1. (a) The governing body responsible for each facility or service shall develop and implement written policies for the following:

   1. (1) delegation of management authority for the operation of the facility and services;
   2. (2) criteria for admission;
   3. (3) criteria for discharge;

   4. (4) admission assessments, including:

      1. (A) who will perform the assessment; and
      2. (B) time frames for completing assessment.

   5. (5) client record management, including:

      1. (A) persons authorized to document;
      2. (B) transporting records;
      3. (C) safeguard of records against loss, tampering, defacement or use by unauthorized persons;
      4. (D) assurance of record accessibility to authorized users at all times; and
      5. (E) assurance of confidentiality of records.

   6. (6) screenings, which shall include:

      1. (A) an assessment of the individual's presenting problem or need;
      2. (B) an assessment of whether or not the facility can provide services to address the individual's needs; and
      3. (C) the disposition, including referrals and recommendations;

   7. (7) quality assurance and quality improvement activities, including:

      1. (A) composition and activities of a quality assurance and quality improvement committee;
      2. (B) written quality assurance and quality improvement plan;
      3. (C) methods for monitoring and evaluating the quality and appropriateness of client care, including delineation of client outcomes and utilization of services;
      4. (D) professional or clinical supervision, including a requirement that staff who are not qualified professionals and provide direct client services shall be supervised by a qualified professional in that area of service;
      5. (E) strategies for improving client care;
      6. (F) review of staff qualifications and a determination made to grant treatment/habilitation privileges;
      7. (G) review of all fatalities of active clients who were being served in area-operated or contracted residential programs at the time of death;
      8. (H) adoption of standards that assure operational and programmatic performance meeting applicable standards of practice. For this purpose, "applicable standards of practice" means a level of competence established with reference to the prevailing and accepted methods, and the degree of knowledge, skill and care exercised by other practitioners in the field;
   8. (8) use of medications by clients in accordance with the rules in this Section;
   9. (9) reporting of any incident, unusual occurrence or medication error;
   10. (10) voluntary non-compensated work performed by a client;
   11. (11) client fee assessment and collection practices;
   12. (12) medical preparedness plan to be utilized in a medical emergency;
   13. (13) authorization for and follow up of lab tests;
   14. (14) transportation, including the accessibility of emergency information for a client;
   15. (15) services of volunteers, including supervision and requirements for maintaining client confidentiality;
   16. (16) areas in which staff, including nonprofessional staff, receive training and continuing education;
   17. (17) safety precautions and requirements for facility areas including special client activity areas; and
   18. (18) client grievance policy, including procedures for review and disposition of client grievances.
2. (b) Minutes of the governing body shall be permanently maintained.

History Note: Authority G.S. 122C-26; 143B‑147;
Eff. May 1, 1996;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 20, 2019.