communication and intervention, as applicable to the needs of persons served in the program;

l. assessment, evaluation, Person-Centered Planning, service delivery, and documentation appropriate to the position and to the persons served in the program.

i. This shall include but not necessarily be limited to identification of needs and coaching/support techniques.

ii. This shall specifically include training in the maintenance of appropriate professional boundaries;

m. technical training on the maintenance of electronic records in the Department's management information system.

2. Assumption of duties following orientation. Employees shall not be assigned to duties requiring direct involvement with persons receiving services until the following elements of orientation and training have been completed and documented:

a. all elements of the position specific orientation,

b. general orientation topics of reporting of abuse and neglect, safety and emergency procedures, child rights, and confidentiality.

The remaining training and orientation elements must be completed within 60 calendar days of hire, unless otherwise specified.

3. Ongoing training and education. The agency shall develop and implement policies and procedures to

a. ensure compliance with on-going professional training for all employees;

b. identify staff training needs and provide such training, as pertinent to the services provided by the agency;

c. provide annual inservice or external training that includes:

i. individual reporting requirements for incidents of abuse, mistreatment, neglect or exploitation,

ii. diversity education and/or cultural competence training,

iii. ethics,

iv. confidentiality,

v. job specific competencies, and

vi. documentation and record keeping. Additional training shall be applicable to the duties of the staff receiving the training.

4. Records of completion of orientation and training. The agency shall maintain written, accessible documentation that orientation and ongoing training have been completed as described in these rules. The documentation shall include, at minimum, curriculum, names and credentials of persons providing orientation or training, dates orientation or training was provided, the length of time of each orientation or training session, and the dated signature of the trainee acknowledging receipt of the orientation or training.

F.Management, Supervision and Discipline

1. Lines of Authority. The agency shall maintain policies and effective procedures governing the application of the lines of authority, as described in the table of organization.

2. Supervision. The agency shall identify a supervisor for each position. Supervisors are responsible for supervising individual support coordinators or case managers, developing and reviewing service plans, and assuring the provision of quality case management services.

a. At minimum, supervision shall be provided according to the following standards:

i. Supervision must be conducted at regularly scheduled times, no less frequently than once monthly for each staff member.

ii. Supervision may be conducted on an individual or group basis. Supervision shall be measured and documented in hours and shall be subject to the review of the Department.

iii. Supervision shall include the following:

(a) review of case records, including the PCP,

(b) documentation in the case records, indicating the occurrence of the review,

(c) review of case record management activities, including adequacy and completeness of screenings, assessments, referrals, etc.,

(d) participation in the development of the employee's individual, group and family support skills, as applicable,

(e) maintenance of a record of supervision, including the dates, employee(s) supervised, duration and content of supervision, signed by the supervisor, and

(f) issues germane to the duties being performed.

b. Policies shall describe day-to-day supervision and performance review of staff members.

3. Performance reviews. The agency shall maintain policies and effective procedures governing the routine, periodic, formal performance review of employees. These policies shall discuss at a minimum,

a. criteria and procedures for employee performance reviews;

b. the development and implementation of individualized performance improvement and training plans;

c. frequency of performance reviews, which shall be completed no less frequently than at the conclusion of the first six and the first twelve months of employment, whether full or part time, and annually thereafter;

d. documentation of performance reviews; and

e. provision of copies of performance reviews to employees.

4. Discipline. The agency shall maintain policies and effective, lawful procedures governing employee discipline. These policies shall discuss at a minimum,

a. the circumstances under which discipline may be administered;

b. the range of interventions or penalties permitted;

c. the circumstances under which particular penalties are required or permitted;

d. the penalties for child abuse, mistreatment, neglect or exploitation;

e. the penalties for violation of individual rights;

f. the penalties for violation of rules of confidentiality, including those specific to the services being provided;

g. the penalties for workplace use or possession of illicit substances, alcohol or firearms;

h. the penalties for working under the influence of illicit substances or alcohol;

i. the penalties for falsification of any documents related to hiring or retaining employees, whether for self or on behalf of others;

j. the penalties for violation of personnel laws (including but not necessarily limited to EEO and THE ADA) and agency personnel policies;

k. procedures for employees' appeal of discipline; and

l. documentation of disciplinary actions and results of appeals.

5. Employee grievances. The agency shall maintain policies and effective procedures governing the acceptance and resolution of grievances brought by employees as a result of management practices, to include but not necessarily be limited to EEO, THE ADA and the Maine Human Rights Act.

G.Personnel Records

1. Policies. The agency shall maintain policies and effective, reasonable procedures governing personnel records. These policies shall discuss at a minimum,

a. custody, security and confidentiality of personnel records;

b. access to personnel records by employees, supervisors and other agency managers;

c. circumstances under which employees may add material to their own records;

d. circumstances under which employees may remove or request the removal of material from their own records;

e. circumstances under which persons other than the employee may add material to records;

f. circumstances under which persons other than the employee may remove material from records;

g. circumstances under which all or part of the personnel record may be discussed with or provided to others.

2. Active Records. The agency shall maintain active records for all current employees, contracted staff and consultants.

3. Inactive Records. The agency shall maintain policies and effective procedures governing the identification, custody, security, confidentiality and disposal of personnel records considered inactive. Inactive records shall be maintained at the agency for a period no less than three (3) calendar years following the last period of employment.

4. Content of Records. Personnel records shall, at minimum, contain

a. a completed, signed, dated application or resume.

i. Applications shall include a statement consistent with 17-A MRSA §453, regarding falsification of information provided in the application.

ii. Resumes submitted in lieu of applications must include a complete description of relevant education and experience. The applicants who submit resumes in lieu of applications shall sign and date a separate document including the statement described above in 4.a.i, which shall be attached to the resume;

b. letters of reference, if provided or acquired. Notes of any telephone reference checks shall be included. Unfavorable references may not be omitted, if provided or acquired;

c. applicable, current professional credentials and certifications;

d. records of completion of orientation and training required under these rules;

e. the results of all background or reference checks, as described at Section V. D. 2, above;

f. current job description;

g. performance reviews;

h. documentation of disciplinary action and results of appeals;

i. starting, transfer, promotion, demotion and termination dates;

j. a statement read, signed and dated by the employee, which clearly defines abuse, mistreatment, neglect, exploitation and breach of confidentiality; outlines the responsibility to refrain from such actions and to report all such incidents or suspected incidents; and describes the consequences of failure to comply with the requirements to refrain from such actions and to report all such incidents or suspected incidents;

k. employment agreements, if applicable, including contracts governing the use of contracted employees or consultants; and

l. letters of accommodation and supporting medical records, if applicable.

14- 197 C.M.R. ch. 10, § V