218 R.I. Code R. 218-RICR-40-00-5.3

Current through December 3, 2024

Section 218-RICR-40-00-5.3 - Organization and Administration of Case Management Agencies

5.3.1 Organizational Philosophy

A. The agency must demonstrate how key components of consumer centered care/service are incorporated into the agency's organizational philosophy, service program and operations in terms of:

1. The degree and character of consumer/family involvement in program development, implementation and evaluation;

2. The degree and character of consumer/family involvement in care/service planning;

3. The emphasis on consumer centered program outcomes;

4. The extent to which programs are flexible enough to meet special and individual needs;

5. Approaches to assuring consumers/families are encouraged to voice concerns, provide input;

6. Combination of formal programs and informal networks;

B. The agency must demonstrate that it has as an agency value, the provision of high quality, professional services.

C. The agency must have a mission and philosophy statement that reflects the needs of the consumers and the care and services the agency is committed to providing.

5.3.2Corporate Structure and Governance

A. The agency may be organized in any legal business form, including but not limited to sole partnership, partnership, joint venture, corporation, non-profit corporation, or trust.

B. If the agency is operated as part of, or in affiliation with, a parent organization, the agency must have a written agreement with the parent organization specifying the relationship between the two entities.

C. The agency must have a governing body with full legal authority and fiduciary responsibility for the overall operation of the agency in accordance with applicable state and federal requirements. The agency must:

1. Provide names and affiliations of members of the agency's governing body;

2. Describe structure of the agency's governing body;

3. Provide functional and staff organizational charts;

4. Provide a copy of the organization's charter, constitution or by-laws that include but are not limited to:

a. a definition of goals, purposes, objectives;

b. a statement of compliance with civil rights act and other federal, state, local laws safe guarding civil rights;

c. evidence of consumer involvement on governing board and/or advisory committee.

5. Provide a copy of the following:

a. annual report and

b. annual budget.

6. Demonstrate that the organization:

a. maintains financial records, provides annual report by independent auditing firm with management letter;

b. adheres to accepted standards of accounting;

c. employs administrator and gives person authority to manage the daily affairs according to established personnel and corporate policies.

d. Operates free of any conflict of interest in adherence to a formal policy to be approved by the Division.

D. The agency must submit to the Division signed written assurances that it follows all applicable federal and state requirements including, but not limited to:

1. Title VI of the Civil Rights Act of 1964;

2. Annual Certification Drug-Free Workplace Requirements;

3. Certification Regarding Lobbying.

E. Agencies that have an advisory committee must provide:

1. A list of members of the advisory committee;

2. Officers of the committee and the effective dates of their terms; and

3. A copy of the by-laws of the advisory committee.

F. The agency must maintain written guidelines for operation, personnel policies, fiscal accountability, organizational structure, organizational philosophy and mission, oversight, partnerships, training, and volunteer opportunities.

G. The agency must demonstrate that it can:

1. Generate, account for, and distribute revenue;

2. Determine future cash requirements and plan for ensuring cash flow;

3. Mitigate liability exposure, including liability for organization, providers, directors, etc.

H. The agency must present a clear and concise annual summary statement of activities and scope of service consistent with the agency's mission and philosophy.

5.3.3Operational Capacity

A. The agency must demonstrate that it has the capacity to carry out various operational functions needed to oversee and support the program, including the ability to:

1. Manage ongoing operations;

2. Coordinate across multiple sites, if applicable;

3. Establish and maintain partnerships with entities and programs; and

4. Demonstrate an effective approach to program management.

B. The agency must demonstrate fiscal responsibility and accountability through the following:

1. Fiscal policies, procedures, record keeping that define responsibility and accountability;

2. A sound approach to financial management, including:

a. timely billing for services;

b. a plan to address long term financial needs;

c. fee schedule, including eligibility for discounts, waivers, etc;

d. evidence that the governing body approves its annual budget, and reviews income and expenditure reports and annual audit;

3. Operating on a sound financial basis according to acceptable accounting practices, and adhering to standards of accounting and reporting for voluntary health and welfare organizations; and

4. Developing and working within a budget with the capacity for ongoing provider review and revision as necessary.

C. Agencies that are first time recipients of Division funding must provide a sound business plan with plans for development and projected monthly revenue and expense statement for twelve (12) months. This plan must:

1. Include assumed consumer base, services, revenues and expenses;

2. Outline management of initial expenses; and

3. Program development and enhancement timetable.

D. The agency must show evidence of comprehensive insurance coverage that includes general liability and malpractice coverage.

E. The agency must adhere to the current Division Records Retention Schedule that applies to financial and consumer records and related documents.

F. The agency must acquire and maintain an approved vendor agreement with the state Medicaid Management Information System (MMIS).

G. If the agency conducts utilization review of health care services, as defined in R.I. Gen. Laws Chapter 23-17.12, the agency must obtain the appropriate certification from the Rhode Island Department of Health.

H. The agency must demonstrate the capacity to communicate (orally and in writing) with non-English speakers within its service area.

I. The agency must demonstrate the ability to work effectively in multiple community and cultural settings with people of different races, ethnicities, languages and religions.

5.3.4Interagency Relationships

A. The agency must demonstrate formal relationships with service providers that require providers to take referred consumers and report to the agency on the outcome of care or services. There must be a written, signed memorandum of understanding (MOU) between the parties that defines the relationship and the parties' expectations.

B. Any agency which refers consumers to any health care facility licensed pursuant to R.I. Gen. Laws Chapter 23-17 or to a residential care/assisted living facility licensed pursuant to R.I. Gen. Laws Chapter 23-17.4 or to an adult day services program licensed pursuant to R.I. Gen. Laws § 42-66-4 in which the referring entity has a financial interest must, at the time a referral is made:

1. Disclose the following information to the consumer:

a. that the referring entity has a financial interest in the facility or provider to which the referral is being made; and

b. that the consumer has the option of seeking care from a different facility or provider which is also licensed by the state to provide similar services to the consumer;

2. Offer the consumer a written list prepared by the Rhode Island Department of Health for licensed health care facilities and residential care/assisted living facilities or a written list prepared by the Department for adult day services programs; and

3. Document this financial disclosure in the individual consumer's file.

C. Noncompliance with §5.3.4(B) of this Part shall constitute grounds to revoke, suspend, or otherwise discipline the certified case management agency or to deny an application for certification by the Director, or may result in imposition of an administrative penalty. In cases of noncompliance involving health care facilities and residential care/assisted living facilities licensed by the Department of Health, referral will be made by the Division of Elderly Affairs to the Director of Health for disposition in accordance with R.I. Gen. Laws Chapter 23-17.10.

D. In cases of noncompliance as a result of the agencies failure to disclose financial interest, the Director of Elderly Affairs shall take appropriate action under R.I. Gen. Laws § 42-66-17.

5.3.5Physical Plant

A. The agency must provide care and services in the most convenient and accessible location for the consumer that also assures confidentiality of service/care delivery.

B. The agency must comply with all current local, state and federal codes, rules and regulations related to the physical plant, including, but not limited to, current requirements of the Americans with Disabilities Act (ADA).

218 R.I. Code R. 218-RICR-40-00-5.3