14- 197 C.M.R. ch. 10, § VI

Current through 2024-51, December 18, 2024

Section 197-10-VI - OPERATIONAL PRACTICES

A. General

1. Policies. The agency shall adopt written operational policies and procedures to adequately address each relevant element of these rules and applicable laws.

2. Tobacco.

a. Agency staff shall not provide, distribute or facilitate access to tobacco products to persons under the legal age.

b. Agency staff shall not use tobacco products in the presence of persons under the legal age.

c. Programs shall not allow persons under the legal age to use tobacco products at the program site or during service provision.

d. Programs shall maintain current and effective policies and procedures to ensure the above standards. Policies shall describe disciplinary action to address employee noncompliance with the above standards. Policies shall be in compliance with Section V.F.

B.Program Organization

1. Program Manager. The agency shall designate an individual as program manager, having overall responsibility for the operation of each program.

a. the program manager shall be responsible for the operation of the program at all times. In the necessary absence of the program manager, there shall be designated a qualified person in charge;

b. program managers shall be at least 21 years of age, shall possess a baccalaureate degree from an accredited college or university in a field of study applicable to the provision of human or social services, and shall have had at least four (4) years of relevant experience in the provision of mental retardation services.

c. the duties of the program manager shall be clearly described in the written job description, including minimum qualifications, responsibilities and lines of authority.

d. nothing in these rules prohibits the sharing of managers between programs, if the programs are adequately managed.

2. Population Served. Characteristics of the population served shall be specifically defined.

a. This description shall include, but not necessarily be limited to, age, gender, geographic area served, income constraints, need-based descriptors and criteria, and diagnostic or service need descriptors.

b. The agency shall ensure the application of a policy of non-discrimination consistent with applicable laws and regulations, and shall publish this policy in all promotional material. Nothing in these rules prohibits agencies from extending the non-discrimination policy to exceed that required by law or regulation.

c. the agency shall ensure the application of a specific policy and procedure regarding compliance with the ADA, Section 504 of the Rehabilitation Act, the Civil Rights Act, and the Maine Human Rights Act.

i. the policy shall specifically address how persons with disabilities may access services.

ii. the agency shall notify the Department of complaints pursuant to the above cited laws which result in a finding of reasonable grounds by an external regulatory body.

C.Program Management

1. General. Each program shall develop, maintain and follow current, accurate policies and procedures governing each and every aspect of the delivery of certified services within the program.

a. there shall be an effective method for development, review and revision of policies and procedures, coordinated and integrated with the review required of the Governing Body, described at Section IV B 4 b vi. Review of policies and procedures shall be no less frequent than every two (2) years and shall include the signature of the program manager and/or chief administrative officer.

b. employees shall have reasonable access to policies and procedures governing program administration. The definition of "reasonable" shall be contained in policy, and shall not be so restrictive as to impede an employee's performance of assigned duties.

c. policies and procedures governing the administration of a program shall form the basis of training required under Section V.E.

d. policies and procedures implemented at the program level shall be consistent and in concert with policies and procedures of other related agency programs and with the agency as a whole.

e. policies regarding hours of operation and access to services shall be clearly articulated and made available to staff and to persons receiving services.

2. Rights of Persons Receiving Services. There shall be specific policies and procedures governing the assurance of rights of persons receiving services.

3. Records. There shall be specific policies and procedures governing the confidential maintenance of records of service provision. These policies and procedures shall be consistent with agency policy and HIPAA, and shall address situations unique to the services provided, population served and site of operation.

4. Interpretive Services. There shall be specific policies and procedures governing the availability and provision of interpretive services, whether spoken language or sign, consistent with applicable law and regulation.

D.Staffing Patterns

1. Number of Staff. The program shall employ a sufficient number of qualified employees to ensure the provision of services. Case managers working full time shall not carry case loads in excess of 35 persons. Case managers working part time shall carry case loads pro-rated to their hours worked.

2. Scheduling. Policies and procedures shall be maintained to govern

a. routine scheduling of staff;

b. emergency, unusual and unplanned changes in staffing requirements;

c. methods employed to ensure adequate program staffing during periods of staff unavailability, such as vacation, holidays, or sick leave;

d. the use of per diem or contracted staff;

e. any other staffing issue particular to the services provided or population served.

3. Staff to Supervisor Ratios. Supervisors shall provide clinical/professional and administrative supervision to direct care staff at a ratio of supervisors to staff that will ensure all supervisory requirements are met.

4. Records. Records of planned staffing and actual attendance shall be retained at each program for a period not less than 180 days and shall be subject to the review of the Department.

E.Person Centered Plans. Programs shall maintain and enforce policies and procedures to ensure adherence to the Department's standards for Person Centered Planning and or Individual Planning.

14- 197 C.M.R. ch. 10, § VI