(a)  The governing body responsible for each facility or service shall develop and implement written policies for the following:

(1)           delegation of management authority for the operation of the facility and services;

(2)           criteria for admission;

(3)           criteria for discharge;

(4)           admission assessments, including:

(A)          who will perform the assessment; and

(B)          time frames for completing assessment.

(5)           client record management, including:

(A)          persons authorized to document;

(B)          transporting records;

(C)          safeguard of records against loss, tampering, defacement or use by unauthorized persons;

(D)          assurance of record accessibility to authorized users at all times; and

(E)           assurance of confidentiality of records.

(6)           screenings, which shall include:

(A)          an assessment of the individual's presenting problem or need;

(B)          an assessment of whether or not the facility can provide services to address the individual's needs; and

(C)          the disposition, including referrals and recommendations;

(7)           quality assurance and quality improvement activities, including:

(A)          composition and activities of a quality assurance and quality improvement committee;

(B)          written quality assurance and quality improvement plan;

(C)          methods for monitoring and evaluating the quality and appropriateness of client care, including delineation of client outcomes and utilization of services;

(D)          professional or clinical supervision, including a requirement that staff who are not qualified professionals and provide direct client services shall be supervised by a qualified professional in that area of service;

(E)           strategies for improving client care;

(F)           review of staff qualifications and a determination made to grant treatment/habilitation privileges;

(G)          review of all fatalities of active clients who were being served in area-operated or contracted residential programs at the time of death;

(H)          adoption of standards that assure operational and programmatic performance meeting applicable standards of practice.  For this purpose, "applicable standards of practice" means a level of competence established with reference to the prevailing and accepted methods, and the degree of knowledge, skill and care exercised by other practitioners in the field;

(8)           use of medications by clients in accordance with the rules in this Section;

(9)           reporting of any incident, unusual occurrence or medication error;

(10)         voluntary non-compensated work performed by a client;

(11)         client fee assessment and collection practices;

(12)         medical preparedness plan to be utilized in a medical emergency;

(13)         authorization for and follow up of lab tests;

(14)         transportation, including the accessibility of emergency information for a client;

(15)         services of volunteers, including supervision and requirements for maintaining client confidentiality;

(16)         areas in which staff, including nonprofessional staff, receive training and continuing education;

(17)         safety precautions and requirements for facility areas including special client activity areas; and

(18)         client grievance policy, including procedures for review and disposition of client grievances.

(b)  Minutes of the governing body shall be permanently maintained.


History Note:        Authority G.S. 122C-26; 143B‑147;

Eff. May 1, 1996.