Code of Massachusetts Regulations
105 CMR - DEPARTMENT OF PUBLIC HEALTH
Title 105 CMR 158.000 - Licensure of Adult Day Health Programs
Section 158.030 - Administration
Universal Citation: 105 MA Code of Regs 105.158
Current through Register 1531, September 27, 2024
(A) The licensee shall be responsible for compliance with all applicable laws and regulations.
(B) Each licensee shall establish by-laws or policies which describe the organizational structure, establish authority and responsibility of the Program, and identify the goals and service components of the Program.
(C) The licensee shall appoint a qualified Program Director who is responsible for establishing and implementing policies and procedures regarding the management and operation of the Program.
(D) The licensee shall ensure the Program is open at least Monday through Friday and is non-residential.
(E) The licensee shall ensure that all required records, reports, and other materials required by 105 CMR 158.000 are complete, accurate, current, and available within the Program.
(F) The licensee shall ensure the Program is administered in a manner that uses its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each participant.
(G) The licensee shall make participant records and copies of participant records available to the Commissioner or his or her designee upon request.
(H) Personnel.
(1) The licensee shall be responsible for
procurement of competent personnel. The licensee and the Program Director shall
each be responsible for the direction and supervision of personnel.
(2) The licensee and Program Director shall
establish and maintain written policies and procedures regarding personnel that
promote quality care of participants.
(3) The licensee shall:
(a) Maintain accurate time records for all
personnel;
(b) Maintain payroll
records, timesheets, and staffing schedules for at least seven years;
(c) Post, and make accessible to participants
and their families, staffing schedules; and
(d) Maintain a written job description for
each position that includes title, reporting authority, qualifications, duties,
and responsibilities.
(4)
The licensee shall maintain a personnel record for each employee and volunteer
that is current, accurate, and available on the premises for seven years.
Personnel records shall contain:
(a)
Pertinent information regarding identification, including maiden name, if
applicable;
(b) Social Security
number, photo copy of a government issued photo identification, professional
registration number or competency determination (if applicable), and year of
original licensure, registration, or competency determination;
(c) Cardiopulmonary resuscitation and first
aid certifications;
(d) Names and
addresses of educational institutions attended, dates of graduation, degrees or
certificates conferred, and name at the time of graduation;
(e) Employment history including experience,
training, names and addresses of previous employers, dates of employment, and
reasons for terminating previous employment;
(f) Completed and signed job application
forms;
(g) Job
descriptions;
(h) Performance
evaluations;
(i) A pre-employment
physical examination completed within 12 months of employment and a physical
examination completed at least once every two years during the period of
employment;
(j) A pre-employment
Tuberculosis (TB) history and risk assessment with additional screening as
indicated within three months prior to employment in accordance with Department
Bureau of Infectious Disease guidelines;
(k) An annual TB risk assessment, symptom
review, and education with additional screening as indicated in accordance with
Department Bureau of Infectious Disease guidelines;
(l) For food service personnel, any
documentation required by
105 CMR 590.000:
State Sanitary Code Chapter X - Minimum Sanitation Standards for Food
Establishments;
(m)
Training attendance records; and
(n) Records of illnesses, incidents, and
complaints involving personnel while on duty.
(5) Prior to hiring staff or approving
volunteers, a Program shall perform a background check that includes the
candidate's references, job history, Criminal Offender Records Information
(CORI), and the Nurse Aide Registry, established under M.G.L. c. 111, §
72J.
(6) A Program shall conduct an
annual performance evaluation for each employee which includes a face-to-face
meeting.
(7) A Program shall have
an organized orientation program for all new employees that explains job
responsibilities, duties, conditions of employment, and relevant participant
care policies. All new personnel shall attend orientation training.
(8) A Program shall provide a minimum of 12
hours of relevant in service training per year for personnel who interact with
participants. The in-service training shall be relevant to the participant
population and to the services provided by the Program.
(9) A Program shall ensure that all personnel
are knowledgeable about the types of medical and behavioral conditions of
participants and their cultural diversity, including, but not limited to, race,
ethnicity, sexual orientation and gender identity, such that personnel are able
to provide care that is appropriate to participants' needs.
(10) A Program shall ensure that all
personnel are adequately trained to understand, respond to, and address the
needs of participants with Alzheimer's disease and related disorders. Training
regarding Alzheimer's disease and related disorders shall include:
(a) Knowledge about Alzheimer's disease and
related disorders;
(b) Behavior
management skills necessary to respond appropriately to participant behaviors
and non-verbal communications; and
(c) Group process skills in working with
special need populations.
(11) No individual may be employed, allowed
to work, or allowed to volunteer, if he or she is infected with a contagious
disease that might endanger the health of participants or personnel.
(12) The Department shall be notified in
writing within two business days of the resignation or dismissal of the Program
Director and the name and qualifications of the new Program Director or interim
Program Director.
(13) A Program
shall require all persons, including students, who examine, observe, or treat a
participant to wear an identification badge that readily discloses the first
name, licensure status, if any, and staff position of the person so examining,
observing, or treating a participant.
(I) In order to promote appropriate placements, a Program shall exchange information regarding resources and services with other agencies and institutions that provide health care or community care in the geographic area of the Program.
(J) Participant and Family Advisory Council.
(1) A Program
shall establish a Participant and Family Advisory Council to advise the Program
on matters including, but not limited to, participant and provider
relationships, community services and needs, quality improvement initiatives,
and participant education related to safety and quality.
(2) A Program operating prior to January 2,
2015 shall establish a Participant and Family Advisory Council on or before May
1, 2015.
(3) Membership of the
Participant and Family Advisory Council shall, to the extent possible, reflect
the cultural diversity of the community served, and at least 50% of the Council
members shall be current or former participants and their family members, legal
representatives or caregivers; at least one member shall be the Program
Director or designee; members may include health care professionals from
outside the Program who work with the target population.
(4) A Program shall develop and implement
written policies and procedures for the Participant and Family Advisory
Council, which shall include:
(a) The
Council's purposes and goals;
(b)
Membership of the Council including qualifications, selection, retention, and
term of service;
(c) Orientation,
training, and continuing education for members of the Council on topics related
to Council membership and community health care services; and
(d) Responsibilities of members of the
Council.
(5) The
Participant and Family Advisory Council shall:
(a) Advise on participant quality of life,
quality of care, safety issues and, if the participant or participant's family
and/or legally authorized representative seeks the Council's advice, specific
grievances;
(b) Advise the Program
Director on physical plant and program related matters;
(c) Review and advise on the Program's QAPI
semi-annual report and make recommendations as applicable;
(d) Review and advise on the Program's
written policies and procedures;
(e) Convene meetings at least one time every
four months;
(f) Maintain minutes
of Council meetings and accomplishments for at least five years; and
(g) Submit Council meeting minutes to the
licensee and Program Director.
(6)
Reporting
Requirements.
(a) At least one
time per year, a Program shall prepare a written report documenting the
Program's compliance with 105 CMR 158.030(J) and describing the Participant and
Family Advisory Council's accomplishments during the preceding year.
(b) A Program shall make the written reports
required by 105 CMR 158.030(J) available to the Department within seven days
upon request.
(7) In the
event a Program's bylaws or organizational structure require it to be overseen
by a Board of Directors, the Board of Directors may assume the roles and
responsibilities of the Participant and Family Advisory Council and may operate
in lieu of such a Council, provided that the Board of
Directors otherwise complies with all requirements specified in 105 CMR
158.030(J). The composition of the Board of Directors need not be reconfigured
to comply with 105 CMR 158.030(J)(3) if the Board has participant, family, or
caregiver representation on the Board; otherwise, in lieu of
reconfiguration, the Board may establish a Participant and Family Advisory
subcommittee to the Board.
(K) Program Director.
(1) A Program with a
licensed program capacity of 35 or fewer participants shall employ a qualified
Program Director for at least ten hours per week to manage the
Program.
(2) A Program with a
licensed program capacity of 36 to 72 participants shall employ a qualified
Program Director for at least 20 hours per week to manage the
Program.
(3) A Program with a
licensed program capacity of 73 or more participants shall employ a qualified
Program Director for at least 35 hours per week.
(4) The Program Director shall be on-site and
available to staff, participants, and legally authorized representatives for at
least a portion of each week during the hours of operation. A senior staff
person may be designated to assume temporary responsibility for a Program
Director in the event that the Program Director requires an absence longer than
a full week. If the Program Director also serves the Program as a registered
nurse, then the temporary designee may only act in the capacity of a Program
Director, and may not act in the capacity as a registered nurse, unless the
temporary designee is also a registered nurse, or licensed nurse acting as a
relief nurse pursuant to
105 CMR
158.032(B)(2).
(5) A Program Director shall be a suitable
and responsible person, 21 years of age or older, who has:
(a) A high school diploma or its
equivalent;
(b) At least two years'
experience working with adults in a health care setting in a professional or
volunteer position; and
(c) At
least two years of related managerial experience.
(6) A licensed nurse may not simultaneously
serve in the capacity of the Program Director and as a nurse required to
satisfy minimum staffing requirements in
105
CMR 158.032.
(7) A Program shall post, and make available
to staff, the name and telephone numbers of the Program Director.
(8) The Program Director shall be responsible
to the licensee and shall operate the Program to ensure that services required
by participants are available and are provided in accordance with professional
standards of care, the Program's written policies and procedures, and
105 CMR
158.000.
(9) The responsibilities of a Program
Director shall include:
(a) Direction and
supervision of all aspects of the Program;
(b) Management of personnel;
(c) Ensuring appropriate supervision and
evaluation of all personnel;
(d)
Overseeing Program safety and emergency evacuation plans;
(e) Managing the fiscal administration of the
Program;
(f) Establishing
collaborative relationships with community services to ensure that necessary
support services are available to participants and their families;
(g) Notifying the participant or his or her
legally authorized representative in the event of change in a participant's
charges, billings, benefit status, or other administrative matters;
(h) Delegating responsibility for managing
the day-to-day operations of the Program during any short term absence of the
Program Director;
(i) Overseeing
the quality assessment and performance improvement program, as described at
105
CMR 158.046; and
(j) Immediately informing the participant,
consulting with the participant's primary care provider, and immediately
notifying the participant's legally authorized representative or contact person
in the following circumstances:
1. An
emergency, serious incident, or fire;
2. Severe illness involving the
participant;
3. An incident
involving the participant which resulted in injury or which required medical
intervention;
4. A significant
change in the participant's status;
5. A need to alter the participant's
treatment significantly;
6. A
significant revision of the participant's plan of care; or
7. A decision to transfer the participant
from the Program.
(k)
Immediately notifying the participant, the participant's primary care provider,
and the participant's legally authorized representative or contact person, upon
a decision to discharge the participant from the Program as specified in
105
CMR 158.034.
(L) Requirement for Personnel to Be Vaccinated against Influenza Virus.
(1) Definitions.
(a) For purposes of
105
CMR 158.030(L), personnel
means an individual or individuals who either work at or come to the licensed
program site and who are employed by or affiliated with the program, whether
directly, by contract with another entity, or as an independent contractor,
paid or unpaid including, but not limited to, employees, members of the medical
staff, contract employees or staff, students, and volunteers, whether or not
such individual(s) provide direct care.
(b) For purposes of
105
CMR 158.030(L), the
requirement for influenza vaccine or vaccination means immunization by either
influenza vaccine, inactivated or live; attenuated influenza vaccine including
seasonal influenza vaccine pursuant to
105
CMR 158.030(L).
(c) For purposes of
105
CMR 158.030, mitigation measures mean
measures that personnel who are exempt from vaccination take to prevent viral
infection and transmission.
(2) Each program shall ensure all personnel
are vaccinated annually with seasonal influenza vaccine, consistent with any
guidelines of the Commissioner, unless an individual is exempt from vaccination
in accordance with
105
CMR 158.030(L)(6).
(3) Each program also shall ensure all
personnel are vaccinated against other pandemic or novel influenza virus(es) as
specified in guidelines of the Commissioner, unless an individual is exempt
from vaccination in accordance with
105
CMR 158.030(L)(6). Such
guidelines may specify:
(a) The categories of
personnel to be vaccinated and the order of priority of vaccination of
personnel, with priority for personnel with responsibility for direct
care;
(b) The influenza vaccine(s)
to be administered;
(c) The dates
by which personnel must be vaccinated; and
(d) Any required reporting and data
collection relating to the personnel vaccination requirement of
105
CMR 158.030(L)(3).
(4) Each program shall provide all
personnel with information about the risks and benefits of influenza
vaccine.
(5) Each program shall
notify all personnel of the influenza vaccination requirements of
105
CMR 158.030(L) and shall,
at no cost to any personnel, provide or arrange for vaccination of all
personnel who cannot provide proof of current immunization against influenza
unless an individual is exempt from vaccination in accordance with
105
CMR 158.030(L)(6).
(6)
Exemptions.
(a) Subject to the provisions set forth in
105
CMR 158.030(L)(6)(b), a
program shall not require an individual to receive an influenza vaccine
pursuant to
105
CMR 158.030(L)(2) or (3) if
the individual declines the vaccine.
(b) F or any individual subject to the
exemption, a program may require such individual take mitigation measures,
consistent with guidance from the Department.
(c) An individual who is exempt from
vaccination shall sign a statement certifying that they are exempt from
vaccination and they received information about the risks and benefits of
influenza vaccine.
(7)
Unavailability of Vaccine. A program shall not be
required to provide or arrange for influenza vaccination during such times the
vaccine is unavailable for purchase, shipment, distribution or administration
by a third-party or when complying with an order of the Commissioner
restricting the use of the vaccine. A program shall obtain and administer
influenza vaccine in accordance with
105
CMR 158.030(L) as soon as
vaccine becomes available.
(8)
Documentation.
(a) A
program shall require and maintain for each individual proof of current
vaccination against influenza virus pursuant to
105
CMR 158.030(L)(2) and (3),
or the individual's exemption statement pursuant to
105
CMR 158.030(L)(6).
(b) Each program shall maintain a central
system to track the vaccination status of all personnel.
(c) If a program is unable to provide or
arrange for influenza vaccination for any individual, it shall document the
reasons such vaccination could not be provided or arranged for.
(9)
Reporting and Data
Collection. Each program shall report information to the
Department documenting the facility's compliance with the personnel vaccination
requirements of
105
CMR 158.030(L), in
accordance with reporting and data collection guidelines of the
Commissioner.
(10)
105
CMR 158.030(L) establishes
requirements for influenza vaccination of adult day health program personnel.
Nothing in
105 CMR
158.000 shall be read to prohibit programs from
establishing policies and procedures for influenza vaccination of personnel
that exceed the requirements set forth in
105
CMR 158.030(L).
(M) Requirement for Personnel to Be Vaccinated against Coronavirus Disease 2019 (COVID-19) Caused by the Virus SARS-CoV-2.
(1)
Definitions.
(a) For
purposes of
105
CMR 158.030(M), personnel
means an individual or individuals who either work at or come to the licensed
program site and who are employed by or affiliated with the program, whether
directly, by contract with another entity, or as an independent contractor,
paid or unpaid including, but not limited to, employees, members of the medical
staff, contract employees or staff, students, and volunteers, whether or not
such individual(s) provide direct care.
(b) For purposes of
105
CMR 158.030(m), COVID-19
vaccination means being up to date with COVID-19 vaccines as recommended by the
Centers for Disease Control and Prevention (CDC).
(c) For purposes of
105
CMR 158.030(M), mitigation
measures mean measures that personnel who are exempt from vaccination take to
prevent viral infection and transmission.
(2) Each program shall ensure all personnel
have received COVID-19 vaccination in the timeframe specified in Department
guidelines, unless an individual is exempt from vaccination in accordance with
105
CMR 158.030(M)(5).
(3) Each program shall provide all personnel
with information about the risks and benefits of COVID-19
vaccination.
(4) Each program shall
notify all personnel of the COVID-19 vaccination requirements of
105
CMR 158.030(M) and shall,
at no cost to any personnel, provide or arrange for vaccination of all
personnel who cannot provide proof of current vaccination against COVID-19
unless an individual is exempt from vaccination in accordance with
105
CMR 158.030(M)(5).
(5)
Exemptions.
(a) Subject to the provisions set forth in
105
CMR 158.030(M)(5)(b), a
program shall not require an individual to receive a COVID-19 vaccine pursuant
to 105 CMR 158.030(M)(2)
if the individual declines the
vaccine.
(b) F or any individual
subject to the exemption, a program may require such individual take mitigation
measures, consistent with guidance from the Department.
(c) An individual who is exempt from
vaccination shall sign a statement certifying that they are exempt from
vaccination and they received information about the risks and benefits of
COVID-19 vaccine.
(6)
Unavailability of Vaccine. A program shall not be
required to provide or arrange for COVID-19 vaccination during such times the
vaccine is unavailable for purchase, shipment, distribution, or administration
by a third-party or when complying with an order of the Commissioner
restricting the use of the vaccine. A program shall obtain and administer
COVID-19 vaccine in accordance with
105
CMR 158.030 (M) as soon as
vaccine becomes available.
(7)
Documentation.
(a) A
program shall require and maintain for each individual proof of current
vaccination against COVID-19 virus pursuant to
105
CMR 158.030(M)(2), or the
individual's exemption statement pursuant to
105
CMR 158.030(M)(5).
(b) Each program shall maintain a central
system to track the vaccination status of all personnel.
(c) If a program is unable to provide or
arrange for COVID-19 vaccination for any individual, it shall document the
reasons such vaccination could not be provided or arranged for.
(8)
Reporting and Data
Collection. Each program shall report information to the
Department documenting the program's compliance with the personnel vaccination
requirements of
105
CMR 158.030(M) in
accordance with reporting and data collection guidelines of the
Commissioner.
(9)
105
CMR 158.030(M) establishes
requirements for COVID-19 vaccination of adult day health program personnel.
Nothing in
105 CMR
158.000 shall be read to prohibit programs from
establishing policies and procedures for COVID-19 vaccination of personnel that
exceed the requirements set forth in
105
CMR 158.030(M).
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