1. Management.

a. Governing authority.

(1) A community mental health and retardation center shall be established in accordance with the provisions of North Dakota Century Code chapter 25-12. (a) If the governing authority is a public organization, it shall describe the administrative framework within which it operates. (b) If the governing authority is a private, nonprofit corporation, it shall provide written documentation of its source of authority through charter, constitution and bylaws, and if required, its state license. (2) A community mental health and retardation center, whether established by a political subdivision or a body corporate, shall be governed by and under the general supervision of a board of directors appointed in the manner described in North Dakota Century Code chapter 25-12-03. (3) The center's governing board shall adopt bylaws which shall state the purposes of the board and shall at least: (a) Define the powers and duties of the board, its officers, and committees. (b) Describe the authority and responsibility delegated to the executive director of the center, and retain the right to rescind such delegation. (c) Provide for selection of its officers, and for appointment of standing and special committees necessary to effect the discharge of its responsibilities. (d) Provide for the adoption of a schedule of meetings and attendance requirements. (e) Require that minutes be kept of the board deliberations and decisions. [1] The center shall provide a copy of the bylaws and any ensuing revisions to the division of mental health and retardation.

1. [2] There shall be documentation verifying that the bylaws of the governing authority are reviewed and updated at least annually.
2. [3] There shall be documentation verifying that the governing board shall be an active agent in the direction and supervision of center operations.(4) The governing board shall appoint an executive director to discharge its responsibilities.- (a) The executive director shall have overall authority and responsibility for the operation of the center.
3. (b) The executive director shall be a qualified mental health professional with clinical, administrative, and community organization training or experience appropriate to a community mental health center setting.
4. (c) Prior to the appointment of the executive director, the governing board shall consult with the division of mental health and retardation, state department of health, regarding the qualifications of the applicant for that position.
5. (d) The executive director shall be a full-time employee of the center, and shall not be permitted to engage in private practice.
6. (e) To ensure effective communication between the governing board and the center staff, the executive director shall attend all its meetings. The board shall also use any other appropriate means to assure adequate communication with the staff of the center.(5) The governing board shall appoint a medical director, who may also be the executive director, who shall assume the medical responsibility for each patient served by the center.- (a) The governing board shall describe in writing the role and responsibilities of the medical director and the medical director's relationship to the executive director, if that position is occupied by another mental health professional.
7. (b) The medical director shall be a board eligible or board certified psychiatrist licensed to practice medicine in North Dakota.(6) The governing board shall prepare an annual report which shall include full disclosure of center ownership and control, fiscal information including receipts and disbursements, a table of organization depicting center programs and staff functions and responsibilities, and a summary of center activities reflecting services provided during the year.- (a) Such a report shall be filed with the division of mental health and retardation, state department of health, funding sources, and others upon request.(7) The governing board shall take an active role in informing the community about the center and its programs, and shall actively solicit the involvement of the community in the affairs of the center.- (a) The governing board shall exert every effort to secure needed financial support for the ongoing operation of the center.(8) The governing board of the center shall assure that there is continuing review of the quality of care provided by the center.

b. Fiscal management.

1. (1) The center's executive director shall designate an administrator or business manager who shall be responsible for the efficient management of the center and the maintenance of buildings and equipment.
2. (a) This individual shall be a full-time professional who shall supervise and coordinate such functions as general maintenance, purchasing and supply, accounting records, transportation, payroll, employee records, inventory control, and patient billings.
3. (2) An accounting system shall be maintained which provides information that reflects the fiscal experience and current financial position of the center.
4. (a) Such system shall accurately account for all revenues by source, federal, state, local, third party payments, and others.
5. (b) Such system shall have the capacity to determine the direct and indirect cost of each type of service provided by the center.
6. (c) Such system shall accurately indicate the center's operational costs.
7. (d) Such system shall be responsive to reporting requirements set by the division of mental health and retardation, state department of health.
8. (3) The center's executive director shall submit an annual budget to the governing body of the center for the purpose of discussion, modification and approval.
9. (a) The budget shall be developed with the participation of appropriate treatment and administrative staff.
10. (b) The budget shall categorize revenues for the center by source.
11. (c) The budget shall categorize expenses by the types of services or program components provided.
12. (d) Revisions of the budget during the fiscal year of operations shall be reviewed and approved by the center's governing body.
13. (e) After review and approval by the governing body, a copy of the budget, and any revisions thereafter, shall be filed with the division of mental health and retardation, state department of health.
14. (4) The fiscal management system shall include a fee schedule.
15. (a) The center shall maintain a current written schedule of rate and charge policies that has been approved by the center's governing body and the division of mental health and retardation, state department of health.
    1. [1] The fee schedule shall be accessible to all center staff and individuals served by the center.
    2. [2] The fee schedule shall be based on the patient's ability to pay taking into consideration income and family size.
16. (b) The center shall provide needed services for persons regardless of ability to pay. All persons shall be able to seek and receive services in the center, and shall not be denied services solely on the basis of inability or ability to pay.

(5) The fiscal management system shall have an audit of the financial operations of the center performed by an independent certified public accountant at least annually, in conformance with guidelines issued by the North Dakota state auditor. A copy of this audit shall be filed with the center's governing body, the state auditor's office, the fiscal officer, state department of health and the division of mental health and retardation, state department of health.

(6) The fiscal management system shall have appropriate insurance coverage for the protection of its staff, governing body, patients, the general public and the physical facilities. This insurance coverage shall include fire and extended coverage for buildings, contents and vehicles; public liability insurance; workmen's compensation for employees; and professional liability insurance.

(7) The fiscal management system shall provide that the center makes use of space owned by an organization other than the center, an agreement covering the terms of such usage shall be consummated.

c. Personnel.

(1) The center shall have written personnel policies and practices covering all employees of the center or its affiliates, or both.

(a) There shall be documentation verifying that the center's governing body has approved all written personnel policies and practices.

(b) There shall be documentation verifying that these personnel policies and practices are reviewed and updated at least annually.

(2) The center shall have written job descriptions for all staff positions.

(a) Each job description shall set forth the qualifications, reporting supervisor, positions supervised, and duties.

(b) There shall be documentation verifying that each job description is reviewed and updated at least annually for continuing appropriateness.

(c) Full-time professionals of the center shall not be permitted to engage in private practice.

(3) The written personnel policies and practices shall require that all personnel meet any local, state, or federal legal requirements for licensing, registration, or certification.

(4) The written personnel policies and practices shall stipulate that qualifications for all positions be nondiscriminatory.

(5) The written personnel policies and practices shall describe methods and procedures for the supervision of all personnel, including volunteers.

(6) The written personnel policies and practices shall include fringe benefits, recruitment, termination, promotions, and employee grievances.

(7) The written personnel policies and practices shall include a mechanism for evaluation of personnel performance on at least an annual basis.

(a) The evaluation shall be in writing.

(b) The evaluation shall be reviewed with the employee.

(8) The center shall maintain individual employee records, including the employee's application and statement of qualifications, transcripts, employment conditions and salary, accumulation and use of sick leave, vacation and administrative leave, and annual evaluations of the employee's performance.

(9) The written personnel policies and practices shall include a mechanism for suspension or dismissal of an employee for cause.

(10) All personnel policies and practices shall be given to each employee and be available to others upon request.

(11) The center shall have a written statement of its policies and practices for handling cases of neglect and abuse of its patients. Alleged violations and the results of any investigation shall be documented.

(12) The center shall have a written plan for the professional growth and development of all personnel. This plan shall include but not be limited to orientation procedures, inservice training programs, outside continuing education opportunities, and availability of professional reference material.

(13) The center shall document the involvement of its staff and governing body in the development and implementation of all of these policies, practices, statements, and plans.

(14) The center shall file with the division of mental health and retardation a copy of its personnel policies and practices at least on an annual basis. The same procedure applies to any changes, modifications or additions which may occur during the year.

d. Planning.

(1) The center shall carry out or have available to it a needs assessment or market study for the population it serves. The center shall document the methods and procedures for completing the needs assessment, as well as an analysis of the results.

(2) The center shall compile an inventory of existing resources for the population it serves, including a listing of all financial, staff, and service resources available.

(3) The center shall involve community participation in the planning process.

(4) The planning process shall be continuous.

(5) There shall be documentation verifying that the center's present services as well as new services are based upon the planning process and approved by the governing board.

(6) The center shall take into consideration and conform with all existing local, regional and state comprehensive planning for human services.

e. Evaluation.

(1) The center shall periodically evaluate its performance against its stated goals and objectives.

(a) The evaluation shall include mechanisms for assessing the attainment of the center's goals and objectives.

(b) The evaluation shall include mechanisms for assessing the effective utilization of staff and program resources toward the attainment of the center's goals and objectives.

(2) The center shall measure the effectiveness of its programs and services in terms of the progress of its patients toward the objectives specified in their individual treatment plans.

(3) The center's evaluation process shall include mechanisms for the consequent review and modification of its objectives, policies, and practices.

(4) The center shall provide its funding sources with qualitative evidence of accomplishments and shortcomings in relation to its stated goals and objectives.

(5) The center shall utilize the results of the evaluation process in its continuous planning efforts.

f. Data collection.

(1) Statistical data concerning caseload, flow of clients into and out of the center, and services rendered by the staff shall be maintained in accordance with guidelines and forms promulgated by the division of mental health and retardation.

(a) The data collected, its analysis, and results shall be made available to the center's governing body, funding sources, and others upon request.

(b) The data collected shall be utilized in the planning process, evaluation of the services provided by the center, and research activities.

g. Patients' rights.

(1) The center's policies and procedures shall be designed to enhance the dignity of all patients and to protect their rights as human beings.

(a) The patient shall have the right to treatment solely on the basis of need.

(b) The patient shall have the right to be received and treated with dignity and concern in accordance with accepted standards of care.

(c) The patient shall have the right to communicate with the patient's family, attorney, physician, clergyman, and any others.

(d) The patient shall have the right to be protected against unwarranted invasion of the patient's privacy.

(2) The center shall review and respond to patient's opinions, recommendations, and grievances in ways that will enhance the center's relationship with patients.

h. Environment.

(1) The center facility shall be structurally sound and shall meet the requirements of applicable federal, state, and local laws and regulations pertaining to physical safety, sanitation, adequacy of entry and exit capability, fire protection, and all other aspects of physical safety and serviceability.

(2) The center facility shall contribute to the patient's comfort and therapy and enhance the positive image of the center.

(3) A disaster plan shall be maintained and rehearsed by the center at least twice a year.

2. Support services.

a. Patients' records.

(1) The center shall develop and maintain a record of clinical information for each patient. (a) The patient record shall include identifying data, evaluation, history, treatment plan, treatment course, and termination and disposition information. The patient record shall include a treatment plan outlining the goals and objectives for the individual during treatment. (b) The patient record shall provide for a continued assessment of the progress of the individual towards the goals and objectives outlined in the treatment plan. (c) The patient record shall not be a public record and shall not be released outside the center without the written authorization of the patient. [1] Documents or reports released outside the center shall contain no references to an identified patient, and shall contain no pictures or other identifying material unless written authorization of the patient is obtained. [2] Administrative and governing boards, funding agencies, or other interested persons or parties shall not have access to clinical information concerning center patients, except that those agencies responsible for assessing, surveying, and determining compliance with these standards shall have access to any and all information available to the center. Information provided to the governing boards, funding agencies, and other interested groups shall be limited to such financial, statistical, and summary data as may be necessary for them to discharge their responsibility. (d) When the patient's treatment is terminated, the center shall enter into the patient's record a discharge summary delineating the progress of the patient toward the goals and objectives set forth in the initial treatment plan.

b. Medication. The center shall have written policies and procedures designed to ensure that all medications are dispensed and administered safely and properly.

(1) Medication orders shall be written only by physicians who are in direct care and treatment of patients. (2) A training program shall be provided for clinical staff members authorized to administer medications in accordance with state laws. (3) There shall be a specific routine of drug administration. (4) There shall be methods of checking to detect unhealthy side effects or toxic reactions. (5) Drug storage areas shall be well lighted, safely secured, and maintained in accordance with the security requirements of federal, state, and local laws.

1. c. Referrals. The center shall have written referral policies and procedures that facilitate patient referral between the various components of the center or other community service providers, or both.
2. (1) The written referral policies and procedures shall include a description of the mechanisms designed to assure continuity of care for the patient.
   1. (a) All services of the center shall be readily accessible on the basis of the patient's needs. This includes the movement of a patient from one direct care component to another as the patient's need dictates and with as few obstacles and as little interruption in the patient's therapeutic treatment as possible.
   2. (b) Pertinent portions of records and other relevant information shall be readily transferable between all service components.
   3. (c) Arrangements shall be made for the same staff member or members to assume primary responsibility for a patient throughout the patient's course of treatment whenever possible.
3. (2) The center shall indicate the means by which it assists in the referral of those patients who seek services the center does not provide.
4. (3) The center shall provide an adequate referral system, including followup, between its various components and private practitioners and other agencies and organizations.
5. (4) The center shall keep a current, confidential record of all referrals that it initiates and receives.
6. d. Research. The center may conduct basic and applied research to provide information regarding community needs resources, the impact of service delivery, and the extent to which the center is meeting its objectives and goals.
7. (1) The center shall have written policies and procedures encompassing the purpose and conduct of all research.
8. (2) When research involves staff, patients or the general public, care shall be taken to assure the anonymity of individual persons and the protection of human rights.

General Authority: NDCC 28-32-02

Law Implemented: NDCC 25-12-04(5)