14-118 C.M.R. ch. 5, § 13 - Contracted Staff, Volunteers and Students

13.1 Contracted staff. An agency utilizing contracted staff to provide counseling services through an agreement shall require contracted staff to fulfill the same requirements in these regulations as non-contracted staff.

13.1.1 Personnel record for contracted staff. The agency shall maintain a-personnel record on contracted staff, including consultants. (See Section 8.2 for rules governing personnel records for agency employees.) Personnel records for contracted staff shall be secured in the same manner as client records. At a minimum, the agency shall have the following in the contracted staff personnel record:

13.1.1.1 evidence of appropriate credentials for the service provided as required by these rules. Documentation of compliance, as applicable, with section 9.2;

13.1.1.2 evidence of liability insurance with a minimum of $500,000.

13.1.1.3 the contract agreement governing the agency's relationship with the contracted staff person, and a resume;

13.1.1.4 documentation of core competencies and evaluation of those competencies, as well as descriptions of training programs, including in-service training, attended while working at the program, as relevant. Competencies and training related to welcoming, COD-C, and cultural competency shall be specifically documented;

13.1.1.5 the results of all background and reference checks;

13.1.1.6 a current job description; and

13.1.1.7 medical information. Copies of medical information must be stored in a separate locked file.

13.1.2 The agency shall provide clinical supervision to contracted staff according to the same standards set forth in regulation for non-contracted clinical staff:

13.1.3 All contracted staff must inform clients of their affiliation with the agency through signage, marketing, and communication technologies.

13.2 Volunteers.

13.2.1 Policies. Agencies engaging volunteers shall adopt and follow policies and procedures for their identification, supervision, orientation and use.

13.2.2 Criteria. Agencies utilizing volunteers who have direct contact with individuals receiving services or who have access to confidential client information shall ensure that volunteers are trained in the specific job responsibilities related to their position, and receive position-related orientation in all areas referred to in Section 13.5.

13.3 Students.

13.3.1 Policies. Agencies providing or participating in the provision of experiential education for students shall adopt and follow policies and procedures for their identification, supervision, orientation and use, including:

13.3.1.1 a description of the purpose of the student's involvement;

13.3.1.2 the student's roles and responsibilities;

13.3.1.3 a description of orientation procedures and training procedures;

13.3.1.4 the student's required minimum qualifications;

13.3.1.5 the designation of a liaison between the agency and the school making such placements.

13.3.2 Criteria. Agencies providing or participating in the provision of experiential education for students resulting in direct contact with individuals receiving services or access to confidential client information shall ensure that students receive appropriate orientation and training as described in Section 13.5.

13.3.2.1 Students shall not provide therapy services for the agency unless they are:

13.3.2.1.1 enrolled in a master's program or above; and

13.3.2.1.2 approved for the practicum by the college/university practicum placement supervisor.

13.3.2.2 Students must be under the close supervision of a certified clinical supervisor, working for the agency, who, along with the practicum placement supervisor, shall accept responsibility for supervision of the clinical services provided by the student.

13.4 Personnel records for volunteers and students. (See Section 8.2 for rules governing personnel records for agency employees and Section 13.1 for rules governing personnel records for contracted staff, including consultants.) Personnel records for volunteers and students must, at a minimum, contain:

13.4.1 evidence of staff credentials as required by these rules. Documentation of compliance, as applicable, with Section 9.2;

13.4.2 documentation of starting and termination dates, as relevant;

13.4.3 descriptions of training programs, including in-service training, attended while working at the agency as a volunteer or student. Competencies and training related to welcoming, COD-C, and cultural competency shall be specifically documented;

13.4.4 the results of background and reference checks;

13.4.5 current job description, and

13.4.6 written agreement governing the agency's relationship with the volunteer or student and a resume.

13.5 Training and Orientation for contracted staff, volunteers, students, and employees.

13.5.1 General Orientation Program. The agency shall provide orientation relevant to the organization to new employees, contracted staff, students, and volunteers. The orientation shall include, but not be limited to:

13.5.1.1 the agency's mission, philosophy, and description of services;

13.5.1.2 the clients' rights regarding privacy and confidentiality;

13.5.1.3 rights of clients applicable to services provided;

13.5.1.4 safety and emergency procedures;

13.5.1.5 review of the agency's policy on physical intervention;

13.5.1.6 information related to welcoming individuals who come from culturally diverse backgrounds, and individuals who may have co-occurring mental and/or medical disorders.

13.5.2 Specific Orientation and Training. The agency shall provide orientation and training specific to the duties and responsibilities of new employees, contracted staff, students, volunteers, and promoted or transferred employees. This orientation and training shall include, but not be limited to:

13.5.2.1 specific job responsibilities. For persons in managerial or supervisory positions, this shall include responsibilities and procedures for management, supervision, and discipline of employees;

13.5.2.2 safety and emergency procedures particular to the type of work, the location of the work and the persons being served;

13.5.2.3 infection control and prevention, particular to the type of work, the location of the work, and the persons being served;

13.5.2.4 specialized techniques of communication and intervention, as applicable to the needs of the persons being served;

13.5.2.5 training in welcoming, cultural competency, coordination of care with mental health and medical providers, and the interrelationship of co-occurring conditions, referral and treatment processes;

13.5.2.6 assessment, treatment planning, treatment delivery, and documentation appropriate to the position and to the persons served in the program including those with co-occurring disorders.

13.5.3 Assumption of duties following orientation. Employees, contracted staff, volunteers, and students shall not be assigned to duties requiring direct involvement with clients until the position-specific orientation, and the general orientation regarding the reporting of abuse and neglect, safety and emergency procedures, client rights, and confidentiality have been completed and documented.

13.5.3.1 The remaining training and orientation elements must be completed within 60 calendar days of hire for an employee. As appropriate, the remaining orientation and training elements must be completed within 60 calendar days of the start date documented in the contract agreement or similar document for contracted staff, volunteers, and students.

13.5.4 Contracted staff orientation. Persons contracted to provide services to clients on behalf of the agency shall complete orientation as described in these rules, or the agency shall provide evidence, subject to the review and approval of the Licensing Authority, of equivalent training.

13.5.5 Consultant orientation. The agency shall maintain policies and procedures governing orientation of consultants consistent with the services provided by the agency, the needs of persons receiving services, and the particular skills and duties of consultants, subject to the review and approval of the Licensing Authority.

13.5.6 Ongoing training and education for clinical staff. The agency shall develop and implement policies and procedures to:

13.5.6.1 ensure compliance with on-going professional training requirements for all licensed, certified, or registered employees;

13.5.6.2 provide staff training pertinent to the services provided by the agency and the needs of the staff member;

13.5.6.3 provide no less than 20 hours of annual in-service or external training to all clinicians, to include at least 4 hours minimum specifically on COD issues, which may be prorated for part-time clinicians.

13.5.7 Ongoing training and education for support staff, volunteers, and students. Ongoing training and education for support staff, volunteers, and students. The agency shall develop and implement a job-specific training plan for each individual, to be reviewed and updated annually.

13.5.8 Records of completion of orientation and training. The agency shall maintain written, accessible documentation that orientation and ongoing training have been completed as described in these rules. Such documentation shall include, at a minimum, curriculum, names and credentials of persons providing orientation or training, dates orientation or training was provided, and the length of time of each orientation or training session.

Notes

14-118 C.M.R. ch. 5, § 13