Code of Maine Rules
14 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
197 - OFFICE OF AGING AND DISABILITY SERVICES
Chapter 10 - CERTIFICATION REQUIREMENTS FOR AGENCIES SEEKING TO PROVIDE COMMUNITY BASED TARGETED CASE MANAGEMENT FOR ADULTS WITH MENTAL RETARDATION AND AUTISM
Section 197-10-V - PERSONNEL MANAGEMENT
Universal Citation: 14 ME Code Rules ยง 197-10-V
Current through 2024-38, September 18, 2024
A. Personnel Policies. The agency shall adopt written personnel policies and procedures to address adequately relevant elements of these rules and applicable laws.
1. Access to personnel
policies. Employees, persons receiving services, guardians, advocates and
representatives of the Department shall have access to personnel policies
during regular business hours of the agency, except as provided below.
a. nothing in these rules prohibits
restricting access to personnel policies by employees, persons receiving
services, families, guardians and advocates to specific locations or
circumstances of oversight and supervision, if the restrictions are reasonable,
are clearly defined in policy and otherwise comport with applicable laws and
regulations.
b. copies of personnel
policies shall be promptly provided to persons receiving services, families,
guardians and advocates, if requested. However, nothing in these rules requires
the agency to provide copies of personnel policies to persons receiving
services, guardians and advocates at the agency's expense.
c. copies of policies governing access to
personnel policies, and specific job descriptions, orientation and training,
shall be provided to employees at the agency's expense. Copies of additional
personnel policies shall be promptly provided to employees, if requested.
Nothing in these rules requires the agency to provide copies of additional
personnel policies to employees at the agency's expense.
d. no restrictions of access may be imposed
on authorized representatives of the Department, nor may fees be charged for
copies of personnel policies when access and requests for copies of personnel
policies are part of the legitimate functions of the Department.
2. Compensation and Benefits. The
agency shall adopt policies and procedures that describe the methods used by
the agency
a. to set salary and compensation
schedules, including premium payments, if applicable;
b. to establish benefit plans and eligibility
requirements to participate in benefit plans, if any benefit program is offered
to any employee. At minimum, the policy shall address paid and unpaid vacation
or other time off, sick leave, leaves of absence, health-related insurance,
educational benefits, retirement and deferred compensation plans. Nothing in
these rules requires the agency to provide specific benefits to any
employee.
3. Collective
Bargaining Agreements. The agency shall adopt policies and procedures regarding
compliance with collective bargaining agreements, if applicable. Copies of
collective bargaining agreements shall be available for review by the licensing
authority if requested.
B. Organizational Structure
1. Table of Organization. The agency shall
maintain current a table of organization that clearly describes the
relationships between
a. overall management,
to include the Governing Body, Advisory Board, the Chief Administrative
Officer, and administrative and management functions described elsewhere in
these rules, as applicable;
b.
overall agency management and the management of each discrete program or other
management division.
2.
Lines of Authority. The table of organization shall clearly describe the
functional lines of authority, oversight, management and/or consultative
relationships between each and every position, body or board depicted in the
table of organization.
3.
Contracted Services. Services provided through contracted relationships shall
be so identified on the table of organization.
C. Job Descriptions
1. Written Job Descriptions. The agency shall
have written job descriptions for all positions within the agency, which
include minimum qualifications, responsibilities, positions supervised and
position(s) providing supervision.
a. Jobs
divided by a "job sharing" or similar program shall further describe the
division of tasks agreed upon among the parties.
b. A copy of the relevant job description(s)
shall be included in the employee's personnel file.
2. Minimum Standards. The following minimum
standards shall apply to all staff providing case management.
a. A case manager must have a minimum of a
bachelor's degree from an accredited four (4) year institution of higher
learning with a specialization in psychology, behavioral health, social work,
special education, counseling, rehabilitation, nursing, or a closely related
field and one (1) year experience in one of the areas listed above.
b. A supervisor of case management or a
regional supervisor must have a baccalaureate degree plus a minimum of four (4)
years experience in the mental retardation or autism field. The supervisor must
also have experience supervising staff providing services to persons with
mental retardation and/or autism, knowledge of the public education system in
Maine, and training in flexible funding and family-focused service
provision.
3. Copies to
Employees. The agency at its own expense shall provide a copy of the applicable
job description to each employee at the time of hire, promotion or
orientation.
4. Access by Managers.
The agency shall ensure access to job descriptions within the individual's
chain of command to every individual who has management or supervisory
responsibilities.
5. Development
Process. The agency shall maintain an effective method for development, review
and revision of job descriptions.
D. Recruitment and Selection of Employees
1. General Criteria
a. The agency shall not hire or retain in any
capacity any person who has a prior criminal conviction or disciplinary action
by a professional licensing, registration or accrediting body, that pertains to
consumer abuse, neglect, or exploitation.
b. For those staff who have other types of
criminal convictions or negative work history known to the agency, the agency
shall document in the individual's personnel file the crime and/or other
sanctions, the agency's assessment of the seriousness of the information
provided and the agency's rationale for hiring and/or retaining the individual.
The agency shall specifically address issues of professional misfeasance,
malfeasance, malpractice or other related misconduct; convictions or findings
in which substance use or the use of firearms or other weapons were elements;
and criminal convictions in which the actual or threatened infliction of
personal injury upon another was an element.
c. The agency shall develop criteria and
procedures specifying the conditions under which persons related to members of
the Governing Body or other staff serving in an administrative, governing or
supervisory capacity are employed.
d. The agency shall ensure that employment is
in compliance with the ADA, the Rehabilitation Act, the Civil Rights Act of
1964, the Maine Human Rights Act, and any other federal, state or local laws or
regulations. All substantiated complaints of violations of these laws or
regulations shall be assessed by the agency and actions shall be taken to
achieve compliance. Plans to achieve compliance shall be subject to the review
of the Department.
e. Nothing in
these rules prohibits an agency from conducting more extensive background
checks on staff.
2.
Reference and Background Checks
a. The agency
shall acquire and retain evidence to demonstrate that all persons engaged in
the provision of case management services meets the standards specified at
10-144 CMR 118, Chapter 2, of a Qualified Mental Retardation Professional
(QMRP).
b. When the operation of a
motor vehicle is expected or reasonably anticipated in the course of the
employee's work, the agency shall conduct a check of the employee's driving
record. For those staff who have convictions for operating under the influence
or any other violations or accidents that indicate an unsafe driving history
within the past three (3) years, the agency shall not permit the employee to
transport persons.
c. The agency
shall acquire and retain evidence that all persons who in the completion of
their duties are expected or could be reasonably anticipated to operate a motor
vehicle, have valid driver's licenses appropriate to the class of vehicle to be
used. If a staff person, in the course of work, is operating a vehicle not
provided by the agency, evidence of registration, inspection and insurance
shall be maintained. Such evidence shall be acquired at the commencement of the
person's employment and shall be maintained current.
d. The agency shall take effective and lawful
action to ensure compliance with V.D.1.a-e, above. This shall include, but not
necessarily be limited to, background checks through the State Bureau of
Identification, Child Protective Services, Adult Protective Services, the
Certified Nursing Assistant register and other similar registers, the Bureau of
Motor Vehicles, and such other relevant and available registers, sources of
information or data bases.
e.
Background checks shall be conducted at the agency's expense.
f. Continued employment of any individual
shall be contingent upon results of the background checks. Background checks
must be completed and the information available to the hiring agency within six
(6) months of the date of hire.
E. Training and Orientation
1. Orientation Program. The agency shall
provide to all new employees orientation relevant to the organization as a
whole and training that relates directly to the provision of case management
services for adults with mental retardation and autism. The content of training
shall be subject to the review and approval of the Department. This orientation
shall include, but not necessarily be limited to,
a. an overview of the service delivery system
as a whole;
b. the agency's
mission, philosophy, and other related services;
c. the person's right to privacy and
confidentiality;
d. safety and
emergency procedures;
e. the
identification, response and reporting of abuse, neglect, and exploitation, and
the consequences of failure;
f.
overview of developmental theory, the nature of mental retardation and autism,
and other relevant introductory information;
g. overview of abuse and trauma, and the
implications for service and treatment programming;
h. cultural competence issues relevant to the
populations served, including age, gender, race, religion, culture and sexual
orientation;
i. specific job
responsibilities. For managers or supervisors, this shall include
responsibilities and procedures for management, supervision and discipline of
employees;
j. supervisory chain of
command;
k. specialized techniques
of communication and intervention, as applicable to the needs of persons served
in the program;
l. assessment,
evaluation, Person-Centered Planning, service delivery, and documentation
appropriate to the position and to the persons served in the program.
i. This shall include but not necessarily be
limited to identification of needs and coaching/support techniques.
ii. This shall specifically include training
in the maintenance of appropriate professional boundaries;
m. technical training on the maintenance of
electronic records in the Department's management information system.
2. Assumption of duties following
orientation. Employees shall not be assigned to duties requiring direct
involvement with persons receiving services until the following elements of
orientation and training have been completed and documented:
a. all elements of the position specific
orientation,
b. general orientation
topics of reporting of abuse and neglect, safety and emergency procedures,
child rights, and confidentiality.
The remaining training and orientation elements must be completed within 60 calendar days of hire, unless otherwise specified.
3. Ongoing training and
education. The agency shall develop and implement policies and procedures to
a. ensure compliance with on-going
professional training for all employees;
b. identify staff training needs and provide
such training, as pertinent to the services provided by the agency;
c. provide annual inservice or external
training that includes:
i. individual
reporting requirements for incidents of abuse, mistreatment, neglect or
exploitation,
ii. diversity
education and/or cultural competence training,
iii. ethics,
iv. confidentiality,
v. job specific competencies, and
vi. documentation and record keeping.
Additional training shall be applicable to the duties of the staff receiving
the training.
4. Records of completion of orientation and
training. The agency shall maintain written, accessible documentation that
orientation and ongoing training have been completed as described in these
rules. The documentation shall include, at minimum, curriculum, names and
credentials of persons providing orientation or training, dates orientation or
training was provided, the length of time of each orientation or training
session, and the dated signature of the trainee acknowledging receipt of the
orientation or training.
F. Management, Supervision and Discipline
1. Lines of Authority. The
agency shall maintain policies and effective procedures governing the
application of the lines of authority, as described in the table of
organization.
2. Supervision. The
agency shall identify a supervisor for each position. Supervisors are
responsible for supervising individual support coordinators or case managers,
developing and reviewing service plans, and assuring the provision of quality
case management services.
a. At minimum,
supervision shall be provided according to the following standards:
i. Supervision must be conducted at regularly
scheduled times, no less frequently than once monthly for each staff
member.
ii. Supervision may be
conducted on an individual or group basis. Supervision shall be measured and
documented in hours and shall be subject to the review of the
Department.
iii. Supervision shall
include the following:
(a) review of case
records, including the PCP,
(b)
documentation in the case records, indicating the occurrence of the
review,
(c) review of case record
management activities, including adequacy and completeness of screenings,
assessments, referrals, etc.,
(d)
participation in the development of the employee's individual, group and family
support skills, as applicable,
(e)
maintenance of a record of supervision, including the dates, employee(s)
supervised, duration and content of supervision, signed by the supervisor,
and
(f) issues germane to the
duties being performed.
b. Policies shall describe day-to-day
supervision and performance review of staff members.
3. Performance reviews. The agency shall
maintain policies and effective procedures governing the routine, periodic,
formal performance review of employees. These policies shall discuss at a
minimum,
a. criteria and procedures for
employee performance reviews;
b.
the development and implementation of individualized performance improvement
and training plans;
c. frequency of
performance reviews, which shall be completed no less frequently than at the
conclusion of the first six and the first twelve months of employment, whether
full or part time, and annually thereafter;
d. documentation of performance reviews;
and
e. provision of copies of
performance reviews to employees.
4. Discipline. The agency shall maintain
policies and effective, lawful procedures governing employee discipline. These
policies shall discuss at a minimum,
a. the
circumstances under which discipline may be administered;
b. the range of interventions or penalties
permitted;
c. the circumstances
under which particular penalties are required or permitted;
d. the penalties for child abuse,
mistreatment, neglect or exploitation;
e. the penalties for violation of individual
rights;
f. the penalties for
violation of rules of confidentiality, including those specific to the services
being provided;
g. the penalties
for workplace use or possession of illicit substances, alcohol or
firearms;
h. the penalties for
working under the influence of illicit substances or alcohol;
i. the penalties for falsification of any
documents related to hiring or retaining employees, whether for self or on
behalf of others;
j. the penalties
for violation of personnel laws (including but not necessarily limited to EEO
and THE ADA) and agency personnel policies;
k. procedures for employees' appeal of
discipline; and
l. documentation of
disciplinary actions and results of appeals.
5. Employee grievances. The agency shall
maintain policies and effective procedures governing the acceptance and
resolution of grievances brought by employees as a result of management
practices, to include but not necessarily be limited to EEO, THE ADA and the
Maine Human Rights Act.
G. Personnel Records
1. Policies. The agency shall maintain
policies and effective, reasonable procedures governing personnel records.
These policies shall discuss at a minimum,
a.
custody, security and confidentiality of personnel records;
b. access to personnel records by employees,
supervisors and other agency managers;
c. circumstances under which employees may
add material to their own records;
d. circumstances under which employees may
remove or request the removal of material from their own records;
e. circumstances under which persons other
than the employee may add material to records;
f. circumstances under which persons other
than the employee may remove material from records;
g. circumstances under which all or part of
the personnel record may be discussed with or provided to others.
2. Active Records. The agency
shall maintain active records for all current employees, contracted staff and
consultants.
3. Inactive Records.
The agency shall maintain policies and effective procedures governing the
identification, custody, security, confidentiality and disposal of personnel
records considered inactive. Inactive records shall be maintained at the agency
for a period no less than three (3) calendar years following the last period of
employment.
4. Content of Records.
Personnel records shall, at minimum, contain
a. a completed, signed, dated application or
resume.
i. Applications shall include a
statement consistent with 17-A MRSA §453, regarding falsification of
information provided in the application.
ii. Resumes submitted in lieu of applications
must include a complete description of relevant education and experience. The
applicants who submit resumes in lieu of applications shall sign and date a
separate document including the statement described above in 4.a.i, which shall
be attached to the resume;
b. letters of reference, if provided or
acquired. Notes of any telephone reference checks shall be included.
Unfavorable references may not be omitted, if provided or acquired;
c. applicable, current professional
credentials and certifications;
d.
records of completion of orientation and training required under these
rules;
e. the results of all
background or reference checks, as described at Section V. D. 2,
above;
f. current job
description;
g. performance
reviews;
h. documentation of
disciplinary action and results of appeals;
i. starting, transfer, promotion, demotion
and termination dates;
j. a
statement read, signed and dated by the employee, which clearly defines abuse,
mistreatment, neglect, exploitation and breach of confidentiality; outlines the
responsibility to refrain from such actions and to report all such incidents or
suspected incidents; and describes the consequences of failure to comply with
the requirements to refrain from such actions and to report all such incidents
or suspected incidents;
k.
employment agreements, if applicable, including contracts governing the use of
contracted employees or consultants; and
l. letters of accommodation and supporting
medical records, if applicable.
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