New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 321 - SPECIALIZED BEHAVIORAL HEALTH SERVICES
Part 11 - CRISIS TRIAGE CENTERS
Section 8.321.11.22 - POLICIES AND PROCEDURES
Current through Register Vol. 35, No. 18, September 24, 2024
The CTC shall establish written policies and procedures that are reviewed annually and approved by the governing body, which govern the CTC's operation. The administrator shall ensure that these policies and procedures are adopted, administered and enforced to provide quality services in a safe environment. At a minimum, the CTC's written policies and procedures shall include how the CTC intends to comply with all requirements of these regulations and address:
A. the establishment, composition, and responsibilities of the governing body;
B. administration including the minimum qualifications of the administrator, the process to hire an administrator, and define the administrator's authority, responsibility, and accountability including plans for the administrator's absence;
C. quality assurance and improvement systems;
D. incident management system;
E. the maintenance of the CTC, equipment and supplies; inspection and maintenance of emergency equipment; maintenance of emergency supplies; maintenance, upkeep and cleaning of the building(s) and equipment; fire and emergency evacuation procedures; and proper disposal of waste liquids used for cleaning contaminated areas;
F. quality of care and services including appropriate and inappropriate admission and discharge criteria; and client risk assessment;
G. referral of clients for services; transfer of clients to a hospital or other CTC or program; ambulance transfer services; and emergency procedures and resuscitative techniques;
H. infectious waste and biohazard disposal in accordance with all applicable statutes and regulations;
I. infection control and prevention;
J. staffing plan, personnel records, and personnel including written job descriptions for all staff with necessary qualifications consistent with these rules; minimum staffing; and staff development;
K. maintenance of the client health record including protection of client confidentiality and privacy as required by law; secure release of medical information and records; and safe handling and storage of client records including appropriate document destruction procedures;
L. the retention, maintenance, security and destruction of client, personnel and CTC records;
M. research procedures for any research being conducted at the CTC in compliance with these regulations;
N. dietary services including: meal service; staff inservice training; dietary records; clean and sanitary conditions; and food management;
O. housekeeping services to keep the CTC safe, clean, and free of hazards and clutter;
P. laundry services for the CTC's laundry and resident's laundry including handling, process and storage of clean and dirty laundry;
Q. pharmacy practices including the storage, administration, and disposal of medications; medication management; and documentation;
R. laboratory services;
S. client's personal belongings including locked storage and contraband;
T. client rights;
U. safety management plan including, but not limited to, risk assessment, control of potentially injurious items, crisis prevention and intervention, physical restraint, and mitigation of high risk behaviors including suicide and assault. The safety plan shall follow a least to most restrictive sequence;
V. authorized entry to or exit from the CTC including the residential and outpatient components;
W. withdrawal management services; and
X. primary source verification of licenses, credentials, experience and competence of staff.
