105 CMR, § 158.031 - Administrative Records, Reporting Requirements, and Policies and Procedures

(A) A Program shall maintain administrative records including the following:

(1) The names and number of participants enrolled;

(2) The names and number of participants waiting for service commencement;

(3) The names and number of personnel;

(4) Incident reports;

(5) Complaint and grievance reports;

(6) A personnel file on each staff person and volunteer, as specified under 105 CMR 158.000;

(7) Contracts for therapy, nutritional, and other services;

(8) Daily attendance records; and

(9) Other records as may be required by the Department.

(B) A Program shall submit records, reports, and other documentation to the Department within seven days upon request.

(C) Serious Incident and Accident Reports.

(1) Each Program shall immediately report to the Department any of the following which occurs on premises covered by its license:

(a) Death that is unanticipated, not related to the natural course of the participant's illness or underlying condition, or that is the result of an error or other incident as specified in guidelines of the Department;

(b) Full or partial evacuation of the facility for any reason;

(c) Fire;

(d) Suicide;

(e) Serious criminal acts;

(f) Pending or actual strike action by its employees, and contingency plans for operation of the Program;

(g) Illness including:

1. Illness believed to be part of a suspected or confirmed cluster or outbreak of any illness;

2. Illness believed to be unusual; or

3. Illness related to food consumption or believed to be transmissible through food.

(h) Other serious incidents or accidents as specified in guidelines of the Department.

(2) A Program shall immediately report to the Department any suspected instance(s) of participant abuse, neglect, mistreatment, or misappropriation of a participant's personal property.

(3) A Program shall report to the Department any other serious incident or accident occurring on premises covered by the Program's license that seriously affects the health or safety of a participant(s) or that causes serious physical injury to a participant(s), within seven days of the date of occurrence of the event.

(D) The Department shall establish guidelines for the reporting of serious incidents and accidents, including the means of reporting.

(E) In accordance with guidelines established by the Department, a Program shall:

(1) Ensure a reliable means for sending information to the Department regarding incidents at the Program;

(2) Ensure a reliable means for receiving information from the Department and from state and local authorities in the event of an emergency; and

(3) Ensure all staff are trained to send and receive information regarding incidents and emergencies.

(F) Policies and Procedures.

(1) A Program shall develop and implement written policies and procedures, consistent with professional standards of care and 105 CMR 158.000, regarding the following:

(a) Enrollment, emergency transport, and discharge;

(b) Diagnostic services, including laboratory services;

(c) Nursing services:

(d) Medication management;

(e) Dietary services;

(f) Rehabilitation services;

(g) Service Coordination;

(h) Therapeutic activities;

(i) Other professional services;

(j) Medical emergencies, including criteria for calling emergency telephone access number 911;

(k) Disaster and emergency plans, including evacuation and transfer plans;

(l) Participant elopement;

(m) Health records;

(n) Participant rights and grievances;

(o) Abuse, mistreatment, neglect, and misappropriation;

(p) Quality assessment and performance improvement;

(q) Infection control;

(r) Personnel policies;

(s) Research;

(t) Safekeeping of participant items, funds, and other property, as appropriate; and

(u) Compliance with antidiscrimination provisions of 105 CMR 158.034(B) and 158.041(A).

(2) The Program Director and licensee shall be responsible for the development and review of the policies and procedures stated in 105 CMR 158.031(F)(1). The Program Director shall consult with the Participant and Family Advisory Council, professionals who may include primary care providers, pharmacists, nursing staff, and representatives from other disciplines in the development of these policies.

(3) The Program Director shall ensure the policies and procedures shall be reviewed at least annually and revised as needed.

(G) Disaster Plan.

(1) A Program shall establish written emergency policies and procedures to be followed in case of fire, or other emergency, developed with the assistance of local and state fire and safety experts, and posted at all nurses' stations and in conspicuous locations throughout the Program.

(2) Written emergency policies and procedures shall include the following:

(a) An emergency evacuation plan that is in compliance with and coordinated with local fire department requirements;

(b) A procedure to be followed in the event a participant is missing or lost;

(c) Procedures for handling medical emergencies at the Program;

(d) Persons to be notified in case of an emergency;

(e) Locations of alarm signals and fire extinguishers; and

(f) Assignment of specific tasks and responsibilities to the personnel. All personnel shall be trained to perform an assigned task.

(3) A Program shall maintain an emergency fact sheet on each participant that contains the following information:

(a) The name and telephone number of the participant's primary care provider;

(b) The participant's diagnosis;

(c) Any special treatments or medications the participant may need;

(d) Insurance information; and

(e) The name and telephone number of the identified contact person and, if applicable, the legally authorized representative to be notified in case of emergency.

(4) A Program shall conduct quarterly fire and evacuation drills. All staff shall participate in these drills. Documentation of evacuation drills shall be kept on file.

(5) A Program shall ensure staff are trained to respond to emergencies in accordance with written policies and procedures.

(6) A Program shall ensure staff are trained to send and receive reports to the Department, and respond to reports in an appropriate manner for the safety of participants as specified at 105 CMR 158.031.

Notes

105 CMR, § 158.031

Adopted by Mass Register Issue 1277, eff. 1/2/2015. Amended by Mass Register Issue 1349, eff. 10/6/2017. Amended by Mass Register Issue 1505, eff. 9/29/2023.