(a) Written administrative, management and
personnel policies shall be established and implemented to govern the
administration and management of the facility.
(b) All policies and procedures required by
these regulations shall be in writing and shall be carried out as written. They
shall be made available upon request to patients or their agents and to
employees and the public. Policies and procedures shall be reviewed at least
annually, revised as needed and approved in writing by the governing body or
licensee.
(c) Each facility shall
establish at least the following:
(1)
Personnel policies and procedures which shall include:
(A) Written job descriptions detailing
qualifications, duties and limitations of each classification of employee
available to all personnel.
(B)
Employee orientation to facility, job, patient population, policies, procedures
and staff.
(C) Staff
Development.
(D) Employee
benefits.
(E) Employee health and
grooming.
(F) Verification of
licensure, credentials and references.
(2) Policies and procedures for patient
admission, leave of absence, transfer, pass and discharge, categories of
patients accepted and retained, rate of charge for services included in the
basic rate, type of services offered, charges for extra services, limitations
of services, cause for termination of services and refund policies applying to
termination of services.
(3)
Policies and procedures for admission or discharge of a patient which state
that a patient shall not be admitted or discharged based on race, color,
religion, ancestry, national origin, sexual orientation, disability, medical
condition, marital status, or registered domestic partner status, except:
Any bona fide nonprofit religious, fraternal or charitable
organization which can demonstrate to the satisfaction of the Department that
its primary or substantial purpose is not to evade this subsection may
establish admission policies limiting or giving preference to its own members
or adherents and such policies shall not be construed as a violation of this
subsection. Any admission of nonmembers or nonadherents shall be subject to
this subsection.
(4) Written
policies and procedures governing patient health records which shall be
developed with the assistance of a person skilled in record maintenance and
preservation.
(A) Policies and procedures
governing access to, duplication of and dissemination of, information from the
patient's health record.
(B)
Policies and procedures shall be established to ensure the confidentiality of
patient health information, in accordance with applicable laws and
regulations.
(5) Policies
and procedures to assure that the facility accepts and retains only those
patients for whom it can provide care.
(6) Procedures for reporting unusual
occurrences.
(d) The
facility shall have a written organizational chart showing the major programs
of the facility, the person in charge of each program, the lines of authority,
responsibility and communication and the staff assignments.
Notes
Cal. Code
Regs. Tit. 22, §
72521
1. Change
without regulatory effect amending subsections (c)(3) and (c)(6) and amending
NOTE filed 6-23-2011 pursuant to section
100, title 1, California Code of
Regulations (Register 2011, No. 25).
Note: Authority cited: Sections
1275
and
131200,
Health and Safety Code. Reference: Section
51, Civil Code;
Sections
297 and
297.5, Family
Code; and Sections
1276,
1285,
131050,
131051
and
131052,
Health and Safety Code.
1. Change without
regulatory effect amending subsections (c)(3) and (c)(6) and amending Note
filed 6-23-2011 pursuant to section 100, title 1, California Code of
Regulations (Register 2011, No. 25).
