COMAR 10.21.17.09. Policies and Procedures

A. The program shall have and maintain written policies that, at a minimum include:

(1) The program's mission and goals;

(2) A description of the organizational structure of the program;

(3) Identification of the duties of the program director and, if applicable, the medical director or clinical director; and

(4) The policies and procedures for:

(a) Ensuring individual rights, including confidentiality, and providing a complaint process;

(b) Providing the services in the chapter under this subtitle that outlines the requirements for the specific program;

(c) Screening, admission, transition, and discharge;

(d) If the program provides case coordination, assisting program enrollees with access to all entitlements, pertinent resources, insurance benefits, and reimbursements for which the individual is eligible;

(e) If applicable to the program, storing, handling, prescribing, administering, and disposing of medications;

(f) If applicable to the program, monitoring of psychiatric and somatic medication;

(g) If applicable, accounting for the use and expenditure of an individual's funds;

(h) Staffing, including, if required under the chapter in this subtitle that outlines the provisions for the specific program, 24 hours, on-call and emergency coverage;

(i) If the program provides services in a facility, a disaster and emergency evacuation plan;

(j) According to federal and State requirements, safety precautions, infection control, and communicable disease control;

(k) Incident reporting;

(l) Crisis response plan; and

nder the chapter in this subtitle that outlines the provisions for the specific program, 24 hours, on-call and emergency coverage;

(i) If the program provides services in a facility, a disaster and emergency evacuation plan;

(j) According to federal and State requirements, safety precautions, infection control, and communicable disease control;

(k) Incident reporting;

(l) Crisis response plan; and

(m) Information about any State and federal laws pertaining to civil or criminal penalties for false claims and statements and whistle blower protections, including the necessity for preventing and detecting fraud, waste, and abuse.

B. At least every 3 years, appropriate program staff shall review and, as necessary, revise the policies and procedures.

C. The program shall maintain written personnel policies, including, at a minimum:

(1) Contents of an employee's personnel file, including, at a minimum:

(a) Name;

(b) Current job classification;

(c) Current job description;

(d) Resume containing educational background, relevant work experience, and specialized skills;

(e) Copies of required certificates and licenses and primary source verification;

(f) Documentation of a criminal background investigation as follows:

(i) If the employee works with or has access to minors, a background investigation following the procedures set forth in Family Law Article, §§ 5-560 — 5-568, Annotated Code of Maryland; and

(ii) If the employee works in a group home, a background investigation following the procedures set forth in Health-General Article, Title 19, Subtitle 19, Annotated Code of Maryland;

(g) Information received from the employee's references;

(h) Documentation of orientation, continuing education and training activities, and privileges granted; and

(i) If the staff person's duties require transportation of staff or individuals served:

p home, a background investigation following the procedures set forth in Health-General Article, Title 19, Subtitle 19, Annotated Code of Maryland;

(g) Information received from the employee's references;

(h) Documentation of orientation, continuing education and training activities, and privileges granted; and

(i) If the staff person's duties require transportation of staff or individuals served:

(i) Proof of a valid driver's license issued in the state of the employee's residence; and

(ii) Updated annually, a driver's license report from the appropriate state;

(2) Staff orientation, supervision, training, and education;

(3) Method of access to an employee's personnel file;

(4) Substance abuse policy;

(5) Ethical guidelines for employees; and

(6) Confidentiality guidelines regarding disclosure requirements of:

(a) Maryland Confidentiality of Medical Records Act, Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland; and

(b) Relevant federal statutes and regulations, including the Health Insurance Portability and Accountability Act, 42 U.S.C. §§1320D et seq., and implementing regulations at 45 CFR Parts 160 and 164.