212 R.I. Code R. 212-RICR-10-00-1.17

Current through December 3, 2024

Section 212-RICR-10-00-1.17 - Licensure

1.17.1Provider Governance

A. Leadership and Organization Planning

1. The Organization shall operate in accordance with all applicable local, state and federal laws, rules, and regulations.

2. Each Organization shall have an organized Board that functions as its governing body and that is ultimately responsible for:

a. Program and fiscal management and operation of the Organization;

b. Assurance of the quality of services;

c. Compliance with all federal, state, and local laws and regulations pertaining to Organizations, and the regulations herein; and

d. Compliance with all applicable components of the Americans with Disabilities Act and other federal and state disability civil rights laws.

3. The Board shall provide appropriate Organizational oversight.

4. The Board shall include persons who represent the greater community, including individual and family participation. At least twenty-five percent (25%) of the Board shall be persons who reflect the population served by the Organization and/or family members of individuals. At a minimum, one (1) Board member shall be an individual served. Evidence of compliance shall be provided to the Department upon request but shall be non-public for purposes of R.I. Gen. Laws Chapter 38-2. Efforts shall be made to recruit members who represent the cultural diversity and population of the local community of the Organization.

5. The Board of Directors shall adopt by-laws, or an acceptable equivalent, that shall:

a. Describe the lines and levels of authority for relationships among itself, the executive director, or equivalent position and the community;

b. Define the ethical standards and the responsibilities for the governance of the operation and performance of the Organization; and

c. Stipulate at least four (4) regular meetings of the Board of Directors each year and shall describe qualifications for membership, quorum requirements and require recording of minutes.

6. There shall be a written statement of the specific responsibilities of the Board of Directors.

7. The Board of Directors shall review and approve major program changes recommended by the executive director, or equivalent position or and equivalent position.

8. The Board of Directors shall adopt an annual budget, approve policies, and receive written reports of income and expenditures by program and receive a copy of the annual audit.

9. The Board of Directors shall be responsible for annually evaluating the performance of the executive director, or equivalent position, or a person serving in an equivalent position, of the Organization.

10. A written plan shall define the mission, vision, and values for the Organization as well as strategic, operational, program-related, and other plans and policies to achieve them.

11. The Organization shall have a written policy and procedure manual that shall be implemented, reviewed, and updated as necessary.

12. The leadership of an Organization shall develop programs to promote staff recruitment, retention, development, and continuing education.

B. Financial Management

1. The Organization shall develop an annual operating budget and long-term capital expenditure plan and strategy to monitor the implementation of the plan, both of which will be approved by the Board of Directors. The plan shall include:

a. An authorized budget with a review of financial performance at least quarterly;

b. Provisions for meeting the needs of individuals and producing the desired outcomes;

c. Attention to long-term financial solvency;

d. Processes to ensure that agency systems are in place to ensure agency appropriate funding streams are available to carry out the purpose for which the provider is licensed;

e. Identification of the sources of funding for the operations of the Organization.

2. The Organization shall contract with an independent certified public accountant to conduct an annual audit of the Organization's financial statements.

3. The Organization shall provide audited financial statements, audit findings and any recommendations, including corrective action plans, and any supplemental schedules, as may be required by the Department.

4. The Organization shall secure insurance to:

a. Cover damage, injury, or loss of life caused by fire, accident, or any other dangers that might occur during the operation of the Organization;

b. Provide liability coverage for all vehicles owned, leased or operated by the Organization;

c. Carry worker's compensation insurance in accordance with the laws of the State of Rhode Island.; and,

d. Protect the personal funds of individuals, to cover damage, injury or loss of life caused by fire, accident or any other dangers which might arise in the operation of the Organization.

5. The Organization shall maintain its financial records in accordance with generally accepted accounting and bookkeeping practices

6. The Organization shall have the infrastructure and ability to develop, support, and maintain a billing system that can track services provided and bill accordingly.

7. Organizations shall bill the appropriate entity for services rendered to individuals in accordance with the appropriate program requirements.

C. Organization Ethics

1. Each Organization shall have a written Code of Ethical Conduct.

2. The Organization's written Code of Ethical Conduct shall address ethical issues in the management and provision of services and in the implementation of clinical practices pursuant to §§ 1.17, 1.21, and 1.26 of this Part.

3. All staff, volunteers, independent contractors directly involved in support services and shared living arrangement contractors shall adhere to both the Code of Ethics of their respective disciplines, as applicable, and the Organization's Code of Ethical Conduct that will include:

a. the use of accurate and respectful language in all communications to and about persons served.

b. the prohibition from engaging in or promising to engage in a personal, scientific, professional, financial, or other relationship, that is outside the professional relationship sanctioned by the Organization, with persons currently or formerly served by the Organization.

c. the prohibition of taking advantage of any professional relationship or exploit others for their personal, religious, financial, sexual, political, or business interests.

d. the respect for the confidentiality of each person served.

4. The Organization's policies and procedures shall reflect ethical practices for marketing, admission, transfer and billing.

5. The Organization 's Code of Ethical Conduct shall address the provision of appropriate care without consideration of the individual's personal financial resources.

6. The Organization's Code of Ethical Conduct shall include a policy regarding gifts, goods, or services given to or received from persons served.

7. The Code of Ethical Conduct shall be made available, in a written or electronic format, in all licensed facilities where services are provided and shall be communicated to all personnel and to all persons served during orientation to the Organization and shall be available upon verbal or written request.

8. Training regarding the Code of Ethical Conduct shall be provided to all staff, volunteers, consultants, and shared living arrangement contractors, as applicable.

a. A record of this training shall be maintained by the Organization.

9. The Organization shall have a written policy and procedure to address any violation of the Code of Ethical Conduct.

10. All staff and volunteers affiliated with the Organization shall sign a copy of the Code of Ethical Conduct to indicate that they understand their responsibility to abide by these standards and maintained in the individual's personnel file.

11. The Organization shall not take retaliatory or punitive action against any employee or person served for his or her report of a possible or perceived violation of any rule, regulation, standard, or statute committed by the Organization or by an employee of the Organization.

212 R.I. Code R. 212-RICR-10-00-1.17

Adopted effective 1/7/2019