Section 22-A6307. GENERAL MANAGEMENT AND ADMINISTRATION STANDARDS

 

6307.1  Each provider shall be established as a recognized legal entity in the United States and qualified to conduct business in the District.  Evidence of qualification to conduct business includes a certificate of good standing or clean hands, or an equivalent document, issued by the District of Columbia Department of Consumer and Regulatory Affairs. Each provider shall maintain the clinical operations, policies, and procedures described in this section.  These operations, policies and procedures shall be, reviewed and approved by the Department during the certification survey process.

 

6307.2  All certified providers shall report to the Department in a form and manner prescribed by the Department’s policy on adverse events including abuse or neglect of client or any other event that may compromise the health, safety, and welfare of clients. 

 

6307.3  Each provider shall:

 

(a)Have a governing body, which shall have overall responsibility for the functioning of the provider;

 

(b)Comply with all applicable Federal and District laws and regulations;

 

(c)Hire personnel with the necessary qualifications in order to provide SUD treatment and recovery services and to meet the needs of its enrolled clients; and

 

(d)For SUD treatment, employ Qualified Practitioners to ensure provision of services as appropriate and in accordance with this chapter.

 

6307.4  Each treatment and recovery provider shall have a full time program director with authorized and responsible for the administrative direction and day-to-day operation of the program(s).  

 

6307.5  Each treatment provider shall have a clinical director responsible for the clinical direction and day-to-day delivery of clinical services provided to clients of the program(s). The clinical director must be a licensed clinician. 

 

6307.6  The program director and clinical director shall devote adequate time and authority to perform necessary duties to ensure that service delivery is in compliance with applicable standards set forth in this chapter and in applicable policies issued by the Department.

 

6307.7  Each provider shall establish and adhere to policies and procedures for selecting and hiring staff (Staff Selection Policy), including but not limited to requiring:

 

(a)Evidence of licensure, certification, or registration, as applicable and as required by the job being performed;

 

(b)Evidence of completion of an appropriate degree, training program, or credentials, such as academic transcripts or a copy of degree;

 

(c)Evidence of all required criminal background checks, and for all unlicensed staff members, application of the criminal background check requirements contained in D.C. Official Code §§ 44-551 et seq., Unlicensed Personnel Criminal Background Check; 

 

(d)Evidence, provided at least quarterly, that no individual is excluded from participation in a Federal health care program as listed on the Department of Health and Human Services List of Excluded Individuals/Entities (http://oig.hhs.gov/fraud/exclusion.asp) or the General Services Administration Excluded Parties List System, or any similar succeeding governmental list;

 

(e)Evidence of completion of communicable disease testing required by the Department; and

 

(f)Evidence of a mechanism for ongoing monitoring of excluded party listing status, and staff licensure/certification.

 

6307.8  Each provider shall establish and adhere to written job descriptions for all positions, including, at a minimum, the role, responsibilities, reporting relationships, and minimum qualifications for each position. The minimum qualifications established for each position shall be appropriate for the scope of responsibility and clinical practice (if any) described for each position.

 

6307.9  Each provider shall establish and adhere to policies and procedures requiring a periodic evaluation of clinical and administrative staff performance (Performance Review Policy) that requires an assessment of clinical competence (if appropriate), general organizational work requirements, and key functions as described in the job description. The periodic evaluation shall also include an annual individual development plan for each staff member.

 

6307.10 Each provider shall establish and adhere to a supervision policy to ensure that services are provided according to this chapter and Department policies on supervision and service standards.

 

6307.11 Each provider shall establish and adhere to a training policy in accordance with § 6318 of this chapter.

 

6307.12 Personnel policies and procedures shall apply to all staff and volunteers working in a program and shall include:

 

(a)Compliance with federal and District equal opportunity laws, including the Americans with Disabilities Act and the D.C. Human Rights Act;

 

(b)A current organizational flowchart reflecting each program position and, where applicable, the relationship to the larger program or provider of which the program is a part;

 

(c)Written plans for developing, posting, and maintaining files pertaining to work and leave schedules, time logs, and on-call schedules for each functional unit, to ensure adequate coverage during all hours of operation;

 

(d)A written policy requiring that a designated individual be assigned responsibility for management and oversight of the volunteer program, if volunteers are utilized;

 

(e)A written policy regarding volunteer recruitment, screening, training, supervision, and dismissal for cause, if volunteers are utilized; and

 

(f)Provisions through which the program shall make available to staff a copy of the personnel policies and procedures.

 

6307.13 A program shall develop and implement procedures that prohibit the possession, use, or distribution of controlled substances or alcohol, or any combination of them, by staff during their duty hours, unless medically prescribed and used accordingly. Staff possession, use, or distribution of controlled substances or alcohol, or any combination of them, during off duty hours that affects job performance shall also be prohibited. These policies and procedures shall ensure that the provider:

 

(a) Provides information about the adverse effects of the non-medical use and abuse of controlled substances and alcohol to all staff;

 

(b) Initiates disciplinary action for the possession, use, or distribution of controlled substances or alcohol, which occurs during duty hours or which affects job performance; and

 

(c) Provides information and assistance to any impaired staff member to facilitate his or her recovery.

 

6307.14 Individual personnel records shall be maintained for each person employed by a provider and shall include, at a minimum, the following:

 

(a) A current job description for each person, that is revised as needed;

 

(b) Evidence of a pre-employment physical examination, which shall include a negative result on a tuberculosis test or medical clearance related to a positive result;

 

(c) Evidence of the education, training, and experience of the individual, and a copy of the current appropriate license, registration, or certification credentials (if any);

 

(d) Documentation that written personnel policies were distributed to the employee;

 

(e) Notices of official tour of duty: day, evening, night, or rotating shifts; payroll information; and disciplinary records;

 

(f) Documentation that the employee has received all immunizations as recommended by the Center for Disease Control (CDC) for healthcare workers except that individuals who are in a position that involves exposure to blood shall also demonstrate evidence of full immunization against hepatitis B or documentation of refusal; and

 

(g) Criminal background check as required under § 6307.8 of this chapter.

 

6307.15 All personnel records shall be maintained during the course of an individual's employment with the program and for three (3) years following the individual's separation from the program.

 

 

authority

Sections 5113, 5115, 5117 and 5118 of the Department of Behavioral Health Establishment Act of 2013, effective December 24, 2013 (D.C. Law 20-61; D.C. Official Code §§ 7-1141.02, 7-1141-04, 7-1141.06 and 7-1141.07 (2012 Repl.)).

source

Final Rulemaking published at 62 DCR 12056 (September 4, 2015).