Section 212-RICR-10-10-1.4 - Organization and Management1.4.1Provider GovernanceA. Organizations shall meet all requirements established in Subchapter 00 Part 1 of this Chapter.B. Entities designated by the Director as a CMHC shall adhere to R.I. Gen. Laws §§ 40.1-8.5-2(3); 40.1-8.5-4; 40.1-8.5-5; 40.1-8.5-7, 40.1-5.4-1; 40.1-5.4-4; and 40.1-5.4-5, which define the organizational structure, board governance structure, board membership duties and services required of a CMHC.C. Economic Distress and Going Concern Issues: In the event that an organization anticipates that its financial viability is becoming structurally unsustainable, its projected net billing or revenue is projected to be negative for longer than usual, or its expenses are projected to exceed regular billing or revenue for longer than usual, the organization shall immediately notify, in writing or by electronic mail, the Director of the Division of Behavioral Healthcare. The written communication shall include the reason or reasons that the organization believes it is in economic distress beyond expected, episodic and routine indebtedness and/or negative cash flow. In the event that the organization's accountant prepares a Going Concern statement, the organization shall notify the Director of the Division of Behavioral Healthcare immediately.D. Staff Shortage: In the event that an organization experiences a shortage of staff that is unplanned and that is not projected to be remedied through its usual hiring process within the usual amount of time needed to file staff vacancies, the organization shall immediately notify, in writing or by electronic mail, the Director of the Division of Behavioral Healthcare. The written communication shall include the number and type of vacancies and the reason or reasons that the organization believes it is unable to fill its staff vacancies within the usual amount of time.1.4.2Personnel/Human ResourcesA. Organizations shall meet all requirements established in Subchapter 00 Part 1 of this Chapter as well as the additional requirements listed below.B. The organization shall have a policy relating to treatment of employees during periods of behavioral health crises.C. Clinical and administrative leaders shall define, for their areas of responsibility, the qualifications and competencies of staff needed to fulfill the organization's mission.1. Staff qualifications shall be commensurate with job responsibilities and applicable licensure, law, Regulation, registration and/or certification.D. The organization shall provide professional development opportunities to all staff that maximize individual cultural competencies.E. The organization shall have recruitment and retention policies to increase the number of personnel who reflect the cultural diversity of the communities in which the BHO provides services.F. The organization shall have policies for recruiting leadership that is culturally representative of the individuals served by the organization.G. The organization shall have policies and procedures to address requests by persons served for a change of provider, clinician or service.1.4.3Staff Competency and TrainingA. The organization shall have a mechanism for receiving regular feedback from staff to help create an environment that promotes self-development and learning.B. The organization shall provide training to improve knowledge, attitudes, and skills necessary for staff to conduct recovery-oriented services.C. The organization shall continuously collect and aggregate data about patterns and trends in staff competence to identify and respond to staff learning needs.1.4.4Management of the Environment of CareThe organization shall plan for and provide a safe, accessible, effective and efficient environment consistent with its mission, services, and applicable Federal, State and local laws, codes, Rules, and Regulations that comport with Subchapter 00 Part 1 of this Chapter.
1.4.5Management of InformationA. The organization shall plan and design information management processes to meet internal and external information needs that comport with Subchapter 00 Part 1 of this Chapter.B. The organization shall maintain a treatment record for every individual assessed, treated or served and incorporate information into the treatment record from subsequent contacts with the individual.C. Only authorized individuals shall make entries in treatment records, as specified in organization policies.D. In the event the organization ceases operation the organization shall maintain a written policy regarding proper transfer or disposal of records consistent with local, State and Federal laws.1.4.6ResearchA. In the event that research, experimentation, or clinical trials involving human subjects is to be conducted, the organization must adhere to the following guidelines and to all applicable State and Federal laws and Regulations. 1. A proposal outlining the research, experimentation, or clinical trial must be submitted to an institutional review board (IRB) formally comprised of individuals who have expertise in research protocols, privacy and confidentiality, as it relates to research convened by the Department and approved through the organizational review process. The proposal shall include:a. The purpose of the study, the treatment proposed and its relation to the organization's mission statement and values;b. A description of the benefits expected;c. A description of the potential discomforts and/or risks that could be encountered;d. A full explanation of the procedures to be followed;e. The criteria for inclusion and exclusion;f. The process to be used to explain the procedures to the subject of the study, experiment, or clinical trial;g. The authorization form is to be a consent to participate in the research, experimentation, or clinical trial;h. The methods of addressing any potential harmful consequences with respect to an individual's right to privacy, confidentiality, and safety.i. The inclusion of any vulnerable populations in the study, such as children, pregnant women, and prisoners.2. The authorization form shall include a description of all the elements described in §1.4.6(A)(1) of this Part above and:a. The name and credentials of the person who supplied the information;b. The signature and date of such person;c. The process for the subject to withdraw at any point, without compromising his or her access to the organization's services;d. The participant's signature indicating willingness to participate.3. If research is proposed in conjunction with a university or college, the organization shall be required to provide documentation verifying that the research has been reviewed by the university's human subject review committee.212 R.I. Code R. 212-RICR-10-10-1.4
Adopted effective 1/7/2019
Amended effective 12/27/2022
Amended effective 2/13/2023
Amended effective 1/1/2024