(a) Policies and procedures. The agency shall have written policies including:

1. (1) Organizational.

   1. (A) A description of the structure showing ownership and line of authority down to the client service level;
   2. (B) The services offered;
   3. (C) Hours of operation; and
   4. (D) Criteria for client acceptance and termination;
2. (2) Orientation of all personnel to the policies and objectives of the agency;
3. (3) Procedures for all tasks;

4. (4) Infection control program.

   1. (A) That has as its goal the prevention and control of infections and communicable diseases.
   2. (B) Work restrictions for employees shall be according to Centers for Disease Control and Prevention recommendations.
   3. (C)

(i) Measures for prevention of communicable disease outbreaks, especially Mycobacterium tuberculosis (TB).

1. (ii) All plans for the prevention of transmission of TB shall conform to the most current Centers for Disease Control and Prevention guidelines for preventing the transmission of Mycobacterium tuberculosis in healthcare facilities;

2. (5)

   1. (A) Personnel records shall be maintained for each employee and/or contracted individual.

   2. (B) A current personnel record shall include the:

      1. (i) Job description, signed by employee;
      2. (ii) Qualifications, education, and/or training;
      3. (iii) Application for employment;
      4. (iv) Verification of:

(b) (b) Certifications; and

1. (c) (c) Work history;

   1. (v) Evidence of orientation and competency for the topics listed in Table 1; and

      1. (vi) Criminal history determination of eligibility for employment;

2. (6)

   1. (A) An agency-wide quality assurance and improvement program that includes all services for the purpose of monitoring the safety and effectiveness of:

      1. (i) Services; and
      2. (ii) Quality of care.

   2. (B) The program will include:

      1. (i) Client satisfaction surveys;
      2. (ii) Supervision of services;
      3. (iii) Results of inspections, surveys, and audits from outside entities; and
      4. (iv) Performance improvement projects as applicable; and

3. (7) Complaints and incidents.

   1. (A) Each agency shall keep a record of complaints received.

   2. (B) Documentation shall include the:

      1. (i) Names of involved individuals;
      2. (ii) Relationship to the client;
      3. (iii) Nature of the complaint;
      4. (iv) Date of incident; and
      5. (v) Action taken to resolve the complaint, including referrals to other entities.

(b) Governing board. A private care agency shall have an organized governing board, consisting of at least one (1) member, which may be the owner, who shall:

1. (1) Be legally responsible for maintaining quality client services and establishing policies for the agency;
2. (2) Be legally responsible for the conduct of the agency; and

3. (3) Establish a mechanism to:

   1. (A) Adopt and periodically review:

      1. (i) Written bylaws; or
      2. (ii) An acceptable equivalent;

   2. (B) Approve written policies and procedures related to:

      1. (i) Safe, adequate services; and
      2. (ii) Operation of the agency;
   3. (C) Appoint an administrator and approve a plan for an alternate in the absence of the administrator; and

   4. (D) Oversee the management and fiscal affairs of the agency, including approving the agency's annual budget.

      1. (c) Administrator responsibilities. The administrator shall:
4. (1) Manage the agency's daily ongoing functions;

5. (2) Ensure all persons providing services on behalf of the agency:

   1. (A) Are qualified; and
   2. (B) Receive ongoing education;
6. (3) Ensure the accuracy of public information materials and activities;
7. (4) Implement and monitor budgeting and accounting systems;
8. (5) Implement quality assurance and infection control programs; and

9. (6) Conduct an annual review of the changes to the policies and procedures.

   1. (d) Client rights.

10. (1) The agency shall provide each client or representative with a copy of the bill of rights affirming the client's right to:

    1. (A) Be informed of the services:

       1. (i) Offered by the agency; and
       2. (ii) Being provided to the client;
    2. (B) Participate in the development of the plan of care and to be informed of the dates and approximate time of service;
    3. (C) Receive an explanation of any responsibilities the client may have in the care process;

    4. (D) Be informed of:

       1. (i) The name of agency; and
       2. (ii) How to contact that agency during all hours of operation;

    5. (E) Be:

       1. (i) Informed of the process for submitting and addressing complaints to the agency; and
       2. (ii) Notified of the state home health hotline number;

    6. (F) Be informed orally and in writing of any charges:

       1. (i) That insurance might not cover; and
       2. (ii) For which the client would be responsible;

    7. (G) Courteous and respectful treatment, privacy, and freedom from:

       1. (i) Abuse; and
       2. (ii) Discrimination;
    8. (H) Confidential management of client records and information;
    9. (I) Access information in the client record upon request;
    10. (J) Receive prior notice and an explanation for the reasons of termination, referral, transfer, discontinuance, or change of service; and
    11. (K) Control access to the client's home.

11. (2) The agency shall provide each client and family with a written list of responsibilities affirming the client's responsibility to:

    1. (A) Assist in developing and maintaining a safe environment;
    2. (B) Treat all agency staff with courtesy and respect;
    3. (C) Participate in the development and update of services; and
    4. (D) Adhere to the plan of care or services as developed by the agency and to assist in the care as necessary.

(e) Records and documentation.

1. (1) The private care agency shall maintain records of all services provided to clients that are:

   1. (A) Orderly, intact, legibly written;

   2. (B) Available and retrievable either:

      1. (i) In the agency; or
      2. (ii) By electronic means; and

   3. (C) Suitable for:

      1. (i) Photocopying; or
      2. (ii) Printing.

2. (2) Records shall be stored in a manner that:

   1. (A) Prevents loss or manipulation of information;
   2. (B) Protects the record from damage; and
   3. (C) Prevents access by unauthorized persons.

3. (3) Records shall be retained for a minimum of:

   1. (A) Five (5) years after discharge of the client; or
   2. (B) Two (2) years after the age of majority.

4. (4) Each record shall include:

   1. (A) Initial assessment performed by a qualified supervisor;
   2. (B) Plan of care that shall detail the services;
   3. (C) Aide Service Plan;
   4. (D) Physician or licensed practitioner orders, if any;
   5. (E) Records of supervisory visits;
   6. (F) Date and time service providers are in the home; and
   7. (G) Tasks completed.

5. (5) Client notes are to be:

   1. (A) Written the day the service is rendered; and
   2. (B) Incorporated into the record no less than every fourteen (14) days.
6. (6) Provisions shall be made for the records in the event an agency ceases operation.