Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This amendment updates terminology and
responsibilities of the governing body, and adds required components for the
organization's policy and procedure manual.
PURPOSE: This rule describes requirements for and
responsibilities of the governing body in Opioid Treatment Programs, Substance
Use Disorder Treatment Programs, Comprehensive Substance Treatment and
Rehabilitation Programs (CSTAR), Gambling Disorder Treatment Programs, Recovery
Support Programs, Substance Awareness Traffic Offender Programs (SATOP),
Required Education Assessment and Community Treatment Programs (REACT),
Community Psychiatric Rehabilitation Programs (CPRP), and Outpatient Mental
Health Treatment Programs.
(1) Governing Body. The organization shall
have a designated governing body with legal authority and responsibility over
its policies and operations. The governing authority ensures the organization
complies with all federal, state, local, and municipal laws and regulations, as
applicable. The chief executive officer is responsible to the governing body
for the overall day-to-day operations of the organization, including the
control, utilization, and conservation of its physical and financial assets and
the recruitment and direction of the staff.
(A) The governing body has written documents
of its source of authority that are available to the public upon request. The
source of authority document includes, but is not limited to-
1. The eligibility criteria for governing
body membership;
2. The number and
types of membership;
3. The method
of selecting members;
4. The number
of members necessary for a quorum;
5. Attendance requirements for governing body
membership;
6. The duration of
appointment or election for governing body members and officers; and
7. The powers and duties of the governing
body and its officers and committees, or the authority and responsibilities of
any person legally designated to function as the governing body.
(B) The requirements of section
(1) are not applicable to state-operated programs except such programs must
have an administrative structure with identified lines of authority to ensure
responsibility and accountability for the successful operation of its
behavioral health services.
(2) Composition of the Governing Body and
Meetings. Members of the governing body shall have a demonstrated interest in
the area(s) and/or region(s) served by the organization. A current roster of
the governing body members shall be maintained and available to the public upon
request.
(A) Members of the governing body
shall represent the demographics of the population served including, but not
limited to, geographic area, race, ethnicity, gender identity, disability, age,
and sexual orientation. Individuals living with mental illness and/or a
substance use disorder and family members/natural supports, and parents/legal
guardians of children, adolescents, and adults receiving services shall have
meaningful input to the governing body.
(B) The governing body shall meet at least
quarterly and maintain an accurate record of meetings including dates,
attendance, discussion items, and actions taken.
(3) Functions of the Governing Body. Duties
of the governing body shall include, but are not limited to-
(A) Providing fiscal planning and
oversight;
(B) Ensuring
implementation of an organizational performance improvement and measurement
process;
(C) Approving policies to
guide administrative operations and service delivery;
(D) Ensuring responsiveness to the
communities and individuals served;
(E) Delegating operational management to a
chief executive officer and, as necessary, to program managers to effectively
operate its services; and
(F)
Designating contractual authority.
(4) Policy and Procedure Manual. The
organization shall maintain a policy and procedure manual which accurately
describes and guides the operation of its services and promotes compliance with
applicable regulations. Additional policies and procedures for specialized
programs/services may be specified in department contracts. The policy and
procedure manual shall be readily available to staff and the public upon
request and shall include, but is not limited to:
(A) Mission, goals, and objectives of the
organization;
(B) Organization of
the agency;
(C) Rights,
responsibilities, and grievance procedures in accordance with
9 CSR
10-7.020;
(D) Service delivery process, documentation,
and individual records in accordance with
9 CSR
10-7.030;
(E) Service array including, but not limited
to:
1. Description of all services available,
including crisis assistance;
2.
Outreach and education strategy for all services;
3. Location of service sites, hours, and days
of operation for each site;
4.
Accessibility, including provisions for individual choice of services and
location;
5. Referral process
including follow-up, continuity of care, and timely transfer of
records.
(F) Performance
measurement and improvement in accordance with
9 CSR
10-7.040;
(G) Research in accordance with
9 CSR
10-7.050;
(H) Emergency safety interventions in
accordance with 9 CSR 10-7.060;
(I) Medications in accordance with
9 CSR
10-7.070;
(J) Dietary services in accordance with
9 CSR
10-7.080;
(K) Governing authority and program
administration in accordance with 9 CSR 10-7.090;
(L) Fiscal management in accordance with
9 CSR
10-7.100;
(M) Personnel in accordance with
9 CSR
10-7.110;
(N) Physical environment and safety in
accordance with 9 CSR 10-7.120;
(O) Background screenings in accordance with
9 CSR
10-5.190;
(P) Report of complaints of abuse, neglect,
and misuse of funds/property in accordance with
9 CSR
10-5.200 and
9 CSR
10-5.206;
(Q) Routine monitoring of individual records
for compliance with applicable standards;
(R) Commonly occurring issues with
individuals served such as missed appointment, accidents on the premises,
suicide attempts, threats, loitering, and non-compliance with program policies
and procedures; and
(S) Relevant
information related to services available for children and youth addressing any
and all aspects of paragraph (4)(A)-(R) of this rule.
(5) Corporate Compliance. Each organization
shall have a corporate compliance plan to assure federal and state regulatory,
contractual obligations, and requirements are fulfilled and services are
provided with integrity and the highest standards of excellence.
(A) A staff member of the organization shall
serve as the corporate compliance officer and be responsible for coordinating,
implementing, and monitoring the corporate compliance plan.
(B) The corporate compliance plan shall
include education and training of staff and specific oversight activities to
monitor and detect potential fraud and abuse.
(6) Agency Contracts. The organization shall
establish a formal, accountable relationship with any contractor that provides
a direct service and is not an employee of the organization.
(A) The organization retains full
responsibility for all services provided by a contractor. All services must
meet the requirements of all laws, rules, regulations, and contracts applicable
to the organization.
(B) The
department reserves the right to approve any contractor utilized by an
organization when the services to be provided are certified or deemed by the
department. The department, at its sole discretion, may require such approval
prior to the utilization of any contractor.
(C) The organization retains full
responsibility for all legal and financial responsibilities related to
execution of the contract.
(7) Health Insurance Portability and
Accountability Act of 1996 (HIPAA) Privacy Regulatory Compliance. The
organization shall comply with applicable requirements as set forth in
9 CSR
10-5.220.
*Original authority: 630.050, RSMo 1980, amended 1993,
1995, 2008 and 630.055, RSMo 1980.