Hawaii Administrative Rules › Title 11 - DEPARTMENT OF HEALTH › Subtitle 1 - GENERAL DEPARTMENTAL PROVISIONS › Chapter 98 - SPECIAL TREATMENT FACILITY › Section 11-98-10 - Minimum standards for licensure; administrative and organizational plan

Current through June, 2024
(a) Every facility shall have and maintain a
				current written plan describing the philosophy, goals, and objectives of its
				program. This program shall be reviewed and evaluated periodically or at least
				annually.
(b) The plan shall also
				include a statement of the geographic area to be served, ages and kinds of
				residents to be served, anticipated average length of stay of its residents,
				and the limitations and scope of service for which the facility is
				established.
(c) A policy of
				nondiscrimination based on age, race, color, creed, or national origin relating
				to admission of residents shall be established.
(d) A policy of nondiscrimination based on
				sex, age, race, color, creed, national origin, or physical handicap relative to
				the personnel policies and practices governing the hiring, promotion and
				dismissal of its staff shall be established.
(e) Each facility shall develop written
				policies and procedures, and criteria governing its management and operations.
				These shall include but are not limited to the following:
(1) Personnel policies, procedures and
				practices including the qualifications, duties and responsibilities for each
				staff position, hiring, suspension, dismissal, assignment, promotion, grievance
				procedures and other related personnel matters;
(2) Policies and procedures, and criteria
				relative to admission of residents to the program, dismissal and
				discharge;
(3) Policies and
				procedures governing the rights (legal, civil, and human) and responsibilities
				of the residents and the confidential nature of resident information;
(4) Procedures for handling complaints and
				grievances expressed by residents, persons, or agencies responsible for
				residents, and the public;
(5) A
				description of the facility's services available to residents and responsible
				parties or agencies and the public. It shall include services directly provided
				or contracted for by the facility. It shall also include arrangements for
				emergency medical transportation on a twenty-four hour basis;
(6) Terms of contractual agreements entered
				into with out side providers of services required in this chapter including the
				description of roles, responsibilities and authority of all parties
				involved;
(7) Policies and
				procedures and copies of written agreements for coordination and liaison
				between the facility and relevant community agencies, concerning the admission,
				treatment, discharge and follow up of residents;
(8) A description of the provisions for
				rendering emergency medical and psychiatric care, including the name, address,
				and telephone number of the physician;
(9) The facility shall submit a copy of its
				policy and procedures regarding the use of physical or chemical restraints. No
				physical or chemical restraints shall be used except as outlined in the policy
				and procedures and only following the approval of the policy and procedures by
				the director;
(10) Policies and
				procedures relative to general rules regarding residents' records, including:
(A) All entries shall be made in ink, be
				legible, dated and signed with first initial and last name;
(B) Symbols and abbreviations shall be
				explained in a legend;
(C) An area
				shall be provided for safe and easy access to residents' records;
(D) Residents' records shall be retained for
				five years after discharge or, if s state-owned facility, a period to comply
				with state law;
(E) Policies
				governing access by the resident and others, duplication of, and dissemination
				of information from the record;
(F)
				Policies protecting the confidentiality of resident information;
(G) Policies requiring written consent of the
				resident, if competent, or the resident's guardian for the release of
				information to persons and agencies not otherwise authorized to receive
				it;
(H) The facility's
				responsibility to secure the information under lock against loss, distribution,
				defacement, tampering, or use by unauthorized persons;