Code of Massachusetts Regulations › 105 CMR - DEPARTMENT OF PUBLIC HEALTH › Title 105 CMR 158.000 - Licensure of Adult Day Health Programs › Section 158.030 - Administration

Current through Register 1525, July 5, 2024
(A) The licensee shall be responsible for
			 compliance with all applicable laws and regulations.
(B) Each licensee shall establish by-laws or
			 policies which describe the organizational structure, establish authority and
			 responsibility of the Program, and identify the goals and service components of
			 the Program.
(C) The licensee shall
			 appoint a qualified Program Director who is responsible for establishing and
			 implementing policies and procedures regarding the management and operation of
			 the Program.
(D) The licensee shall
			 ensure the Program is open at least Monday through Friday and is
			 non-residential.
(E) The licensee
			 shall ensure that all required records, reports, and other materials required
			 by
			 105 CMR 158.000 are
			 complete, accurate, current, and available within the Program.
(F) The licensee shall ensure the Program is
			 administered in a manner that uses its resources effectively and efficiently to
			 attain or maintain the highest practicable physical, mental, and psychosocial
			 well-being of each participant.
(G)
			 The licensee shall make participant records and copies of participant records
			 available to the Commissioner or his or her designee upon request.
(H)
Personnel
.
(1) The licensee shall be responsible for
			 procurement of competent personnel. The licensee and the Program Director shall
			 each be responsible for the direction and supervision of personnel.
(2) The licensee and Program Director shall
			 establish and maintain written policies and procedures regarding personnel that
			 promote quality care of participants.
(3) The licensee shall:
(a) Maintain accurate time records for all
			 personnel;
(b) Maintain payroll
			 records, timesheets, and staffing schedules for at least seven years;
(c) Post, and make accessible to participants
			 and their families, staffing schedules; and
(d) Maintain a written job description for
			 each position that includes title, reporting authority, qualifications, duties,
			 and responsibilities.
(4)
			 The licensee shall maintain a personnel record for each employee and volunteer
			 that is current, accurate, and available on the premises for seven years.
			 Personnel records shall contain:
(a)
			 Pertinent information regarding identification, including maiden name, if
			 applicable;
(b) Social Security
			 number, photo copy of a government issued photo identification, professional
			 registration number or competency determination (if applicable), and year of
			 original licensure, registration, or competency determination;
(c) Cardiopulmonary resuscitation and first
			 aid certifications;
(d) Names and
			 addresses of educational institutions attended, dates of graduation, degrees or
			 certificates conferred, and name at the time of graduation;
(e) Employment history including experience,
			 training, names and addresses of previous employers, dates of employment, and
			 reasons for terminating previous employment;
(f) Completed and signed job application
			 forms;
(g) Job
			 descriptions;
(h) Performance
			 evaluations;
(i) A pre-employment
			 physical examination completed within 12 months of employment and a physical
			 examination completed at least once every two years during the period of
			 employment;
(j) A pre-employment
			 Tuberculosis (TB) history and risk assessment with additional screening as
			 indicated within three months prior to employment in accordance with Department
			 Bureau of Infectious Disease guidelines;
(k) An annual TB risk assessment, symptom
			 review, and education with additional screening as indicated in accordance with
			 Department Bureau of Infectious Disease guidelines;
(l) For food service personnel, any
			 documentation required by
			 105 CMR 590.000:
State Sanitary Code Chapter X - Minimum Sanitation Standards for Food
			 Establishments
;
(m)
			 Training attendance records; and
(n) Records of illnesses, incidents, and
			 complaints involving personnel while on duty.
(5) Prior to hiring staff or approving
			 volunteers, a Program shall perform a background check that includes the
			 candidate's references, job history, Criminal Offender Records Information
			 (CORI), and the Nurse Aide Registry, established under M.G.L. c. 111, §
			 72J.
(6) A Program shall conduct an
			 annual performance evaluation for each employee which includes a face-to-face
			 meeting.
(7) A Program shall have
			 an organized orientation program for all new employees that explains job
			 responsibilities, duties, conditions of employment, and relevant participant
			 care policies. All new personnel shall attend orientation training.
(8) A Program shall provide a minimum of 12
			 hours of relevant in service training per year for personnel who interact with
			 participants. The in-service training shall be relevant to the participant
			 population and to the services provided by the Program.
(9) A Program shall ensure that all personnel
			 are knowledgeable about the types of medical and behavioral conditions of
			 participants and their cultural diversity, including, but not limited to, race,
			 ethnicity, sexual orientation and gender identity, such that personnel are able
			 to provide care that is appropriate to participants' needs.
(10) A Program shall ensure that all
			 personnel are adequately trained to understand, respond to, and address the
			 needs of participants with Alzheimer's disease and related disorders. Training
			 regarding Alzheimer's disease and related disorders shall include:
(a) Knowledge about Alzheimer's disease and
			 related disorders;
(b) Behavior
			 management skills necessary to respond appropriately to participant behaviors
			 and non-verbal communications; and
(c) Group process skills in working with
			 special need populations.
(11) No individual may be employed, allowed
			 to work, or allowed to volunteer, if he or she is infected with a contagious
			 disease that might endanger the health of participants or personnel.
(12) The Department shall be notified in
			 writing within two business days of the resignation or dismissal of the Program
			 Director and the name and qualifications of the new Program Director or interim
			 Program Director.
(13) A Program
			 shall require all persons, including students, who examine, observe, or treat a
			 participant to wear an identification badge that readily discloses the first
			 name, licensure status, if any, and staff position of the person so examining,
			 observing, or treating a participant.