Louisiana Administrative Code
Title 48 - PUBLIC HEALTH-GENERAL
Part I - General Administration
Subpart 3 - Licensing and Certification
Chapter 87 - Adult Brain Injury Facilities Licensing Standards
Subchapter B - Organization and Administration
Section I-8743 - Governing Body Responsibilities

Universal Citation: LA Admin Code I-8743

Current through Register Vol. 50, No. 9, September 20, 2024

A. An ABI facility shall comply with all federal, state and local laws, rules and regulations in the development and implementation of its policies and procedures. The governing body shall ensure all of the following requirements are met.

B. Policies and Procedures. The facility shall have:

1. written policies and procedures approved by the governing body that address the following:
a. confidentiality of client information and security of client files;

b. advertising;

c. personnel;

d. clients rights;

e. a grievance procedure to include documentation of grievances, investigation, resolution and response to complainant in a timely manner, time frame in which facility will respond, and an appeals process for grievances;

f. safekeeping of personal possessions, if applicable;

g. clients funds, if applicable;

h. emergency and evacuation procedures;

i. abuse, neglect and exploitation, and documentation and reporting of same;

j. incidents and accidents and documentation of same;

k. admissions and discharge procedures;

l. medication administration; and

m. safety of the client while being transported by an agency employee, either contracted or staff, that includes a process for evaluation of the employees drivers license status inquiry report which may prohibit an employee from transporting clients;

2. minutes of formal governing body meetings;

3. organizational chart of the facility; and

4. written leases, contracts and purchase-of-service agreements (including all appropriate credentials) to which the facility is a party.

C. Organizational Communication

1. A facility shall establish procedures to assure written communication among personnel to provide continuity of services to all clients.

2. Direct care staff shall have access to information concerning clients that is necessary for effective performance of the employees assigned tasks.

D. Confidentiality and Security of Records. The facility shall ensure the confidentiality of client records, including information in a computerized medical record system, in accordance with applicable federal privacy laws and any state laws and regulations which provide a more stringent standard of confidentiality than the applicable federal privacy regulations and laws.

1. Information from, or copies of, records may be released only to authorized individuals, and the facility shall ensure that unauthorized individuals cannot gain access to or alter client records.

2. Original medical records shall not be released outside the facility unless under court order or subpoena or in order to safeguard the record in the event of a physical plant emergency or natural disaster.

E. Clinical Records

1. A facility shall maintain a separate record for each client. Such record shall be current and complete and shall be maintained in the facility or in a central administrative location readily available to facility staff and to the department.

2. All records shall be maintained in an accessible, standardized order and format and shall be retained and disposed of in accordance with state laws.

3. Each record shall include but not be limited to at least the following information:
a. identifying information to include at least clients name, marital status, date of birth and gender;

b. dates of admission and discharge;

c. clients written authorization and contact information of the representative or responsible person;

d. name and 24-hour contact information for the primary physician and any other physician involved in the clients care;

e. the admission assessment;

f. individual service plan, updates and quarterly reviews;

g. progress notes of care and services received and response to treatment;

h. a record of all personal property and funds which the client has entrusted to the facility; and

i. written acknowledgements that the client has received verbal and written notice of clients rights, grievance procedures and clients responsibilities.

4. Storage of any client information or records may be maintained electronically or in paper form.
a. If stored electronically, documents shall be viewable and reproducible as necessary and relevant.

F. Advertising. A facility shall have written policies and procedures regarding the photographing and audio or audiovisual recordings of clients for the purposes of advertising.

1. No client shall be photographed or recorded without the clients or representatives prior informed written consent.
a. Such consent cannot be made a condition for admission into, remaining in, or participating fully in the activities of the facility.

b. Consent agreements shall clearly notify the client of his/her rights under this regulation and shall specify precisely what use is to be made of the photograph or recordings.

c. Consents are valid for a maximum of one year from the date of execution.

d. Clients are free to revoke such agreements at any time, either orally or in writing.

2. All photographs and recordings shall be used in a way that respects the dignity and confidentiality of the client.

G. Personnel Policies. A facility shall have written personnel policies that include:

1. orientation, ongoing training, development, supervision and performance evaluation of personnel members;

2. written job descriptions for each position, including volunteers;

3. requirements for a health assessment of personnel prior to employment. These policies shall, at a minimum, require that the individual has no evidence of active tuberculosis and is re-evaluated as recommended by the Office of Public Health;

NOTE: Policies shall be in accordance with state rules, laws and regulations for employees, either contracted or directly employed, and volunteers.

4. abuse prevention and reporting procedures that include what constitutes abuse, how to prevent it and requirement that all personnel report any incident of abuse or neglect to the director or his/her designee, whether that abuse or neglect is done by another staff member, either contracted or directly employed, a family member, a client or any other person;

5. criteria for determining employment based on the results of a statewide criminal background check conducted by the Louisiana State Police, or its designee, which shall be conducted upon hire, rehire and in accordance with facility policy for any unlicensed facility personnel:
a. the facility shall have documentation on the final disposition of all charges that bars employment pursuant to applicable state law; and

6. clarification of the facility's prohibited use of social media. The policy shall ensure that all staff, either contracted or directly employed, receive training relative to the restrictive use of social media and include, at a minimum, ensuring confidentiality of client information and preservation of client dignity and respect, including protection of client privacy and personal and property rights.

H. Orientation

1. A facility's orientation program shall include training in the following topics for all personnel:
a. the policies and procedures of the facility, including but not limited to the prohibited use of social media;

b. emergency and evacuation procedures;

c. clients rights;

d. abuse and neglect prevention and requirements concerning the reporting of abuse and neglect of clients;

e. procedures for reporting of incidents and accidents; and

f. instruction in the specific duties and responsibilities of the employees job and a competency evaluation of those duties and responsibilities.

2. Orientation for direct care staff, either contracted or directly employed, shall include the following:
a. training in client care services (ADLs and IADLs) provided by the facility;

b. infection control to include universal precautions;

c. any specialized training to meet clients needs; and

d. a new employee shall not be given sole responsibility for the implementation of a clients program plan until this training is documented as successfully completed.

3. All direct care staff shall receive and/or have documentation of certification in basic life support and general first aid procedures within the first 30 days of employment. Direct care staff, either contracted or directly employed, shall have this training prior to being assigned sole responsibility for a clients care.

4. In addition to the topics listed above, orientation for direct care staff, either contracted or directly employed, shall include an evaluation to ensure competence to provide ADL and IADL assistance.

5. A new direct care staff employee shall not be assigned to carry out a clients care until competency has been demonstrated and documented.

I. Annual Training

1. A facility shall ensure that each direct care staff participates in required training each year. Routine supervision of direct care staff shall not be considered as meeting this requirement.

2. The facility shall document that direct care staff, either contracted or directly employed, receive training on an annual basis in:
a. facility's policies and procedures;

b. emergency and evacuation procedures;

c. clients rights;

d. abuse and neglect prevention and requirements concerning the reporting of abuse and neglect and incidents and accidents;

e. client care services (ADLs and IADLs);

f. infection control to include universal precautions; and

g. any specialized training to meet clients needs.

3. All direct care staff, either contracted or directly employed, shall have documentation of current certification in basic life support and general first aid.

J. Evaluation. An employees annual performance evaluation shall include his/her interaction with clients, family, and other employees.

K. Personnel Files

1. A facility shall maintain a separate personnel record for each employee. At a minimum, this file shall contain the following:
a. the application for employment including the applicants education, training and experience;

b. a statewide criminal background check conducted by the Louisiana State Police, or its designee, prior to an offer of employment for any unlicensed personnel:
i. the facility shall have documented disposition of any charges, if applicable;

c. evidence of applicable professional credentials;

d. documentation of required health assessment as defined in the facility's policies;

e. annual performance evaluation;

f. employees hire and termination dates;

g. documentation of orientation and annual training;

h. documentation of competency evaluations for duties assigned, including, but not limited to, safety in transporting clients;

i. documentation of a current, unrestricted drivers license (if driving or transporting clients);

j. documentation of a current drivers license status inquiry report available on-line from the state Office of Motor Vehicles for staff, either contracted or directly employed, who are required to transport clients as part of their assigned duties; and

k. comply with the provisions of R.S. 40:2179-2179.2 and the rules regarding the direct service worker registry.

2. A facility shall not release an employees personnel file without the employees written permission, except as required by state law.

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and 40:2120.31-40.

Disclaimer: These regulations may not be the most recent version. Louisiana may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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