Current through Register Vol. XLI, No. 38, September 20, 2024
7.1. The
organization shall have a clearly identified group of people (or person or
partnership when applicable) that exercises authority over and has
responsibility for its operation, policies, and practices.
7.2. An employee or member of the immediate
family of an employee of any public organization that regulates or purchases or
arranges the services of a privately run organization may not be a member of
the governing body of the organization.
7.3. All members of the governing body shall
be provided:
7.3.1. A formal orientation to
the organization and responsibilities of membership of the governing body,
which shall be documented;
7.3.2.
Written information that specifies the member's fiduciary and other
responsibilities of the organization;
7.3.3. Annual reports of the activities of
the organization; and
7.3.4.
Reports from all regulatory bodies.
7.4. The Governing Body shall:
7.4.1. Identify in writing the mission of the
organization and develop a plan to meet that mission;
7.4.2. Ensure that all planned or provided
services are consistent with the organization's mission and plan;
7.4.3. Oversee the organization's operations
and services;
7.4.4. Determine
whether services are within the organization's capabilities and
resources;
7.4.5. Adopt
administrative, employees, and program policies that are reviewed at least
every two years;
7.4.6. Review and
approve a budget prior to the beginning of the fiscal year;
7.4.7. Annually review and formally accept
the financial audit;
7.4.8. Employ
an administrator and delegate authority to that person to employ and dismiss
employees, implement board policies, and manage day-to-day operation of the
organization;
7.4.9. Permit the
administrator or his or her designee to attend all meetings of the governing
body and committee, with the exception of those held for the purpose of
reviewing the performance, status, or compensation of the
administrator.
7.4.10. Initiate a
continuous quality improvement program and direct needed changes based on the
results;
7.4.11. Annually review
facility needs related to risk management;
7.4.12. Maintain a long-range plan and review
it annually;
7.4.13. Maintain
minutes and records generated from all meetings, including members who were
present or absent;
7.4.14. Annually
visit each organizational site;
7.4.15. Annually review facility needs
related to capital improvements; and
7.4.16. Meet at least twice
annually.
7.7.
Administrator.
7.7.1. The administrator shall
be responsible for the organization's daily operations.
7.7.2. The administrator shall perform the
duties as prescribed by the governing body.
7.8. Conflicts of Interest.
7.8.1. The organization shall have a policy
that defines and limits conflicts of interest.
7.8.2. All persons employed by or
volunteering for the organization, the governing body, and consultants shall
follow the policy.
7.9.
Administrative File for the Organization.
7.9.1. An organization shall maintain an
administrative file and make it available upon request of the appropriate
governmental organization. It shall contain the following information and
documents:
7.9.1.a. The governing structure
including the charter and articles of incorporation as appropriate;
7.9.1.b. The most recent audit and financial
statement;
7.9.1.c. The by-laws or
other legal basis for its existence;
7.9.1.d. The name and position of persons
authorized to sign agreements and submit official documentation to the
appropriate government organization;
7.9.1.e. The governing body structure and its
composition with names and addresses and terms of membership as
appropriate;
7.9.1.f. Existing
purchase of service agreements;
7.9.1.g. Insurance coverage (all types)
including bonding documents if appropriate; and
7.9.1.h. A master list of all clinical and
social service professionals used by the organization, either as employees or
contractors.