Code of Massachusetts Regulations
104 CMR - DEPARTMENT OF MENTAL HEALTH
Title 104 CMR 28.00 - Licensing and Operational Standards for Community Services
Subpart A - STANDARDS FOR COMMUNITY SERVICES
Section 28.12 - Standards Applicable to all Services

Universal Citation: 104 CMR 28.00 MA Code of Regs 28.12

Current through Register 1531, September 27, 2024

(1) Written Policies and Procedures. Each provider shall ensure that each service it provides has and implements written policies and procedures which are consistent with the requirements of 104 CMR 28.00 and which address:

(a) Provider philosophy and objectives;

(b) Enrollment, intake and discharge, including criteria for enrollment into and discharge from the service;

(c) Maintenance of person records, consistent with the provisions of 104 CMR 28.09 and all other applicable state and federal laws and regulatory requirements;

(d) Development, implementation and review of individualized treatment plans consistent with 104 CMR 29.00: Application for DMH Services, Referral, Service Planning and Appeals, as appropriate;

(e) Quality and utilization management;

(f) Medication, for those services prescribing or administering medications, consistent with 104 CMR 28.06;

(g) Protection of human rights consistent with 104 CMR 28.03;

(h) Searches of property consistent with 104 CMR 28.08;

(i) Use of physical restraints consistent with 104 CMR 28.05;

(j) Billing third party payers and persons for residential services and supports and Department charges, when applicable, cancellation procedures, fee reductions, and abandoned of property consistent with 104 CMR 30.00: Fiscal Administration and any agreements with the Department;

(k) Personnel, including job descriptions and minimal staff qualifications, staff supervision, and training;

(l) Fire safety and other emergencies and disasters, including at least:
1. Procedures for evacuating persons and staff;

2. Provision for first aid, through the availability of first aid supplies, and appropriate staff training;

3. Provision for notification of fire, police, and hospital facilities for assistance;

4. Training for persons and staff in emergency procedures and regular fire drill procedures;

5. Ensuring the provision of transportation, when necessary;

6. The identification of an alternate site for relocation, when necessary; and

7. Notification and coordination with the Department and other state or federal agencies as applicable;

(m) Implementation of appropriate protocols for when a person is missing;

(n) Risk management and mitigation;

(o) Procedures for compliance with the Community Residence Tenancy Law, M.G.L. c. 186, § 17A, as applicable.

(p) Provision for training and adhering to practices relating to infection control.

(q) Safety monitoring around swimming areas, if applicable.

(r) Procedures to ensure that each resident receives appropriate grooming and hygiene articles, including hair products that reflect the diversity of persons served.

(s) Procedures regarding missing persons or runaway youth, including requirements for implementing searches and appropriate notifications.

(t) A policy and procedure for nutritional services, where applicable, including the purchase, storage, preparation and serving food in a manner appropriate to the age and persons served, including special dietary needs.

(2) Staffing, Supervision and Consultation.

(a) Director. The Director shall be responsible for the direction and control of all staff and operation of the service. The Director shall possess sufficient training, education, and professional experience.

(b) The service shall have adequate staffing and staff shall have relevant work, personal and educational qualifications to enable the service to satisfy the requirements of 104 CMR 28.00.

(c) Staff shall receive an orientation to all relevant provider policies and procedures including, but not limited to, those required by 104 CMR 28.12(1).

(d) All staff and volunteers shall receive ongoing training as appropriate to their responsibilities, including training on human rights.

(e) Staffing patterns must be appropriate to meet the linguistic and cultural needs of persons within the service. The provider shall ensure there is sufficient staff fluent in the preferred language of the persons served or professional interpreters, including professional interpreter services, must be available.

(f) Staff positions and qualifications shall be documented in writing through:
1. An organizational outline detailing the working relationships and responsibilities of staff.

2. Documentation of individual staff training, education and experience.

3. Individual job descriptions.

4. Individual work schedules.

(g) The provider shall provide regular supervision and/or consultation for all staff as appropriate to their responsibilities.
1. The provider shall provide adequate supervision of staff and shall maintain records concerning supervised staff.

2. The supervisor shall have adequate training, knowledge and experience to supervise any service performed by the supervised staff member.

(3) Location and Physical Plant.

(a) Services shall be located in areas and among other buildings which are appropriate to the services provided, the general design of which does not emphasize the service's separateness or differences from the surrounding community in such a way as to stigmatize or devalue persons.

(b) Service sites shall comply with applicable state and federal laws including physical accessibility for individuals with disabilities.

(c) Buildings shall meet all applicable fire, health, building, and safety codes.

(d) Requirements for Fire Drills. The provider shall conduct fire drills at each service site at least quarterly and shall maintain written records of such fire drills.

(e) As appropriate, a service shall provide adequate space for administration needs, privacy in evaluation, and treatment. For services that serve distinct groups, e.g., children, separate space shall be provided for use by the distinct groups, consistent with their needs

(4) Notification of Legal Proceedings. Every provider shall report in writing to the Commissioner any legal proceeding brought against the provider or any person employed by the provider, if such proceeding arises out of circumstances related to the provision of services or would impact the provider's ability to provide such services. Such report shall be made as soon as practicable after the provider has received notice of the initiation of such legal proceeding.

(5) Mandated Reporting. Provider staff shall comply with all mandated reporting requirements as required by law including reporting allegations of abuse and neglect to the Disabled Persons Protection Commission as required by M.G.L. c. 19C, § 10; the Executive Office of Elder Affairs as required by M.G.L. c. 19A, § 15, and the Department of Children and Families as required by M.G.L. c. 119, §§ 151A and 151B. The provider shall have a written policy and procedure for staff to file such mandated reports. The written plan shall also provide for notification to the Department of Mental Health no later than the next business day after a report has been filed alleging abuse or neglect of a person receiving services.

(6) Emergency Procedures. For each service, a provider shall:

(a) Have the capacity to access staff as appropriate to provide or arrange crisis intervention and stabilization support to meet the individual needs of persons.

(b) Have a written plan for providing or arranging emergency services during all hours of the service's operation.

(c) Be responsible for providing or arranging transportation in an emergency situation (d) Maintain an emergency fact sheet(s) for each person which shall be readily available to staff and held in more than one location. The emergency fact sheet shall include, to the extent available:
1. Name (and nicknames, if any);

2. Age;

3. General physical characteristics, including gender identity, weight, height, build, hair and eye color;

4. A recent photograph;

5. General nature of abilities and physical disabilities;

6. Strengths and limitations;

7. Location of person's crisis plan, if any;

8. Special medical problems, including allergies and the names and doses of medications used;

9. Preferred language, and contact information for an interpreter, if available;

10. Pattern of movement, if missing previously;

11. Current addresses of family members, previous residence, place of employment, school, or day programs, and places frequented;

12. Name, telephone, and address of person's treating physician; and

13. The person's legally authorized representative contact information, if applicable.

Disclaimer: These regulations may not be the most recent version. Massachusetts 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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