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PDFWAC 388-71-0738

What operating policies and procedures does the center need?

(1) All policies and procedures must include date of initial development and/or revision along with date of being reviewed and approved on a regular basis, at least annually, by the advisory committee, and conform to the requirements outlined in WAC 388-71-0702 through 388-71-0774, as applicable.
(2) Policies and procedures must include:
(a) Procedures for evaluations, reevaluation, and the development of a negotiated care plan with clients and/or representatives, including provisions for the utilization of a multidisciplinary team for this process;
(b) If applicable, research procedures that comply with chapter 388-04 WAC;
(c) Procedure for developing staffing schedules with staff to participant ratios being at a minimum one staff to six participants;
(d) Policy regarding the utilization of community resources;
(e) Gift policy;
(f) Marketing policy and procedures;
(g) Policy and procedure for contracting for services;
(h) Medication policy including but not limited to: Disposal of wasted or contaminated medications;
(i) Emergency and evacuation policy and procedures for fire safety as approved by the local fire authority must be adopted and posted, including provisions for fire drills, inspection and maintenance of fire extinguishers, and periodic inspection and training by fire department personnel. The center must conduct and document quarterly fire drills and document the center's ability to meet procedures. Improvements must be based on the fire evaluation drills;
(j) Grievance and complaint policies and procedures for staff and participants;
(k) Admission and discharge criteria policy and procedure. Discharge policies must include specific measurable criteria that establish when the participant is no longer eligible for services and under what circumstances the participant may be discharged. Unless the discharge is initiated by the client's department or authorized case manager, the center must notify the client, client representative if applicable, and case manager in writing of the specific reasons for the discharge. The center must also provide the client with adequate information about appeal and hearing rights. The discharge may occur due to the client's choice, other criteria as defined in the center's policy such as standards of conduct or inappropriate behavior, or changes in circumstances making the client ineligible for services under WAC 388-71-0708 or 388-71-0710;
(l) Health Insurance Portability and Accountability Act (HIPAA) policy and procedure;
(m) Confidentiality policy and procedure;
(n) Policy regarding how the center will comply with all applicable nondiscrimination laws, including but not limited to age, race, color, gender, religion, national origin, creed, marital status, sexual orientation, Vietnam era or disabled veteran's status, or sensory, physical, or mental handicap;
(o) A policy and procedure to afford the participants' their bill of rights describing the client's rights and responsibilities must be developed, posted, distributed to, and explained to participants, families, staff, and volunteers. Participants will be provided the bill of rights in the language understood by the individual upon request;
(p) Policies and procedures to ensure that the client's record/chart is appropriately organized and thinned according to the center's policy.
(q) Client record policy and procedures for:
(i) Confidentiality and the protection of records that define procedures governing the use and removal, and conditions for release of information contained in the records;
(ii) The release of client information and circumstances under which a signed authorization from the client or client representative is required; and
(iii) The retention, storage and access to records per the agency's contract with the department and/or the department's designee, including contingency plans in the event the center discontinues operation.
(r) The center must have an advance directive policy as required by the Patient Self Determination Act of 1990 (see 42 C.F.R. § 489.102 and chapter 70.122 RCW); and
(s) A policy and procedure for illness/injury/medical emergency/death must be followed in the event a participant becomes ill, is injured, or dies. The procedures must describe arrangements for hospital inpatient and emergency room service and include directions on how to secure ambulance transportation and complete incident reports.
[Statutory Authority: RCW 74.08.090, 74.09.520. WSR 15-01-174, § 388-71-0738, filed 12/23/14, effective 1/23/15. Statutory Authority: RCW 74.04.050, 74.04.057, 74.04.200, 74.08.090, 74.09.520, and 74.39A.030. WSR 03-06-024, § 388-71-0738, filed 2/24/03, effective 7/1/03.]
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