R501-21-4. Administration and Direct Services

  (1) In addition to the following rules, all outpatient treatment programs shall comply with R501-1 General Provisions and R501-14 Background Screening Rules.

  (2) Programs shall have current program information readily available to the Office and the public, including a description of:

  (a) program services;

  (b) the client population served;

  (c) program requirements and expectations;

  (d) information regarding any non-clinical services offered;

  (e) costs, fees, and expenses that may be assessed, including any non-refundable costs, fees or expenses; and

  (f) complaint reporting and resolution processes.

  (3) The Program shall:

  (a) provide outpatient and/or intensive outpatient treatment services not to exceed nineteen hours per week, as clinically recommended and documented;

  (b) identify and provide to the Office the organizational structure of the program including:

  (i) names and titles of owners, directors and individuals responsible for implementing all aspects of the program, and

  (ii) a job description, duties and qualifications for each job title;

  (c) identify a director or qualified designee who shall be immediately available at all times that the program is in operation;

  (d) ensure at least one CPR/First Aid trained or certified staff member is available onsite at all times with clients present;

  (e) disclose any potential conflicts of interest to the Office;

  (f) ensure that staff are licensed or certified in good standing as required and that unlicensed individuals providing direct client services shall do so only in accordance with the Mental Health Professional Practices Act;

  (g) train and monitor staff compliance regarding:

  (i) program policy and procedures;

  (ii) the needs of the program's consumers;

  (iii) Office of Licensing rule 501-21 and annual training on the Licensing Code of Conduct and client rights as outlined in R501-1-11;

  (iv) emergency procedures;

  (h) create and maintain personnel files for each staff member to include:

  (i) applicable qualifications, experience, certifications and licenses;

  (ii) approved and current Office of Licensing background screening except as excluded in 501-14-17; and

  (iii) training records with date completed, topic and employee signature(s) verifying completion.

  (i) comply with Office rules and all local, state and federal laws to include maintaining a current business license, fire inspection and health clearance as applicable;

  (j) maintain proof of financial viability of the program;

  (k) maintain general liability insurance, professional liability insurance that covers all program staff, vehicle insurance for transport of clients, fire insurance and any additional insurance required to cover all program activities; and

  (l) maintain proof of completion of the National Mental Health Services Survey (NMHSS) annually for each site providing mental health services; and

  (m) ensure that all programs and individuals involved with the prescription, administration or dispensing of controlled substances shall do so per state and federal law, including maintenance of DEA registration numbers for:

  (i) all prescribing physicians; and

  (ii) the specific site where the controlled substances are being prescribed, as required.

  (4) The program shall develop, implement and comply with policies and procedures sufficient to ensure the health and safety and meet the needs of the client population served. Policies and procedures shall address:

  (a) client eligibility;

  (b) intake and discharge process;

  (c) client rights as outlined in R501-1-12;

  (d) staff and client grievance procedures;

  (e) behavior management;

  (f) medication management;

  (g) critical incident reporting as outlined in R501-1-2-9 and R501-1-9-2d;

  (h) emergency procedures;

  (i) transportation of clients to include requirement of insurance, valid driver license, driver and client safety and vehicle maintenance;

  (j) firearms;

  (k) client safety including any unique circumstances regarding physical facility, supervision, community safety and mixing populations; and

  (l) provision of client meals, administration of required medications, maximum group sizes, and sufficient physical environment providing for the comfort of clients when clients are present for six or more consecutive hours.

  (5) Programs shall maintain client files to include the following:

  (a) client name, home address, email address if available, phone numbers, date of birth and gender;

  (b) legal guardian and emergency contact names, address, email address and phone numbers;

  (c) all information that could affect the health, safety or well-being of the client including all medications, allergies, chronic conditions or communicable diseases;

  (d) intake assessment;

  (e) treatment plan signed by the clinical professional or service plan for non-clinical services;

  (f) detailed documentation of all clinical and non-clinical services provided with date and signature of staff completing each entry;

  (g) signed fee disclosure statement including Medicaid number, insurance information and identification of any other entities that are billed for the client's services;

  (h) client or guardian signed consent or court order of commitment to services in lieu of signed consent, for all treatment and non-clinical services; and

  (i) grievance and complaint documentation.

  (j) discharge documentation

  (6) Programs shall document a plan detailing how all program, staff, and client files shall be maintained and remain available for the Office and other legally authorized access, for seven years, regardless of whether or not the program remains licensed.

  (7) The program shall ensure that assessment, treatment and service planning practices are clinically appropriate, updated as needed, timely, individualized, and involve the participation of the client or guardian.

  (8) Programs shall maintain documentation of all critical incidents; critical incident reports shall contain:

  (a) time of incident;

  (b) summary of incident;

  (c) individuals involved; and

  (d) program response to the incident.