Subchapter C. GENERAL STANDARDS FOR FREESTANDING
TREATMENT ACTIVITIES

 (a)  The intake, evaluation and referral, inpatient nonhospital, partial hospitalization, outpatient and inpatient hospital activities shall comply with this chapter.

 (b)  A facility in which freestanding treatment activities are provided that has a valid full license from the Department of Public Welfare under 55 Pa. Code Chapters 5300 and 5310 (relating to private psychiatric hospitals; and community residential rehabilitation services for the mentally ill) is deemed to be in compliance with the following standards: Sections 709.22—709.27, 709.29 and 709.32. This subsection shall remain in effect as long as the Department finds the standards in 55 Pa. Code Chapters 5300 and 5310 to be consistent with of this subchapter.

 (a)  A project shall have a governing body and legal responsibility for the project rests in the governing body.

 (b)  If a project is publicly funded, not more than one staff member of the project may sit on the governing body at a designated time.

 (c)  If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to:

   (1)  A method of selection for membership.

   (2)  Qualifications for membership.

   (3)  Criteria for continued membership.

   (4)  Frequency of meetings.

 (d)  The duties of the governing body include, but are not limited to, the following:

   (1)  Selecting a project director as the person officially responsible to the governing body.

   (2)  Identifying the project’s purpose and philosophy.

   (3)  Describing the project’s organizational structure.

 (e)  If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:

   (1)  Activities and accomplishments of the preceding year.

   (2)  A financial statement of income and expenses.

   (3)  A statement disclosing the names of officers, directors and principal shareholders, where applicable.

 (a)  The project director shall prepare and annually update a written manual delineating project policies and procedures.

 (b)  The project director shall assist the governing body in formulating policy and present the following to the governing body at least annually:

   (1)  Project goals and objectives which include time frames and available resources.

   (2)  Written reports of project operations.

   (3)  A performance report summarizing the progress towards meeting goals and objectives.

 (a)  The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:

   (1)  Defined target population.

   (2)  Treatment models utilized by the project.

   (3)  Written procedures for the management of treatment/rehabilitation services for clients.

   (4)  Written procedures for referral outlining cooperation with other service providers.

 (b)  The project shall obtain written letters of agreement or understanding with primary referral sources.

 (c)  The project shall maintain a current community resource listing of other health and social service agencies.

 (d)  Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.

 (a)  The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project’s drug/alcohol abuse services.

 (b)  Projects shall develop a service fee schedule which shall be posted in a prominent place.

 (a)  The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:

   (1)  Recruitment, selection, promotion and termination of staff.

   (2)  Utilization of volunteers.

   (3)  Wage and salary administration.

   (4)  Employe benefits.

   (5)  Working hours.

   (6)  Vacation and sick leave.

   (7)  Rules of conduct.

   (8)  Disciplinary actions.

   (9)  Supervision of staff.

   (10)  Work performance evaluations.

   (11)  Employe accidents and safety.

   (12)  Employe grievances.

 (b)  The governing body shall adopt a written policy to implement and coordinate personnel management, which includes, but is not limited to:

   (1)  Confidential maintenance of personnel records.

   (2)  The dissemination of employment information to project staff.

   (3)  The orientation of new employes.

   (4)  The implementation of Federal, State and local statutes concerning fair employment practices.

 (c)  The project director shall develop written policies and procedures to provide for ongoing staff training and staff evaluation. Documentation shall include, but is not limited to:

   (1)  An assessment of staff training needs.

   (2)  Plans for addressing these needs.

   (3)  A mechanism to collect feedback on training completed.

   (4)  An annual evaluation of the overall training program.

 (d)  The personnel records shall include, but not be limited to:

   (1)  The application for employment.

   (2)  The results of reference investigations.

   (3)  The verification of training experience and professional licensure or registration, where applicable.

   (4)  Salary information.

   (5)  Work performance evaluation including the following:

     (i)   Individual staff performance shall be evaluated at least annually.

     (ii)   The individual shall be informed, by written copy, of the annual evaluation.

   (6)  Disciplinary actions.

 (e)  The project director shall develop written policies on employe rights and demonstrate the project’s efforts toward informing staff of the following:

   (1)  The employe’s right to inspect his own records.

   (2)  The employe’s right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.

   (3)  The employe’s right to submit rebuttal data or memoranda to his own records.

 (f)  There shall be written job descriptions for project positions which include, but are not limited to:

   (1)  Job title.

   (2)  Tasks and responsibilities of the job.

   (3)  The requisite skills, knowledge and experience.

 (a)  A written procedure shall be developed by the project director which shall comply with 4 Pa. Code §  255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:

   (1)  Confidentiality of client identity and records.

   (2)  Staff access to client records.

 (b)  The project shall secure client records within locked storage containers.

 (c)  The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:

   (1)  Name of the person, agency or organization to whom disclosure is made.

   (2)  Specific information disclosed.

   (3)  Purpose of disclosure.

   (4)  Dated signature of client or guardian.

   (5)  Dated signature of witness.

   (6)  Expiration date of the consent.

 (d)  A copy of a client consent shall be offered to the client and a copy maintained in the client records.

 (e)  Where consent is not required, the project personnel shall:

   (1)  Fully document the disclosure in the client records.

   (2)  Inform the client, as readily as possible, that the information was disclosed, for what purposes and to whom.

 (a)  Client records, whether original, reproductions or microfilm, shall be kept on file for a minimum of 4 years following the discharge of a client.

 (b)  If the project discontinues operation, it shall make known to the Department where its records are stored.

 The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:

   (1)  A person receiving care or treatment under section 7 of the act (71 P. S. §  1690.107), shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.

   (2)  The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.

   (3)  A client has the right to inspect his own records. The project director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented and kept on file.

   (4)  The client has the right to appeal a decision limiting access to his records to the project director.

   (5)  The client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records.

 (a)  If a project utilizes Department funds, it shall comply with the Department’s UDCS.

 (a)  Projects which furnish pharmaceutical services shall comply with applicable Federal, State and local ordinances, statutes and regulations regarding the storing, compounding, administering or dispensing of medication.

 (b)  Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.

 (c)  The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:

   (1)  Administration of medication.

   (2)  Drug storage areas.

   (3)  Inspection of storage areas.

   (4)  Methods for control and accountability of drugs.

   (5)  Security of drugs.

   (6)  Inventories.

   (7)  Medication errors and drug reactions.

 (a)  Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client’s treatment at the project. The notice shall include the reason for termination.

 (b)  The client shall have an opportunity to request reconsideration of a decision terminating treatment.

   This section cited in 28 Pa. Code §  709.41 (relating to exceptions to the general standards for freestanding treatment facilities).