R03-203. Program Structure

A.        The executive director, program director, or designee shall:

1.         Be responsible for the organization and the administrative and clinical management of the treatment program, and

2.         Ensure compliance with applicable federal, state, and local regulations.

1. Review job description for executive director, program director or designee to verify it contains language to address R03-203 A 1-2.

 

B. The executive director, program director, or designee shall:

1. For each service the treatment program is licensed to provide have available at the program for public review, a current written program description,

2. Notify the Department of Social and Rehabilitation Services if the executive director, program director, or designee changes and provide to SRS, in writing, the new individual’s name and qualifications within 30 days after the effective date of the change,

3. Develop, implement, and comply with a written staffing plan to ensure there is sufficient staff to provide services to address the:

a. Scheduled needs of the clients, such as, client-to-staff ratio as stipulated in Section 7, and

b. Unscheduled circumstances such as staff illness, unexpected client needs, holidays, and other emergencies,

4. Make reasonable modifications in their policies, practices, and procedures to avoid discrimination on the basis of disability as defined in the American Disability Act of 1990,

5. Develop, implement, and comply with a policy for insuring the ethical management of client funds for individuals served in residential treatment.

1. Review program description example: brochure. 2. Review policy and procedure manual. 3. a. Review policy and procedure manual, and verify client roster and counselor assignment meet compliance of ratio requirement. 3. b. Review policy and procedure manual. 4. Review policy and procedure manual. 5. Review policy and procedure manual. Verify compliance with client funds management.

 

C. The executive director, program director or designee shall:

1. Review, approve, and, if necessary, update policies and procedures on an annual basis as indicated by a dated signature, a record of which is maintained on the premises or at the administrative offices,

2. When a policy or procedure is approved or updated, ensure each staff member whose duties are affected by the policy and procedure reviews the policy and procedure within 30 days after the policy and procedure is approved or updated,

3. Ensure a licensee provides or contracts for crisis intervention services and utilizes the services as needed, and

4. Ensure that all current records, reports, or documents required to be maintained by these standards or federal, state or local law is provided to the Department of Social and Rehabilitation Services upon request, such as, annual fire drills or Qualified Service Organization Agreement for ancillary services.

1. Review record of annual review and or update of policy and procedures verified by signature and date. 2. Review policy and procedure manual and verify that staff affected by policy change is notified as required. 3. Review policy and procedure manual and verify services are provided by program or contract services.

 

D. An executive director, program director or designee shall develop, implement, and comply with policies and procedures that ensure that programs are in compliance with all licensing standards and regulations.

1. Review policy and procedure manual.

 

E. The executive director, program director, or designee shall ensure the following documents are maintained by programs and are available to program staff and the Department of Social and Rehabilitation Services:

1. A resource directory or a list of referral sources for ancillary services for: a. Medical, psychological, psychiatric, laboratory, and toxicology services that are a more intensive modality of treatment, or b. Ancillary service according to the severity and urgency of the client’s condition,

2. The licensee’s organizational chart showing all staff member positions and the lines of supervision, authority, and accountability,

3. A list of the names of current clients,

4. Reports of incidents required to be reported under R03-401,

5. Fire inspection reports, if applicable,

6. Documentation of fire and tornado drills required by R03-502(D),

7. Food establishment inspection reports, if applicable,

8. Proof of liability insurance,

9. The program policy and procedure manual,

10. The most recent licensing visit report prepared by Kansas Department of Social and Rehabilitation Services,

11. Each approved plan of correction with the Kansas Department of Social and Rehabilitation Services shall be retained for five years immediately following the approval date, and

12. The Department of Social and Rehabilitation Services, Standards for Licensure/Certification of Alcohol and/or Other Drug Abuse Treatment Programs.

1. The internet is permissible as the overall resource directory for R03-203 E. 3. Review a list of current clients. 4. Review incident reports. 5. Review fire inspection reports, if applicable. 6. Review documentation of drills. 7. Review KDHE inspection reports. 8. Verify liability insurance. 10. Verify most recent licensing report. 11. Verify last five years of corrective actions, if applicable. 12. Verify copy Standards for Licensing /Certification.

 

F. A licensee shall develop and maintain policies:

1. Regarding the hiring of current and former clients, and

2. That ensure labor performed for a licensee by current and former clients is consistent with applicable state and federal law.

1. Review policy and procedure manual and verify it contains all elements of R03-203 F1-2.

 

G. The Licensee shall develop and implement written client grievance procedure to ensure prompt, impartial review of any alleged or apparent incident, a violation of rights or confidentiality.

1. The procedure shall include but not be limited to the following:

a. Completion of the review within 30 calendar days.

b. Appeal process including the address and phone number of the Department of Social and Rehabilitation Services which shall be conspicuously posted in the facility.

2. The licensee shall cooperate with the Department of Social and Rehabilitation Services in completion of any inquiries related to client rights conducted by SRS staff.

3. The licensee shall ensure that no client or agency personnel who has submitted a complaint or has participated in the investigation will be discharged or discriminated against in any way.

1. Review policy and verify that it reflect the requirements as stated in R03-203 G. 1. a. Review the policy and procedure manual and verify that date of review is completed within 30 days. 1. b. Verify the AAPS current address/ phone number and appeal process is posted conspicuously. 3. Review written policy.

 

H. The Licensee shall ensure that the current license or certificate to provide substance abuse services is conspicuously posted in the facility.

Verify location of license.

 

J. A licensee shall ensure that research or treatment that is not a professionally recognized treatment is approved by a Research, Experimentation, and Clinical Trials Committee before a staff member, client, or client record is involved in the research or treatment. A licensee may establish and implement a Research, Experimentation, and Clinical Trials Committee or may use a Research, Experimentation, and Clinical Trials Committee established and implemented by the Department of Social and Rehabilitation Services or a state university. A Research, Experimentation, and Clinical Trials Committee established and implemented by a licensee shall:

1. Establish criteria for the approval or disapproval of research or treatment,

2. Protect, during each phase of research or treatment:

a. Client rights,

b. Client health, safety, and welfare,

c. Client privacy,

d. The confidentiality of client records and information, and e. Client anonymity,

3. Ensure that oversight is provided by a medical professional, if research or treatment may impact a client's health or safety,

4. Inform a client of:

a. The purpose, design, scope, and goals of the research or treatment,

b. The full extent of the client's role in the research or treatment,

c. Any risks to the client involved in the research or treatment, and d. The client's right to privacy, confidentiality, and voluntary participation,

5. Obtain documentation of a client's informed consent, completed as required by R03-602, before allowing a client to participate in research or treatment, and

6. Review research or treatment requests and approve or deny requests.

Review in Policy and Procedure manual.