Rule 111-8-2-.04. Governing Body and Administration

1. (1) There shall be a governing body which assumes full legal responsibility for the overall conduct of the program and an administrator reporting to the governing body. The administrator must be at least 21 years of age and must have at least one-year of experience in managing a health care program and supervising health care staff.
2. (2) The governing body shall be responsible for compliance with all applicable laws and regulations pertaining to the program.
3. (3) The governing body shall provide the name and credentials of the administrator at the time of initial application and provide the department written notice of any change to the administrator within thirty (30) days following such change.
4. (4) The governing body must adopt and abide by a code of ethics pertaining to each member of the governing body and its administrator. At a minimum, the code of ethics shall include a conflict of interest policy, whistleblower policy, sexual harassment policy, discrimination policy, and other policies required for proper governance.
5. (5) The words "sanitorium," "sanitarium" and "hospital" shall not be used in the official title or marketing materials of any program permitted under the provisions of these rules and regulations.

6. (6) The governing body and administrator shall develop and implement policies, procedures and practices that support the core values of dignity, respect, choice, independence and privacy of the clients in a safe environment and in accordance with these rules. A copy of the program policies and procedures must be provided to the client upon admission, or prior to admission if requested by a client considering treatment at the program. At a minimum, such policies and procedures must comply with all these rules and regulations and provide clear instruction for the staff and clients on the following matters:

   1. (a) The services available in the program and provide direction on how clients may access such services.
   2. (b) Admissions, discharges and transfers which ensure that the program does not admit or retain clients who need more care than the program is authorized for or capable of providing.
   3. (c) A code of conduct and statement of rights for all clients in accordance with Ga. Comp. R. & Regs. r. 111-8-2-.15.
   4. (d) Payment for services, including optional services, and refund policy when a client is transferred or discharged.
   5. (e) Training and ongoing evaluation of staff, including offerings of any specialized training.
   6. (f) Program rules applicable to staff and clients and their enforcement.
   7. (g) Protecting the rights of the staff and clients as set forth in these rules.
   8. (h) Medication management, controls, procurement and the professional oversight provided for such services.
   9. (i) Health and hygiene requirements for the program, clients, and staff, including but not limited to, issues relating to illness and infection control, work policies and return to work policies, food-borne illnesses and reportable diseases. The policy shall also include any restrictions on a client's ability to utilize designated substances, such as nicotine and caffeine, and the program's expectations regarding same.
   10. (j) Clear instructions for method of reporting and investigation of claims of abuse, neglect, harassment, discrimination, or exploitation of clients and staff. Furthermore, the policies and procedures shall detail requirements for the reporting of accidents, injuries, voluntary discharge from the program, and changes in clients' conditions and status to family members, legal surrogates, and required parties.
   11. (k) Discipline procedures for handling conduct which is inconsistent with the policies of the program committed by staff, and circumstances which may lead to discharge by the program.
   12. (l) Emergency preparedness, drills and evacuation requirements.
   13. (m) Quality assurance and peer review mechanisms to determine opportunities for improving care utilizing information acquired from reports and investigations of serious incidents, including client and family feedback.
   14. (n) The right of clients to receive visitors and responsibilities and obligations regarding visitor access.
   15. (o) The right of clients to use electronic equipment including but not limited to, mobile phones, computers, tablets, televisions, audio equipment, video game devices, and other equipment utilized for entertainment.
   16. (p) The safety and security precautions that will be employed by the program to protect clients from harm from self, other clients and staff.
   17. (q) The staffing plan which takes into account the specific needs of the clients and also includes arrangements for staffing in the absence of regularly scheduled staff.
   18. (r) Procedures ensuring the confidentiality of client records and security measures to ensure that all client records are maintained on a confidential basis.

Authority: O.C.G.A. §§ 37-3-204, 31-2-4, 31-2-7, 31-7-2.1.

History. Original Rule entitled "Governing Body and Administration" adopted. F. Dec. 10, 2024; eff. Dec. 30, 2024.