Ga. Comp. R. & Regs. R. 111-8-68-.05 - Organization and Administration

(1) Incorporation. All facilities shall be incorporated unless operated by a local or state governmental authority. The purpose or function of the facility shall be stated in the charter of incorporation.

(2) Governing Body. The governing body must ensure that the following requirements are met:

(a) Every facility shall have a governing body which has responsibility for the overall operation of the facility. Each governing body shall establish and be operated by a set of bylaws and guidelines.

(b) Bylaws or rules and regulations shall be in accordance with legal requirements and shall assure the quality of patient care. They shall also include:

1. a definition of powers and duties of the governing body, its officers and committees;

2. a statement of the qualifications of members, method of selection, numbers and terms of appointments, or election of officers and committees;

3. a determination of frequency of meetings, which shall be at least quarterly, attendance requirements and quorums at meetings;

4. provision for the appointment of a full-time administrator with a description of the qualifications, authority and responsibilities of such a person;

5. provision for the appointment of a clinical director with a description of the qualifications, authority and responsibilities of such a person;

6. a mechanism by which the administrative and clinical staff consult with and report to the governing body;

7. an effective, formal means by which the administrative and clinical staff may participate in the development of the facility's policies relative to both facility management and patient care; and

8. provision to establish rules and regulations that are not limited to, but shall include:

(i) a statement of the regulations by which the clinical staff and administrative staff shall function;

(ii) a requirement that controls are established for insuring that each professional member of the staff will observe all the ethical principles and standards of his profession, and will assume and carry out clinical and/or administrative functions consistent with local, state and federal laws and regulations; and

(iii) a requirement that the evaluation and authentication of psychiatric and medical histories, the performance and recording of physical examinations, and the prescribing of medication be carried out by physicians with appropriate qualifications, licenses and clinical privileges within his/her sphere of authorization.

9. For a facility whose governing body does not solely function in support of the residential mental health facility, then an advisory board shall also be appointed to advise and advocate for the residential mental health program for children and youth. This board's members shall be selected with a broad community representation with specific expertise and/or interest in the mental health of children and youth. The advisory board shall meet at regular intervals, not less often than quarterly.

(3) Finances. The facility shall be operated in a fiscally responsible manner and addresses the following:

(a) Each facility shall have a sound plan for financing, which assures sufficient funds to enable it to carry out its defined purposes.

(b) A new facility shall have sufficient funding assured to carry it through its first year of operation.

(c) An accounting system shall be maintained that produces information reflecting fiscal experience and the current financial position of the facility.

(d) The facility shall employ a system of accounting that clearly indicates the cost elements for assessment and therapeutic services for each program.

(e) All accounts shall be audited at least annually by a certified public accountant and the report made a part of the facility's records. A copy of this report shall be made available to the department upon request if the facility is subsidized by state or federal funds.

(4) Goals, Policies and Procedures. The facility shall develop and update as necessary, goals, policies and procedures which address the following:

(a) Each facility shall have a clear written statement of its purpose and objectives, with a formal, long-range plan adapted to guide and schedule steps leading to attainment of its projected objectives. This plan shall include a specifically delineated description of the services the facility offers. The plan shall also include:

1. the population to be served, age groups and other limitations;

2. an organizational chart with a description of each unit or department and its services, its relationship to other services and departments and how these are to contribute to the priorities and goals of the facility; and

3. plans for cooperation with other public and private agencies to assure that each patient will receive comprehensive treatment. Ongoing working arrangement contracts with agencies, such as schools and/or welfare agencies, shall be included as indicated, as well as regularly planned interagency conferences, which shall be documented.

(b) The facility shall develop and implement effectively policies and procedures for operations, including but not limited to:

1. the initial screening process;

2. the intake or admission process;

3. the development of treatment plans, including the involvement of the patient, parent(s), and/or legal guardian;

4. the appropriate use of behavior management techniques and emergency safety interventions;

5. the appropriate use of patient safety methods to ensure the continuous provision of sufficient regular, special, and emergency observation and supervision of all patients;

6. the provision of any community education consultation programs; and

7. the provision or arrangement for services required by the patient:

(i) other medical, dental, special assessment and therapeutic services, which shall become a part of the clinical services plan;

(ii) medical emergency services;

(iii) educational services for all patients; and

(iv) discharge and follow-up care and evaluation.

(5) Personnel. The facility shall meet the following personnel requirements:

(a) Composition. The composition of the staff shall be determined by the needs of the patients being served and the goals of the facility, and shall have available a sufficient number of mental health professionals, child care workers and administrative personnel to meet these goals.

1. The administrator of the facility shall have a master's degree in administration or a professional discipline related to child and adolescent mental health, and have at least three (3) years administrative experience. A person with a baccalaureate degree may also qualify for administrator with seven (7) years experience in child and adolescent mental health care with no less than three (3) year's administrative experience.

2. The clinical director shall be at least board eligible in psychiatry with experience in child and adolescent mental health.

3. If the clinical director is not full-time, then there shall also be a full-time service coordinator who is a professional person experienced in child and adolescent mental health and is responsible for the coordination of treatment aspects of the program.

4. Mental health professionals shall include, but are not limited to, child psychiatrists, qualified psychologists, qualified social workers and qualified psychiatric nurses. These persons, if not on a full-time basis, must be on a continuing consulting basis. The authority and participation of such mental health professionals shall be such that they are able to assume professional responsibility for supervising and reviewing the needs of the patients and the services being provided. Such individuals shall participate in certain specific functions, e.g., assessment, treatment planning, treatment plan and individual case reviews, and program planning and policy and procedure development and review.

5. Other professional and paraprofessional staff shall include, but not be limited to, physicians, registered nurses, educators and twenty-four (24) hour child care staff. Also included on a regular basis, or as consultants on a continuing basis shall be activity therapists and vocational counselors.

6. Consultation shall be available as needed from dietitians, speech, hearing and language specialists, and other therapeutic professionals.

(b) Organization. The facility shall have an organizational plan which clearly explains the responsibilities of the staff. This plan shall also include:

1. lines of authority, accountability and communication;

2. committee structure and reporting or dissemination of material; and

3. established requirements regarding the frequency of attendance at general and departmental/service and/or team/unit meetings.

(c) Policies and Records. Personnel policies and practices shall be designed, established and maintained to promote the objectives of the facility and to ensure that there are sufficient qualified personnel to provide for the needs, care, safety, and supervision of patients.

1. Each facility shall have written personnel policies covering at least the following areas: job classifications; personnel selection; procedures and requirements for health evaluations; staff orientation and training programs; the maintenance and content of personnel records and, for all persons employed after effective date of these rules, the use of employment and criminal background checks to ensure that the employee has no history of violent or abusive behavior. Each new employee shall be given a copy of personnel practices when hired, including the policy to conduct employment and criminal background checks.

2. All prospective personnel must be checked against state sex offender registries where the applicant has lived since becoming an adult or have satisfactory criminal records check information on file prior to employment by the facility. The facility shall not hire or retain staff who have a history of violent or abusive behavior.

3. There shall be clear job descriptions for all personnel. Each description shall contain the position title, immediate supervisor, responsibilities and authority. These shall also be used as a basis for periodic evaluations by the supervisor.

4. Accurate and complete personnel records shall be maintained for each employee and include at least the following:

(i) current background information, including the application, employment references, the results of employment and criminal background checks, and any accompanying documentation sufficient to justify the initial and continued employment of the individual and the position for which he was employed. Applicants for positions requiring a license shall be employed only after the facility has obtained verification of the license. Where certification is a requirement, this shall also be verified. Evidence of renewal of a license or certification shall be maintained in the employee's personnel record;

(ii) current information relative to work performance evaluations, including any records of employee discipline arising from the inappropriate use of behavior management techniques and/or emergency safety interventions;

(iii) records of initial, regular, and targeted health screenings, sufficient in scope to ensure that all facility personnel who are employed or under contract with the facility who may have patient contact or are providing patient care services do not have conditions that may place patients or other personnel at risk for infection, injury, or improper care; and

(iv) records of orientation training and any continuing education or staff development programs completed.

(d) Staff Development. The facility shall provide and document completion of orientation programs and other staff training.

1. There shall be appropriate orientation and training programs provided for all new employees. Prior to working with patients, all employees, including administrative staff who work with the patients shall complete an orientation program which includes at a minimum instruction in:

(i) the employee's assigned duties and responsibilities;

(ii) facility policies and procedures for receiving and handling family and patient grievances and complaints;

(iii) policies and procedures related to child abuse, neglect and exploitation including reporting requirements.

(iv) policies and procedures regarding appropriate behavior management and emergency safety interventions; and

(v) policies and procedures to protect the confidentiality of patient records.

2. The staff development program shall be facility-based with a designated person or committee who is responsible, on a continuing basis, for planning and insuring that training programs are implemented. The facility shall also make use of educational programs outside the facility.

(6) Volunteer Program. When volunteers are utilized in a program, a qualified staff member of the facility shall be designated to plan, supervise and coordinate the volunteer's functions as well as an appropriate training program.

(7) Research and Human Rights Review. Research practices involving human subjects shall comply with the State of Georgia agency policy on "Protection of Human Subjects."

(8) Reporting. Written summary reports shall be made to the department in a form acceptable to the department within twenty-four (24) hours (with a detailed investigative report to follow in five working days if not provided initially) regarding the following serious occurrences involving patients in care:

(a) Serious injury which causes any significant impairment of the physical condition of the resident as determined by qualified medical personnel. This includes, but is not limited to burns, lacerations, bone fractures, substantial hematoma, and injuries to internal organs, whether self-inflicted or inflicted by someone else;

(b) deaths;

(c) suicide attempts;

(d) emergency safety interventions resulting in any injury of a patient requiring medical treatment beyond first aid;

(e) elopements when the patient cannot be located within twenty-four (24) hours or where there are circumstances that place the health, safety, or welfare of the patient or others at risk; or

(f) any incident which results in any federal, state, or private legal action by or against the facility which affects any patient or the conduct of the facility. However, legal action involving the juvenile justice system is not required to be reported.

(9) Child Abuse Reports. Whenever the facility has reason to believe that a patient in care has been subjected to abuse, neglect or exploitation, the facility shall make a report of such abuse to the child welfare agency providing protective services as designated by the Department of Human Services (Division of Family and Children Services) or in the absence of such an agency to an appropriate police authority or district attorney in accordance with the requirements of O.C.G.A. § 19-7-5. A copy of the report shall also be filed with the Division of Healthcare Facility Regulation, Department of Community Health.

Notes

Ga. Comp. R. & Regs. R. 111-8-68-.05

O.C.G.A. Secs. 19-7-5, 31-7-2.1.

Original Rule entitled "Organization and Administration" adopted. F. July 14, 2010; eff. August 3, 2010.