3508 POLICIES AND PROCEDURES

3508.1 Each CRFPID shall have on site a written or electronic manual that contains its most current policies and procedures, which shall be as detailed as is necessary to meet the needs of each person served and provide guidance to each staff member.3508.2 The on-site manual shall have been approved by the management of the CRFPID. The CRFPID management shall review the manual at least annually and revise it as necessary. All policies and procedures shall be in final form and signed and approved by the CRFPID management.3508.3 The manual shall be available for review and approval by government personnel who have licensing responsibility over CRFPIDs.3508.4 The CRFPID shall ensure that all staff and contractors are aware of the policies and procedures required by this section and that all policies and procedures are implemented. All employees and contractors shall be kept informed of policy changes that affect the performance of their duties.3508.5 The manual shall incorporate policies and procedures for at least the following:- (a) Admission and readmission, which covers admission criteria and exclusions; transfer and discharge; assessments and who shall conduct assessments; services offered; program planning;

- (b) Appropriate conduct between staff and persons residing in the CRFPIDs, and the monitoring of such conduct;

- (c) Behavior support planning;

- (d) Confidentiality of protected health information;

- (e) Emergencies and safety, which cover fire safety, emergency evacuation, infection control, and continuity of operations planning;

- (f) Protocols for managing affairs related to the death of a person;

- (g) Protocols for medical emergencies, first aid and changes in a person's health status;

- (h) General administration, which covers the organization charts, internal assessment of the quality of care, and fiscal management;

- (i) Grievance procedures indicating how a person is to present complaints, including complaints regarding staff, person's rights and investigation of

complaints; procedures must include ability for a person to complain anonymously;

1. (j) Health care, which covers treatment of acute and chronic health conditions; ensuring the availability of physician and dental services for preventative treatment and emergencies; and development and implementation of medical care plans in accordance with the person's needs and the ISP;
2. (k) People's rights and the formation and composition of a human rights committee in compliance with D.C. Law 2-137, the Citizens with Intellectual Disabilities Constitutional Rights and Dignity Act of 1978 (D.C. Official Code §7-1301.01 et seq.);
3. (l) Maintenance and use of medical and adaptive equipment;
4. (m) Medication management which covers administration of medication, medication administration errors, medication storage and disposal (in accordance with Section 3521);
5. (n) Personnel, which shall include job descriptions and qualifications, staff/person ratios, training and competency evaluations, staff development, health inventories and criminal background checks (in accordance with Section 3512);
6. (o) Electronic and manual recordkeeping, including confidentiality, accessibility, security, and retention of records (in accordance with Section 3517);
7. (p) Prohibition of mistreatment, neglect or abuse of persons by staff (in accordance with Section 3524);
8. (q) Identifying, investigating, managing and reporting of unusual incidents;
9. (r) Policies for handling funds of persons receiving services, which shall include:
10. (i) Providing for separate accounting for personal funds and prohibiting comingling of personal and CRFPID funds;
11. (ii) Requirements that persons control their own funds whenever possible, be provided training in money management whenever needed, endorse checks made out to them unless a legal guardian or personal representative has been authorized by law to endorse

their checks; and

(iii) Requirement that persons receive receipts of funds unless the person has been deemed by court to be incompetent, in which case the receipts shall be given to a guardian or personal representative;

(s) Policies and procedures detail a Quality Assurance Program in accordance with which the CRFPID shall evaluate its operations, staff, contractors and quality of services; and

(t) Policies regarding fees, payments, refunds and services, which shall be available at the time of admission. Policies regarding fees related to the Home and Community-Based Services Waiver Program shall be determined by DDS.

SOURCE: Final Rulemaking published at 39 DCR 3280, 3289 (May 8, 1992); as amended by Final Rulemaking published at 68 DCR 4282 (April 23, 2021).