Current through Register Vol. 40, No. 16, March 25, 2024
A. The organization shall implement written
policies and procedures approved by the governing body.
B. All policies and procedures shall be
reviewed at least annually, with recommended changes submitted to the governing
body for approval, as necessary.
C.
Administrative and operational policies and procedures shall include, but are
not limited to:
1. Administrative
records;
2. Admission and discharge
or termination from service criteria;
3. Informed consent;
4. Advance directives, including Durable Do
Not Resuscitate Orders;
5. Client
rights;
6. Contract
services;
7. Medication management,
if applicable;
8. Quality
improvement;
9. Mandated reporting
of abuse, neglect and exploitation pursuant to § 63.2-1606 of the Code of
Virginia;
10. Communicable and
reportable diseases;
11. Client
records, including confidentiality;
12. Record retention, including termination
of services;
13. Supervision and
delivery of services;
14. Emergency
and on-call services;
15. Infection
control;
16. Handling consumer
complaints;
17. Telemonitoring;
and
18. Approved
variances.
D. Financial
policies and procedures shall include, but are not limited to:
1. Admission agreements;
2. Data collection and verification of
services delivered;
3. Methods of
billing for services by the organization and by contractors;
4. Client notification of changes in fees and
charges;
5. Correction of billing
errors and refund policy; and
6.
Collection of delinquent client accounts.
E. Personnel policies and procedures shall
include, but are not limited to a:
1. Written
job description that specifies authority, responsibility, and qualifications
for each job classification;
2.
Process for maintaining an accurate, complete and current personnel record for
each employee;
3. Process for
verifying current professional licensing or certification and training of
employees or independent contractors;
4. Process for annually evaluating employee
performance and competency;
5.
Process for verifying that contractors and their employees meet the personnel
qualifications of the organization;
6. Process for obtaining a criminal
background check and maintaining a drug-free workplace pursuant to §
32.1-162.9:1 of the Code of Virginia; and
7. Process for reporting licensed and
certified medical personnel for violations of their licensing or certification
to the appropriate board within the Department of Health Professions.
F. Admission and discharge or
termination from service policies and procedures shall include, but are not
limited to:
1. Criteria for accepting clients
for services offered;
2. The
process for obtaining a plan of care or service;
3. Criteria for determining discharge or
termination from each service and referral to other agencies or community
services; and
4. Process for
notifying clients of intent to discharge/terminate or refer, including:
a. Oral and written notice and explanation of
the reason for discharge/termination or referral;
b. The name, address, telephone number and
contact name at the referral organization; and
c. Documentation in the client record of the
referral or notice.
G. Policies shall be made available for
review, upon request, to clients and their designated
representatives.
H. Policies and
procedures shall be readily available for staff use at all times.
Statutory Authority
§§ 32.1-12 and 32.1-162.12 of the Code of
Virginia.