Tenn. Comp. R. & Regs. 0940-05-06-.02 - POLICIES AND PROCEDURES FOR ALL SERVICES AND FACILITIES

(1) The governing body must ensure that a written policies and procedures manual is maintained. The manual must include the following elements:

(a) A description of each facility service provided by the licensee. The description must include the hours of operation and admission and discharge criteria and rules for service recipients, if any;

(b) An organizational chart or a statement which clearly shows or describes the lines of authority between the governing body, the chief executive officer, and the staff;

(c) Policies and procedures which ensure that someone is delegated the authority to act in the absence of the individual responsible for the operation of the facility;

(d) A schedule of fees currently charged to the client, if any, for all services provided by the licensee, including a refund policy. The schedule shall include:

1. The fee or fees for each service, including any additional charges for services not covered by the basic service fee;

2. The process by which licensee will apply any governmental or other funds or donations to the fee or fees for services. This may include, but not be limited to, use of a client's food stamps as payment for his or her meals; use of federal, state or other funds or donations to finance all or part of the client's cost for services; or payments made to the agency for a client's participation in an employment or rehabilitation program to finance the cost of services provided; and,

3. The total cost of services to the client;

(e) A statement of client rights and the grievance procedures to be followed when a suspected violation of client rights has been reported. This statement shall, at a minimum, include those client rights found in Rule 0940-05-06-.06 and, if applicable, 0940-05-06-.09;

(f) Policies and procedures which ensure the confidentiality of client information and which include the following provisions:

1. The facility staff must comply with applicable confidentiality laws and regulations (e.g. T.C.A. § 33-3-103; federal alcohol and drug regulations found at 42 C.F.R. Part 2);

2. The client must not be required to make public statements which acknowledge gratitude to the licensee or for the licensee's facility services;

3. The client must not be required to perform in public gatherings; and,

4. Identifiable photographs of the client must not be used without the written and signed consent of the client or the client's guardian;

(g) A medication administration policy and control procedures for facilities involved in the administration of medication to clients or facilities that supervise the self-administration of medication by the client;

(h) The plans and procedures to be followed in the event of fire evacuation and natural disaster emergencies;

(i) The plans and procedures to be followed in the event of an emergency involving client care which will provide for emergency transportation of clients, emergency medical care, and staff coverage in such events;

(j) A policy which prohibits clients, except those who may be certified by the Department as peer or family support specialists and who are working at a facility in that capacity, from having any of the following responsibilities:

1. Responsibility for the care of other clients;

2. Responsibility for the supervision of other clients unless on-duty/on-site staff are present; and,

3. Responsibilities requiring access to confidential information;

(k) Policies and procedures to be followed in the reporting and investigation of suspected or alleged abuse, neglect, or other critical incidents, whether perpetrated by or on the client by staff, other clients or outside parties. The procedures must include provisions for corrective action, if any, to be taken as a result of such reporting and investigation. These procedures shall also include provisions for reporting incidents or allegations to the department and, when necessary other appropriate state agencies and local law enforcement;

(l) Policies and procedures which ensure that volunteers, if used by the facility, are in a supportive capacity and are under the supervision of appropriate designated staff members. A record should be maintained on each volunteer which shall include the volunteer's status on the Tennessee Sexual Offender Registry (Sex Offender Registry). A volunteer included on either the Abuse Registry or the Sex Offender registry shall not work in an agency providing services to vulnerable adults or children. It is recommended that the volunteer's record also include a criminal background check and references.

(m) Policies and procedures which govern the use of client behavior-management techniques, if used by the facility;

(n) A policy regarding the use of human subjects in research, if the facility is involved or planning to be involved in such research, which includes procedures for the following:

1. Identification of subjects, projects and staff;

2. Provisions to protect the personal and civil rights of the subjects;

3. Obtaining the consent of the subject involved;

4. Assurance that all research projects are conducted under the direction and supervision of professional staff qualified by education and experience to conduct research;

5. Emergency guidelines for problems that may develop during research activities; and,

6. Appointment of a facility representative to act as a coordinator of the research activities;

(o) Policies and procedures for ensuring that employees and volunteers comply with procedures for detection, prevention and reporting of infectious and communicable diseases to the Tennessee Department of Health;

(p) Policies and procedures ensuring that employees and volunteers practice infection control procedures and standard precautions to protect the service recipient from infectious diseases;

(q) Policies and procedures regarding coordination of care with the client's other health, mental health, social, educational and residential service providers;

(r) Policies and procedures describing the process by which the licensee will comply with Rule 0940-05-06-.03 Financial Management of All Services and Facilities, including process by which the client or client's representative may register a complaint with the licensee to address the licensee's holding and disbursement of client's funds or property;

(s) Policies and procedures that address inappropriate relationships of a business, social, professional, romantic and sexual nature between the client and the licensee, its staff and/or volunteers; and,

(t) Policies and procedures that address sanctions against an employee for violations of the licensee's policies and procedures and a process by which a complaint or grievance may be registered with the licensee.

Notes

Tenn. Comp. R. & Regs. 0940-05-06-.02

Original rules filed May 26, 1988; effective July 11, 1988. Amendment filed May 28, 2010; to have been effective August 26, 2010. Stay of amendment filed by the Tennessee Department of Mental Health and Developmental Disabilities on July 21, 2010; new effective date November 9, 2010. Withdrawal of amendment filed August 2, 2010. Amendment filed August 30, 2010; to have been effective January 29, 2011. Stay of amendment filed by the Tennessee Department of Mental Health and Developmental Disabilities on January 29, 2011; new effective date March 7, 2011. Withdrawal of amendment filed by the Department of Mental Health and Developmental Disabilities on February 25, 2011. Repeal and new rules filed November 30, 2016; effective 2/28/2017.

Authority: T.C.A. §§ 4-4-103, 33-1-302, 33-1-305, 33-1-309, 33-2-302, 33-2-304, 33-2-404, 33-2-405, 33-2-407, and 33-2-504.