Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 164.000 - Licensure of Substance Abuse Treatment Programs › Part ONE - LICENSING AND APPROVAL PROCEDURES AND REQUIREMENTS › Licensee Administration and Organization › Section 164.040 - Written Policies

Current through Register 1525, July 5, 2024
(A) Each Licensed
				  or Approved Provider shall have written policies and procedures consistent with
				  and implemented in accordance with the requirements established in
				  105 CMR 164.000, Department
				  administrative guidelines, accepted standards of care for substance use
				  disorder treatment services and applicable laws. All policies required under
				  105 CMR 164.000 shall be in
				  writing, and available to staff, patients, residents and Department inspectors,
				  and shall at a minimum address the following areas:
(1) organizational structure including lines
				  of authority, responsibility, communication, personnel practices, supervisory
				  mechanisms for staff, and staff assignment;
(2) statement of goals and objectives of the
				  program;
(3) types of services
				  offered;
(4) fiscal management
				  including establishment and collection of fees;
(5) criteria for admission, treatment,
				  termination and discharge planning, involuntary termination, aftercare,
				  post-discharge and follow-up, including for patients or residents who leave the
				  program without notice;
(6) program
				  rules;
(7) prohibition of alcohol
				  and drugs, other than those medications properly prescribed or ordered by a
				  patient's practitioner, are prohibited on the premises.
(8) confidentiality in accordance with
				  105 CMR
				  164.084;
(9) security of and access to patient and
				  resident records, and patient and resident information;
(10) personnel policies, including:
(a) the criteria and procedures for hiring,
				  assigning, promoting, and suspending or dismissing a staff member;
(b) the procedure for handling staff
				  complaints and grievances;
(c)
				  prohibition of sexual harassment and procedures for handling and investigating
				  sexual harassment complaints;
(d)
				  prohibited interactions between staff and patients or residents, and between
				  patients or residents;
(e)
				  provisions for vacations, holidays, paternity and maternity leave, educational
				  leave, sick leave, other leaves of absence, and fringe benefits;
(f) staff member accident and safety
				  procedures;
(g) employee assistance
				  plan;
(h) restrictions on the use
				  of tobacco products and vaping;
(i)
				  requirements of 42 CFR Part 2 (federal confidentiality regulations) and 45 CFR
				  Parts 160, 162 and 164 (Health Insurance Portability and Accountability Act,
				  HIPAA), where applicable;
(j)
				  annual tuberculosis screening, and testing as indicated by the results of the
				  screening; and
(k) provision of
				  employee assistance, which shall include the following provided directly or
				  through QSOAs:
1. Confidential assessment and
				  referral for services related to personal or professional difficulties which
				  affect the employee's ability to perform assigned duties, including substance
				  use disorders, gambling or other addictive behaviors, and domestic
				  violence.
2. Response for employees
				  who experience injury or stress related to workplace incidents.
3. Information about tobacco treatment
				  programs, and encouragement of staff to utilize resources.
(11) development and
				  implementation of policies to ensure equitable access to services on a
				  non-discriminatory basis in accordance with state and federal law;
(12) when providing 24-hour diversionary
				  services and residential services: care of patient and resident possessions,
				  safe storage, administration and disposal of medication, handling of patient
				  and resident mail, visits and communication;
(13) transfer or referral of a patient or
				  resident to another program or for additional services not provided by the
				  Licensed or Approved Provider directly or through a QSOA;
(14) ensuring patient safety, including
				  adequate patient and resident oversight and periodic patient and resident
				  safety checks;
(15) behavior
				  management;
(16)
				  grievances;
(17) staff response to
				  patient and resident threats to harm self or others;
(18) submission of mandated reports of child
				  abuse or neglect under M.G.L. c. 119, § 51A, elder abuse under M.G.L. c.
				  19A, § 15, and abuse of a disabled person under M.G.L. c. 19C, § 4
				  and maintenance of records of any such reports made by staff;
(19) staff response and reporting
				  requirements in accordance with
				  105 CMR
				  164.035;
(20) procedures for conducting internal
				  investigations for any alleged or suspected serious incident at or under
				  circumstances connected with the program involving the health, safety, or
				  well-being of the patients or residents.
(21) all-hazard and emergency planning and
				  procedures;
(22) employee
				  assistance;
(23) orientation and
				  supervision of staff from contract or temporary agencies;
(24) for Licensed or Approved Providers
				  providing opioid treatment services, severe weather;
(25) controlling access to records and to
				  information pertaining to HIV/AIDS testing pursuant to M.G.L. c. 111,
				  §70F;
(26) care and treatment
				  protocols developed in accordance with all applicable federal
				  regulation;
(27) clinical
				  supervision of direct care staff by appropriately licensed staff qualified to
				  deliver supervision;
(28) storing,
				  prescribing, and administering medications including methadone and
				  buprenorphine take home medication; and
(29) monitoring safe sleep conditions in
				  client rooms as well as conducting periodic safety checks with parents and
				  children overnight and during any napping times.