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<regulation prefix="Regulation" num=".09" citation="COMAR 10.21.17.09" title_num="10" subtitle_num="21" chapter_num="17" heading="Policies and Procedures.">
  <paragraph num="A.">
    <text>The program shall have and maintain written policies that, at a minimum include:</text>
    <paragraph num="(1)">
      <text>The program's mission and goals;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>A description of the organizational structure of the program;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Identification of the duties of the program director and, if applicable, the medical director or clinical director; and</text>
    </paragraph>
    <paragraph num="(4)">
      <text>The policies and procedures for:</text>
      <paragraph num="(a)">
        <text>Ensuring individual rights, including confidentiality, and providing a complaint process;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Providing the services in the chapter under this subtitle that outlines the requirements for the specific program;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Screening, admission, transition, and discharge;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>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;</text>
      </paragraph>
      <paragraph num="(e)">
        <text>If applicable to the program, storing, handling, prescribing, administering, and disposing of medications;</text>
      </paragraph>
      <paragraph num="(f)">
        <text>If applicable to the program, monitoring of psychiatric and somatic medication;</text>
      </paragraph>
      <paragraph num="(g)">
        <text>If applicable, accounting for the use and expenditure of an individual's funds;</text>
      </paragraph>
      <paragraph num="(h)">
        <text>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;</text>
      </paragraph>
      <paragraph num="(i)">
        <text>If the program provides services in a facility, a disaster and emergency evacuation plan;</text>
      </paragraph>
      <paragraph num="(j)">
        <text>According to federal and State requirements, safety precautions, infection control, and communicable disease control;</text>
      </paragraph>
      <paragraph num="(k)">
        <text>Incident reporting;</text>
      </paragraph>
      <paragraph num="(l)">
        <text>Crisis response plan; and</text>
      </paragraph>
      <paragraph num="(m)">
        <text>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.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>At least every 3 years, appropriate program staff shall review and, as necessary, revise the policies and procedures.</text>
  </paragraph>
  <paragraph num="C.">
    <text>The program shall maintain written personnel policies, including, at a minimum:</text>
    <paragraph num="(1)">
      <text>Contents of an employee's personnel file, including, at a minimum:</text>
      <paragraph num="(a)">
        <text>Name;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Current job classification;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Current job description;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Resume containing educational background, relevant work experience, and specialized skills;</text>
      </paragraph>
      <paragraph num="(e)">
        <text>Copies of required certificates and licenses and primary source verification;</text>
      </paragraph>
      <paragraph num="(f)">
        <text>Documentation of a criminal background investigation as follows:</text>
        <paragraph num="(i)">
          <text>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</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>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;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(g)">
        <text>Information received from the employee's references;</text>
      </paragraph>
      <paragraph num="(h)">
        <text>Documentation of orientation, continuing education and training activities, and privileges granted; and</text>
      </paragraph>
      <paragraph num="(i)">
        <text>If the staff person's duties require transportation of staff or individuals served:</text>
        <paragraph num="(i)">
          <text>Proof of a valid driver's license issued in the state of the employee's residence; and</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Updated annually, a driver's license report from the appropriate state;</text>
        </paragraph>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>Staff orientation, supervision, training, and education;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Method of access to an employee's personnel file;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Substance abuse policy;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Ethical guidelines for employees; and</text>
    </paragraph>
    <paragraph num="(6)">
      <text>Confidentiality guidelines regarding disclosure requirements of:</text>
      <paragraph num="(a)">
        <text>Maryland Confidentiality of Medical Records Act, Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>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.</text>
      </paragraph>
    </paragraph>
  </paragraph>
</regulation>