Haw. Code R. § 11-98-10 - Minimum standards for licensure; administrative and organizational plan
(a) Every facility shall have and maintain a
current written plan describing the philosophy, goals, and objectives of its
program. This program shall be reviewed and evaluated periodically or at least
annually.
(b) The plan shall also
include a statement of the geographic area to be served, ages and kinds of
residents to be served, anticipated average length of stay of its residents,
and the limitations and scope of service for which the facility is
established.
(c) A policy of
nondiscrimination based on age, race, color, creed, or national origin relating
to admission of residents shall be established.
(d) A policy of nondiscrimination based on
sex, age, race, color, creed, national origin, or physical handicap relative to
the personnel policies and practices governing the hiring, promotion and
dismissal of its staff shall be established.
(e) Each facility shall develop written
policies and procedures, and criteria governing its management and operations.
These shall include but are not limited to the following:
(1) Personnel policies, procedures and
practices including the qualifications, duties and responsibilities for each
staff position, hiring, suspension, dismissal, assignment, promotion, grievance
procedures and other related personnel matters;
(2) Policies and procedures, and criteria
relative to admission of residents to the program, dismissal and
discharge;
(3) Policies and
procedures governing the rights (legal, civil, and human) and responsibilities
of the residents and the confidential nature of resident information;
(4) Procedures for handling complaints and
grievances expressed by residents, persons, or agencies responsible for
residents, and the public;
(5) A
description of the facility's services available to residents and responsible
parties or agencies and the public. It shall include services directly provided
or contracted for by the facility. It shall also include arrangements for
emergency medical transportation on a twenty-four hour basis;
(6) Terms of contractual agreements entered
into with out side providers of services required in this chapter including the
description of roles, responsibilities and authority of all parties
involved;
(7) Policies and
procedures and copies of written agreements for coordination and liaison
between the facility and relevant community agencies, concerning the admission,
treatment, discharge and follow up of residents;
(8) A description of the provisions for
rendering emergency medical and psychiatric care, including the name, address,
and telephone number of the physician;
(9) The facility shall submit a copy of its
policy and procedures regarding the use of physical or chemical restraints. No
physical or chemical restraints shall be used except as outlined in the policy
and procedures and only following the approval of the policy and procedures by
the director;
(10) Policies and
procedures relative to general rules regarding residents' records, including:
(A) All entries shall be made in ink, be
legible, dated and signed with first initial and last name;
(B) Symbols and abbreviations shall be
explained in a legend;
(C) An area
shall be provided for safe and easy access to residents' records;
(D) Residents' records shall be retained for
five years after discharge or, if s state-owned facility, a period to comply
with state law;
(E) Policies
governing access by the resident and others, duplication of, and dissemination
of information from the record;
(F)
Policies protecting the confidentiality of resident information;
(G) Policies requiring written consent of the
resident, if competent, or the resident's guardian for the release of
information to persons and agencies not otherwise authorized to receive
it;
(H) The facility's
responsibility to secure the information under lock against loss, distribution,
defacement, tampering, or use by unauthorized persons;
(f) Every facility shall maintain
financial records, include an annual budget and its income and
expenditures.
(g) New facilities
shall document in writing assurances of funding sufficient to meet projected
program costs, plus sufficient funds to cover the initial implementation
costs.
(h) Each facility shall
maintain statistical and other administrative records as provided in section
11-98-04.
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