14- 118 C.M.R. ch. 5, § 3 - AGENCY ORGANIZATION

3.1 Statement of Ownership.

3.1.1 Authority. The agency shall maintain documentary evidence of its source(s) of authority to provide services. Such evidence will include articles of incorporation, corporate charter or similar documents.

3.1.2 Records. Corporations, partnerships or associations, whether for-profit or not-for-profit, shall maintain records of the names and current addresses of officers and directors, charters, partnership agreements, constitutions, articles of association and by-laws, as applicable.

3.1.3 For Profit Organizations. Organizations operating on a for-profit basis shall maintain the names and current addresses of principal owners.

3.2 Governance.

3.2.1 Definition. There shall be an individual or association of persons (board of directors) with ultimate managerial control and legal responsibility for the operation of the agency, called the Governing Authority. All agencies shall minimally have either:

3.2.1.1 an advisory board which shall

3.2.1.1.1 include community members and local public officials who reflect diverse perspectives;

3.2.1.1.2 meet on a regular basis;

3.2.1.1.3 provide advice to the Governing Authority; and

3.2.1.1.4 maintain a record of meetings that includes the dates, attendance, and topics discussed.

3.2.1.2 or a board of directors which shall

3.2.1.2.1 include community members who reflect diverse perspectives;

3.2.1.2.2 meet on a regular basis; and

3.2.1.2.3 maintain a record of meetings that includes the dates, attendance, and topics discussed.

3.2.2 Membership of the Governing Authority.

3.2.2.1 Members of the Governing Authority who are assigned responsibilities associated with the licensing of, purchase of services from, or contracting with the agency, or members of the immediate family of such employees shall not be employees of any state or Federal government entity.

3.2.2.2 The agency shall maintain a record of the membership of the Governing Authority, indicating the position and term of office for each member.

3.2.3 Duties of the Governing Authority.

3.2.3.1 Meetings. The Governing Authority shall:

3.2.3.1.1 meet at least quarterly;

3.2.3.1.2 maintain records of attendance and minutes of its meetings. Records of attendance and minutes shall be maintained by the agency and made available to the Licensing Authority;

3.2.3.1.3 Minutes. Minutes must, at a minimum, reflect board discussions around the treatment services, client satisfaction, and significant fiscal and administrative issues.

3.2.3.2 Conflict of interest policy. The governing authority must adopt a policy regarding conflicts of interest among its members, that at minimum defines a conflict of interest and a matter of self interest, and the procedures for resolving same.

3.2.3.3 Agency Operation and Management. The Governing Authority shall:

3.2.3.3.1 develop a mission statement describing the overall philosophy and function of the agency that at a minimum incorporates how the agency welcomes individuals who come from culturally diverse backgrounds, and individuals who may have co-occurring mental and/or medical disorders;

3.2.3.3.2 be responsible for and have authority over the policies and operations of the agency;

3.2.3.3.3 make available to the Licensing Authority any policies or records required by these rules or reasonably related to the assessment of compliance with these rules;

3.2.3.3.4 meet with representatives of the Licensing Authority when requested to do so;

3.2.3.3.5 ensure that every discrete program, service, facility or other management division is in compliance with the Americans with Disabilities Act (ADA) ( 42 USC §12101, et seq.), Section 504 of the Rehabilitation Act ( 42 USC § 794 ) and the Maine Human Rights Act (MHRA) ( 5 M.R.S.A. §4551, et seq.);

3.2.3.3.6 be governed in all respects by the laws, statutes, and regulations of the United States of America and of the State of Maine;

3.2.3.4 Fiscal Management. The Governing Authority shall:

3.2.3.4.1 ensure that the agency is adequately funded to provide licensed/certified services;

3.2.3.4.2 provide physical facilities, staff, equipment, supplies and other needs adequate and sufficient to provide licensed/certified services;

3.2.3.4.3 review and approve the agency's annual budget;

3.2.3.5 Communication with the Licensing Authority. The Governing Authority shall ensure written notification to the Licensing Authority:

3.2.3.5.1 ninety calendar days in advance of any proposed change in location, name or ownership of the agency;

3.2.3.5.2 thirty calendar days prior to any planned change or within ten calendar days following any unplanned change of Chief Administrative Officer of the agency;

3.2.3.5.3 sixty calendar days in advance of any substantial change in policy or service, including but not limited to the addition of a new service or program;

3.2.3.5.4 within two working days after the agency receives notice of any legal proceedings arising from circumstances related to the provision of services or the continued operation of the facility or program, whether brought against the agency or against any employee;

3.2.3.5.5 within two calendar days after receiving notice or learning of criminal convictions for events occurring in the workplace;

3.2.3.5.6 within ten calendar days after receiving notice of significant discrepancies found at audit.

3.3 Chief Administrative Officer.

3.3.1 Selection and Appointment.

3.3.1.1 The Chief Administrative Officer shall be appointed by the Governing Authority from among persons knowledgeable, by training and experience, and capable of managing the affairs of the agency.

3.3.1.2 Nothing in these rules prohibits the Governing Authority from selecting a contracted management company to fulfill the duties of the Chief Administrative Officer, so long as the individual(s) assuming actual duties fulfill those duties in a manner consistent with these rules.

3.3.2 Duties of the Chief Administrative Officer. The Chief Administrative Officer shall:

3.3.2.1 manage the affairs of the agency in accordance with policies established by the Governing Authority and ensure compliance with all rules and regulations applicable to the provision of services and all programs operated by the agency, except those specifically noted to be the responsibility of the Governing Authority;

3.3.2.2 have directional authority over all operations of the agency;

3.3.2.3 ensure written notification to the Licensing Authority and the Office of Substance Abuse within 24 hours of an incident resulting in a death, suicide attempt, serious injury, or elopement, or other critical incident, pursuant to 1.189 and 5.2; an allegation of abuse or violation of rights; or any other serious event or occurrence;

3.3.2.4 ensure written notification to the Licensing Authority of arrests or indictments of staff related to drug use or other criminal activity on the grounds of any program or location for the provision of services, within 24 hours of learning of the event;

3.3.2.5 ensure written notification to the Licensing Authority in the event of fire, structural damage or other catastrophe which renders any structure used for the provision of licensed/certified services, unsafe, unusable or uninhabitable, within 24 hours following such event;

3.3.2.6 ensure timely written notification to the Licensing Authority prior to a change in a program director, medical director, or clinical director, or closure, or changes in program components, modules, substance abuse treatment services or sites;

3.3.2.7 make timely and complete applications prior to changes in or additions to programs;

3.3.2.8 post current, applicable license/certificate(s) issued under these rules in clearly visible place(s) within each licensed /certified facility or program.

Notes

14- 118 C.M.R. ch. 5, § 3