10-144 C.M.R. ch. 126, § 4.A - Organizational Structure and Lines of Authority

4.A.1. All ESRD Facilities will identify, in writing, the services provided, administrative control, and lines of authority for the delegation of responsibility down to the patient/client care level. A policy and procedure manual(s), including patient care protocols, for the organization and operation of the facility shall be established, implemented, and reviewed at least annually. Each review of the manual(s) shall be documented. This written material shall be maintained at the ESRD Facility's office so that Department staff can examine it during licensing survey visits. This material will include:

a. A statement describing the organizational goal(s) of the ESRD Facility, its philosophy and objectives, and the services provided by the facility;

b. An organizational diagram delineating the lines of responsibility and accountability so as to ensure continuity of care down to the patients;

c. Job descriptions of employees. The job descriptions shall include the qualifications necessary for the position, an outline of the scope of duties, competencies, responsibilities and accountability required of employees in that position;

d. A description of the orientation programs provided for employees directly employed by the ESRD Facility;

e. If the organization has an advisory or governing body, a set of bylaws specifying the following will be required:

1. Membership;

2. Authority;

3. Administration's role;

4. Frequency of meetings; and

5. Recorded minutes.

The bylaws shall be adopted and updated as deemed necessary by the advisory or governing body.

Notes

10-144 C.M.R. ch. 126, § 4.A