(a) A center shall develop, implement, and comply with center-specific written policies and procedures governing the requirements of 7 AAC 12.375 - 7 AAC 12.389, including

1. (1) the protection of each patient's health, safety, and well-being;
2. (2) the provision of treatment for patients to achieve optimal stabilization;
3. (3) patient access to medically necessary care;

4. (4) uniform physical and mental health screenings for

   1. (A) patient placement and quality assessment;
   2. (B) diagnosis;
   3. (C) evaluation; and
   4. (D) referral to an appropriate level of care;
5. (5) operational capability and compliance;
6. (6) the delivery of cost-effective services in conformity with current standards of practice;
7. (7) confidentiality and security of patient information, records, and files;
8. (8) prohibiting illegal or coercive inducement, solicitation, or kickbacks;
9. (9) patient rights;
10. (10) a patient grievance procedure;
11. (11) emergency preparedness;
12. (12) abuse or neglect;
13. (13) incident or accident response, including medical emergencies;
14. (14) universal precautions;
15. (15) service documentation;
16. (16) admission, including descriptions of physical and mental health screening and assessment procedures;
17. (17) transfer and discharge procedures;
18. (18) behavior management;
19. (19) infection control practices that meet current state and federal infection control guidelines;
20. (20) transportation for patient transfer, if applicable;
21. (21) quality assurance;
22. (22) medical and nursing services;
23. (23) emergency care;
24. (24) photographing or recording patients;
25. (25) contraband; and

26. (26) an operational and safety plan to prevent adult patients from visual or physical contact with minor patients; the plan must identify

    1. (A) areas for adult and minor patient use at separate times;
    2. (B) areas exclusively for adult or minor patient use; and
    3. (C) staff oversight protocols to implement the operational and safety plan.

(b) A center shall develop, implement, and comply with written personnel policies that include

1. (1) staff and volunteer

   1. (A) recruitment;
   2. (B) screening;
   3. (C) orientation;
   4. (D) ongoing training;
   5. (E) development;
   6. (F) supervision; and
   7. (G) performance evaluation;
2. (2) a written job description for each staff and volunteer position;
3. (3) an employee grievance procedure;

4. (4) an abuse reporting procedure that requires a staff member to report

   1. (A) an allegation of patient abuse or mistreatment under state and federal law; and
   2. (B) an allegation of patient abuse, neglect, exploitation, or misappropriation to appropriate state agencies;
5. (5) a non-discrimination policy;
6. (6) a policy that requires an employee to report signs or symptoms of a communicable disease or personal illness to the employee's supervisor, manager, or clinical director as soon as possible to prevent the spread of disease or illness to other individuals;
7. (7) a procedure to ensure that only qualified personnel provide care within the scope of the center's services;
8. (8) a policy that governs staff conduct and a procedure for reporting a law, rule, or professional and ethical code of conduct violation;
9. (9) a policy that governs staff organization related to the center's purpose, setting and location;
10. (10) a procedure to verify staff credentials are legal and from an accredited institution; and
11. (11) criminal background checks, adverse action, and registry checks under AS 47.05.300 - 47.05.390 (criminal and civil history) and 7 AAC 10.900 - 7 AAC 10.990 (barrier crimes and conditions; background checks).

(e) A center shall develop and implement patient policies and procedures that include a clearly written list of rules that govern patient conduct in the center. The center shall

1. (1) provide a copy of the center's rules to each patient or the patient's parent or legal guardian, if applicable; and
2. (2) post the rules in a conspicuous location that is accessible to patients.

(f) A crisis stabilization center shall develop, implement, and comply with policies and procedures that

1. (1) consider a patient's chronological and developmental age, diagnosis, and severity of illness before the center assigns a chair to the patient; and
2. (2) assign a chair to each patient.

(g) A crisis residential center shall develop, implement, and comply with policies and procedures that

1. (1) consider a patient's chronological and developmental age, diagnosis, and severity of illness before the center assigns a sleeping area or bedroom to the patient; and
2. (2) assign a bed to each patient.

(h) A center shall have a written emergency preparedness plan to

1. (1) maintain continuity of the center's operations in preparation for, during, and after an emergency or disaster;
2. (2) conduct a hazard vulnerability assessment every two years;
3. (3) manage the consequences of a disaster or emergency that disrupts the center's ability to render care and treatment, or that threatens patient lives or safety; and
4. (4) comply with current state and federal infection control guidelines in preparation for, during, and after a public health emergency or disaster.

(i) A center shall

1. (1) post exit diagrams that show how to clear the building safely and in a timely manner;

2. (2) have a clearly labeled and legible master floor plan that indicates

   1. (A) the areas for patient use as shelter or a safe zone during an emergency;
   2. (B) the location of emergency power outlets, if applicable;
   3. (C) the locations where emergency information is posted and accessible;
   4. (D) the equipment and devices that an emergency generator will power during an emergency, if applicable; and
   5. (E) the location of smoke or fire barriers and of smoke compartments; and

3. (3) provide emergency or disaster preparedness training to center employees; the training must

   1. (A) include orientation, ongoing training, and participation in planned drills for all personnel;
   2. (B) be developed based on high-risk disasters identified in the center's most recent hazard vulnerability assessment; and
   3. (C) include a fire response plan.

(j) A center's emergency preparedness plan must include provisions for

1. (1) an evacuation plan that includes

   1. (A) evacuating and delivering essential services to each patient;

   2. (B) a method to notify the patient's legal guardian, chosen representative, family member, or parent of a minor patient, if applicable, that includes

      1. (i) the date and approximate time of evacuation;
      2. (ii) the location to which the patient will be or was evacuated, including the location's name and address; and
      3. (iii) a telephone number that patient's legal guardian, chosen representative, family member, or parent of a minor patient may call for information regarding the patient's evacuation;
   3. (C) transferring the patient's supplies, medications, clothing, and treatment plan to the location to which the patient is evacuated;

   4. (D) transferring the evacuating patient's identification, including the patient's

      1. (i) diagnoses;
      2. (ii) medication, including dosage and administration times;
      3. (iii) allergies;
      4. (iv) special dietary needs or restrictions; and
      5. (v) next of kin name and contact information, if applicable; and
   5. (E) transporting or arranging for transportation during an evacuation;
2. (2) maintaining continuity of care during an emergency, including distributing and assigning responsibilities and functions among the staff;
3. (3) delivering essential care and services to each patient who is housed in the center or by the center at an alternate location during an emergency or disaster;
4. (4) determining when the center will shelter in place or evacuate in response to a disaster or emergency and the conditions the center will consider in making an evacuation determination; and

5. (5) necessary supplies that the center will provide during a shelter-in-place emergency, including

   1. (A) drinking water or fluids; and
   2. (B) non-perishable food.

(k) A center

1. (1) shall follow and execute the emergency preparedness plan in response to a declared disaster or other emergency;
2. (2) may not abandon a patient during a disaster or emergency;
3. (3) shall review and update the emergency preparedness plan at least every two years, or if significant changes occur in the emergency preparedness planning process;
4. (4) cooperate with the department and other government agencies in the event of an emergency or disaster and shall provide information as requested;
5. (5) monitor weather warnings and watches and evacuation orders from local and state emergency preparedness officials;
6. (6) submit a copy of the emergency preparedness plan for review to the department upon request; and

7. (7) submit a post-disaster written summary to the department upon request; the summary must describe how the center followed and executed the emergency preparedness plan, including

   1. (A) the type of emergency or disaster and the date the emergency or disaster occurred;
   2. (B) the evacuation status of the staff and patients;
   3. (C) the plan provisions applicable to the emergency or disaster;

   4. (D) a list of each patient injury or death that occurred during a shelter-in-place event, evacuation, or temporary relocation, including the

      1. (i) date;
      2. (ii) time; and
      3. (iii) cause and circumstances;
   5. (E) a list of complete or partial service or structure losses; and
   6. (F) a patient care impact report that includes incidents of inability to care for patients.

(l) A center shall develop and implement a safety plan that

1. (1) prohibits weapons of any kind in patient care areas, except for a weapon in the possession of a local, state, or federal law enforcement or peace officer who is conducting an authorized duty;
2. (2) prohibits hazardous materials or plastic bags in areas accessible to patients;

3. (3) requires poisonous, toxic, or flammable material to be

   1. (A) maintained in an appropriate and clearly labeled container;
   2. (B) securely stored in a locked cabinet or closet; and

   3. (C) used in a safe manner

      1. (i) in accordance with federal and state law and regulations;
      2. (ii) following manufacturer instructions; and
      3. (iii) without endangering patients, staff, and visitors;
4. (4) requires equipment, furnishings, or other items that are in a state of disrepair to be removed and made inaccessible to patients until replaced or repaired;
5. (5) allows only staff members to use a potentially harmful material, including a cleaning solvent or detergent; and
6. (6) requires a staff member who uses a potentially harmful material, including a cleaning solvent or detergent, to be trained on the safe use of the material.

(p) A center shall have an ongoing safety program that includes

1. (1) continuously inspecting the center for possible hazards;
2. (2) continuously monitoring safety equipment and performing maintenance or repair when needed;
3. (3) investigating and documenting accidents or emergencies;
4. (4) fire control, evacuation planning, and other emergency drills; and
5. (5) performing fire and other emergency drills at least once a quarter and maintaining patient safety and security during each drill.

(q) A center shall have a quality assurance plan and program that

1. (1) keeps the center's overall function in compliance with federal, state, and local laws;
2. (2) meets the needs of each patient in the area;
3. (3) meets the goals and objectives established in the center's mission, vision, and core values;
4. (4) maintains a system to effectively monitor, evaluate, identify, correct, or reassess a care practice that
5. (A) negatively affects the quality of patient care or services provided;
6. (B) results in an accident or injury to a patient or staff member; and
7. (C) documents deficiencies found and remedial actions taken;
8. (5) improves individual outcomes and individual satisfaction; and
9. (6) is updated on an ongoing basis to reflect changes, corrections, or other modifications.

(r) A center's quality assurance plan must include

1. (1) a quarterly sample review of patient case records to ensure that

   1. (A) individual treatment plans are current;
   2. (B) records are accurate, complete, and current; and
   3. (C) treatment plans have been developed and implemented as ordered;

2. (2) a quarterly review to identify risk factors that may affect the health, safety or welfare of each patient, including

   1. (A) patient grievances, including grievance resolution;
   2. (B) incidents that resulted in patient harm or elopement;
   3. (C) allegations of abuse, neglect, or exploitation; and

   4. (D) seclusion and restraint data; the center shall

      1. (i) maintain and analyze seclusion and restraint data for patterns of occurrences and negative outcomes; and
      2. (ii) develop and implement an action plan based on data analysis;
3. (3) a process to correct an identified problem and track improvement;
4. (4) a process to identify and implement opportunities for improvement;
5. (5) an internal evaluation procedure to collect data necessary for the plan's development; and
6. (6) semi-annual meetings of the center's quality assurance committee to evaluate the quality assurance process and activities; the committee must include the center administrator, clinical director, and at least two other staff members.

(t) A center shall report the following to the department in writing not more than 24 hours after the center becomes aware of the event:

1. (1) a disaster, emergency, or other unexpected event that causes significant program operation disruption;

2. (2) a patient's death or serious injury if

   1. (A) the death or serious injury is potentially related to program activities; and
   2. (B) the patient was an active patient of the center;
3. (3) an allegation of patient abuse, neglect, exploitation, or misappropriation of patient funds.