Current through Register Vol. 35, No. 18, September 24, 2024
A. The agency
provides personnel who are trained, supervised and in all respects qualified to
perform the functions for which they are responsible.
B. Each position, or group of like positions,
is detailed in a written job description that clearly states qualifications,
responsibilities and requirements.
C. Each agency employee meets all state
registration, licensing and/or certification requirements applicable to his or
her position and/or use of professional title(s) and the agency has copies of
such licenses, etc. on file.
D.
Orientation of personnel:
(1) The agency
orients its personnel to the agency's goals, services, policies and procedures,
and to the responsibilities of the staff member's position. Initial and ongoing
orientation is documented in the personnel record.
(2) Orientation includes training on the
establishment and maintenance of appropriate and responsive relationships and
boundaries with clients.
E. Personnel training, development,
responsibilities and supervision:
(1) The
agency provides a training and development program to allow personnel to
improve their knowledge, skills and abilities and to promote awareness and
appreciation of the cultural background and need of persons served by the
agency. This training will be documented in the personnel file.
(2) The agency provides staff development
opportunities for personnel, including in-service training.
(3) Staff who require training to qualify for
a position in which they are responsible for the care of children do not have
sole responsibility for the care of children until after the successful
completion of the training.
(4)
Staff designated as direct service staff under service-specific certification
requirements receive ongoing training related to the age and/or emotional
development of the children for whom they are responsible.
(5) All certified services are provided under
supervision of a clinical director who provides clinical oversight of the
program, by way of documented supervision and consultation to all agency staff.
Supervision may be direct, or may occur through a clinical supervisor who is
directly supervised by the clinical director.
(6) All clinical supervision/consultation is
documented and documentation includes the theme, date, length of time of
supervision and signatures of those participating.
(7) In the event that the therapist and
clinical supervisor are the same person, another properly credentialed
clinician, either from within the agency or from outside the agency, provides
supervision at least one time per month to the clinical supervisor.
(8) The responsibilities of the therapist
include providing therapy and participating in the development of a treatment
plan. These activities are documented.
(9) When the agency utilizes the services of
professionals on a per interview, hourly, part-time, or independent contractor
basis, the agency documents regular assessment of the quality of services
provided.
F.
Accountability:
(1) The agency ensures that
the performance of all employees, consultants, contractors, and volunteers is
consistent with agency policy and these certification requirements.
(2) At least once a year, written performance
reviews are conducted jointly between each staff member, including volunteers,
and the person's supervisor.
G. Personnel records:
(1) A personnel record is maintained for each
employee and volunteer. Each personnel record is readily accessible to the LCA
at each site visit, and contains, at a minimum:
(a) documentation of all orientation and
training, including dates, hours or credits, names of trainer and trainee, and
written confirmation by trainer or training organization that the training has
occurred;
(b) employee's name,
current address, telephone number and emergency contact(s);
(c) job title and description;
(d) evidence of licensure for those employees
required to be licensed;
(e) date
first employed and dates of transfers or changes in position;
(f) documentation of a minimum of three
employment reference checks within three weeks prior to employment (if this
process yields fewer than three employment reference checks, additional
professional and/or personal references are obtained to achieve the required
minimum of three references);
(g) a
copy of the employee's current CPR and first aid certificates;
(h) for cleared staff, the criminal records
clearance letter, or for uncleared staff, a signed statement by the
administrator, director, or operator attesting to direct supervision of the
uncleared employee by a cleared employee until the clearance is
received;
(i) application for
employment or resume consistent with agency policy;
(j) performance reviews, as
applicable.
(2) The
agency's written policies and practices require that an applicant for
employment disclose any prior criminal convictions, and employees report any
arrests and/or convictions that occur while employed.
(3) The agency's written policies provide
personnel with access to their records and a process to review the record and
to make additions and corrections to the record.
H. Schedules of direct service staff in day
treatment and residential facilities:
(1) Each
facility or licensed unit maintains a written, legible schedule clearly
identifying direct service staff responsible for care of clients.
(2) Each uncleared employee is identified on
the staff schedule.
(3) The staff
schedule is updated daily to reflect actual hours staff are present and changes
in attendance as they occur.
(4)
Original updated staff schedules are kept on file for at least 12
months.
(5) The updated schedule
documents the client census for each unit of a residential treatment services
center or group home service on a daily basis.