105 CMR, § 143.007 - Administrative Records

(A) Each program shall maintain and have available current, complete, and accurate administrative records in a safe location.

(B) Administrative records shall include:

(1) Updated articles of organization and by-laws, partnership agreement or trust instrument. as appropriate. The documents shall specify the organizational structure of the governing body and the methods of the selection of its members.

(2) Minutes of meetings of the governing body and of the members.

(3) An organizational chart for the entire organization.

(4) Written policies and procedures designed to safeguard the health and safety of patients and staff. These policies and procedures shall be reviewed and updated annually. At a minimum the policies shall address:

(a) Selection of personnel and the qualifications for each position. A job description for each position must be included in the administrative records.

(b) Employee health policies that assure employees are free of communicable disease.

(c) Release of information to another facility, agency, or health care provider.

(d) Obtaining informed consent.

(e) Services which the program provides.

(f) Smoking on the premises. Such policies shall assure the comfort of all patients including patients in waiting areas. In the case of a program operated by a health care facility licensed by the Department, said program shall comply with any regulations concerning smoking that are applicable to such facility.

(g) Informing patients of the admission criteria, services available. and third party coverage and personal charges.

(5) Personnel records for each employee, including evidence of any required license or registration number; documentation of any specialty certification, education and job experience.

Notes

105 CMR, § 143.007