W. Va. Code R. § 69-9-5

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 69-9-5 - ADMINISTRATIVE ORGANIZATION

5.1. Each neonatal abstinence syndrome center shall identify a program sponsor, a governing body, an administrator, an advisory council, and a quality improvement committee.

5.2. Each member of the administrative organization, including staff, shall not have any actual or perceived conflict of interest.

5.3. Program Sponsor.

5.3.a. The program sponsor is the person named in the application for certification and licensure of a neonatal abstinence syndrome center.

5.3.b. The program sponsor shall agree on behalf of the center to adhere to all requirements set forth in federal and state laws, rules or regulations regarding the use of pharmacological medications in the treatment of neonatal abstinence syndrome.

5.3.c. The program sponsor is responsible for the general establishment, certification, licensure and operation of the neonatal abstinence syndrome center.

5.3.d. The program sponsor need not be a licensed physician. If the program sponsor is not a licensed physician, the center shall employ a licensed physician for the position of medical director. The medical director shall meet all requirements as specified in this rule.

5.4. Governing Body. The governing body is one or more persons identified by the program sponsor as being legally responsible for the operation of the neonatal abstinence syndrome center.

5.5. Administrator.

5.5.a. The administrator of the center shall have:

5.5.a.1. A minimum of a bachelor's degree in an appropriate area of study and a minimum of four years of management or administrative experience with programs for neonatal abstinence syndrome, neonatal care, pediatric care, substance abuse, mental health, or other related field at the discretion of the governing body, or

5.5.a.2. A minimum of a master's degree in an appropriate area of study and a minimum of two years of management or administrative experience with programs for neonatal abstinence syndrome, neonatal care, pediatric care, substance abuse, mental health, or other related field at the discretion of the governing body.

5.5.b. The administrator is responsible for the day-to-day operation of the center in a manner consistent with all applicable federal and state laws and regulations.

5.5.c. The duties of the administrator include, but are not limited to:

5.5.c.1. Development of policies and procedures for operation of the center;

5.5.c.2. Maintenance and security of the center;

5.5.c.3. Employment, credentialing, evaluation, scheduling, training and management of staff;

5.5.c.4. Protection of patient rights;

5.5.c.5. Conformity of the program with confidentiality laws and regulations;

5.5.c.6. Security of medication storage and safe handling of medications;

5.5.c.7. Management of the facility budget;

5.5.c.8. Implementation of a quality improvement committee;

5.5.c.9. Implementation of governing body policy; and

5.5.c.10. Communication with the governing body.

5.6. Advisory Council.

5.6.a. Each center shall have an advisory council comprised of a designated group of individuals to serve in a non-managerial advisory capacity to the administrator and governing body.

5.6.b. The advisory council shall consist of individuals previously served by the program, at least one staff representative and interested community members and/or advocates. "Individuals previously served by the program" includes but is not limited to, parents, grandparents, foster parents, adoptive parents, and legal representatives. Individuals who were previously served by the program who have or have had addiction disorders shall be in recovery or have completed a recovery program to participate on the advisory council.

5.6.c. The advisory council shall not have access to any patient medical records unless personally identifying information has been redacted.

5.6.d. The advisory council shall meet at least quarterly in an area of the center where there are no patients present.

5.6.e. The advisory council shall:

5.6.e.1. Review program policies and procedures annually, or as proposed for revision;

5.6.e.2. Make recommendations for operational changes or improvements;

5.6.e.3. Be trained in patient confidentiality laws and regulations;

5.6.e.4. Keep records of meetings and describe business conducted, members present and members absent; and

5.6.e.5. Work to assist the neonatal abstinence center in identifying, addressing and resolving problems.

5.6.f. The advisory council shall not review information related to specific patients, staffing, security, and medication storage and security.

5.6.g. The advisory council shall report any recommendations Quality Improvement Committee.

5.7. Quality Improvement Committee.

5.7.a. A member of the Quality Improvement Committee shall report to the governing board on an annual basis with regard to safety, case review, compliance and quality measures.

5.7.b. The Quality Improvement Committee shall consist of, at a minimum, the:

5.7.b.1. Administrator;

5.7.b.2. Medical Director;

5.7.b.3. Director of Nursing;

5.7.b.4. Registered Professional Nurse; and

5.7.b.5. Patient Care Assistant.

5.7.c. The Quality Improvement Committee will meet at least quarterly to:

5.7.c.1. Review both critical and noncritical incidents;

5.7.c.2. Address reports of and allegations of abuse and neglect;

5.7.c.3. Conduct case review;

5.7.c.4. Address grievances;

5.7.c.5. Establish standards and measurable outcomes, analyze outcome data as self-assessment;

5.7.c.6. Review any recommendations submitted by the Advisory Council;

5.7.c.7. Provide feedback to the governing board; and

5.7.c.8. Identify problems or service deficits, and develop plans to correct areas of concern.

5.7.e. [5.7.d.] The Quality Improvement Committee will conduct, at least quarterly, the following reviews:

5.7.e.1. Safety review;

5.7.e.2. Medication administration review; and

5.7.e.3. Security review.

5.8. Contractual Relationships.

5.8.a. The organization shall use written purchase of service agreements or written contracts with both general contractors and/or vendors and professional contractors of clinical services.

5.8.b. Purchase of non-clinical service or material contracts shall describe all significant terms and conditions including as appropriate:

5.8.b.1. Roles and responsibilities of participants;

5.8.b.2. Services to be provided;

5.8.b.3. Provisions for training and technical support as necessary;

5.8.b.4. Duration of the contract, including delineation of follow up services;

5.8.b.5. Methods for resolving disputes;

5.8.b.6. Documentation necessary for, and means of reporting to, funding or oversight bodies;

5.8.b.7. Conditions for termination; and

5.8.b.8. Expected outcomes as appropriate.

5.8.c. If the organization arranges externally or contractually for the provision of clinical services, the organization shall have a written agreement which specifies:

5.8.c.1. Roles and responsibilities of the organization and the contracting party;

5.8.c.2. Documentation required of the contracting individual or service with time lines for provision of the documentation;

5.8.c.3. Services to be provided;

5.8.c.4. Provision of appropriate liability or malpractice insurance either by the contractor or contracting party;

5.8.c.5. Procedures for exchange of information;

5.8.c.6. Definition of the patients to be served and the services to be provided;

5.8.c.7. Time lines for provision of service;

5.8.c.8. Methods for resolving disputes;

5.8.c.9. Terms of payment;

5.8.c.10. Assurances that the contracting party shall adhere to state and federal requirements of confidentiality; and

5.8.c.11. Expected outcomes as appropriate.

5.8.d. The organization shall ensure a complete personnel file on each contracted clinical employee and consultant who provides direct services to patients on site, including:

5.8.d.1. Evidence of clinical training;

5.8.d.2. Evidence of appropriate licensure or certification;

5.8.d.3. Evidence of malpractice or liability insurance as specified in the contract;

5.8.d.4. Evidence of ability to conduct business in the state of West Virginia; and

5.8.d.5. Evidence of state and federal fingerprint-based criminal background check.

5.8.e. If the organization contracts for professional services with a licensed practitioner who serves patients in his or her own location, the organization shall have a personnel file containing the following:

5.8.e.1. Evidence of clinical training;

5.8.e.2. Evidence of licensure;

5.8.e.3. Evidence of state and federal fingerprint-based criminal background check;

5.8.e.4. Evidence of liability insurance; and

5.8.e.5. Evidence of a license to operate a business in the State of West Virginia.

5.8.f The organization shall ensure that contractual vendors are oriented to and adhere to the organization's policies and procedures regarding professional practices and confidentiality.

W. Va. Code R. § 69-9-5