Sec.19-13-D68. General requirements

An agency shall be organized and staffed in compliance with the following:

(a) The agency shall be governed by a governing authority, maintain an active professional advisory committee, be directed by an administrator and operate any services offered in compliance with these regulations. Compliance with these regulations shall be the joint and several responsibility of the governing authority and the administrator.

(b) Governing Authority:

(1) There shall be a formal governing authority with full legal authority and responsibility for the operation of the agency which shall adopt bylaws or rules that are periodically reviewed and so dated. Such bylaws or rules shall include, but are not limited to:

(A) Purposes of the agency;

(B) Delineation of the powers, duties and voting procedures of the governing authority, its officers and committees;

(C) Qualifications for membership, method of selection and terms of office of members and chairpersons of committees;

(D) A description of the authority delegated to the administrator;

(E) The agency's conflict of interest policy and procedures.

(2) The bylaws or rules shall be available to all members of the governing authority and all individuals to whom authority is delegated.

(3) The governing authority shall:

(A) Meet as frequently as necessary to fulfill its responsibilities as stated in these regulations, but no less than one (1) time per year;

(B) Provide a written agenda and minutes for each meeting;

(C) Provide that minutes reflect the identity of those members in attendance and that, following approval, such minutes be dated and signed by the secretary;

Ensure that the agenda and minutes of any of its meetings or any of its committees are available at any time to the commissioner.

(4) Responsibilities of the governing authority include, but are not limited to:

(A) Services provided by the agency and the quality of care rendered to patients and their families;

(B) Selection and appointment of a professional advisory committee;

(C) Policy and program determination and delegation of authority to implement policies and programs;

(D) Appointment of a qualified administrator;

(E) Management of the fiscal affairs of the agency;

(F) The quality assurance program.

(5) The governing authority shall ensure that:

(A) The name and address of each officer and member of the governing authority are reported to the commissioner annually;

(B) The name and address of each owner and, if the agency is a corporation, all ownership interests of ten percent (10%) or more (direct or indirect) are reported to the commissioner annually;

(C) Any change in ownership is reported to the commissioner within ninety (90) days;

(D) The name of the administrator of the agency is forwarded to the commissioner within three (3) days of his/her appointment and notice that the administrator has left for any reason is so forwarded within forty-eight (48) hours.

(c) Professional Advisory Committee:

(1) There shall be a professional advisory committee, appointed by the governing authority, consisting of at least one physician, one public health nurse, one therapist representing at least one of the skilled therapy services provided by the agency and one social worker. Representatives appointed to the professional advisory committee shall be in active practice in their professions, or shall have been in active practice within the last five (5) years. No member of the professional advisory committee shall be an owner, stockholder, employee of the agency, or related to same, including by marriage. However, provision may be made for employees to serve on the professional advisory committee as ex officio members only, without voting power.

(2) The functions of the professional advisory committee shall be to participate in the agency's quality assurance program to the extent defined in the quality assurance program policies and to recommend and at least annually review agency policies on:

(A) Scope of services offered;

(B) Admission and discharge criteria;

(C) Medical and dental supervision and plans of treatment;

(D) Clinical records;

(E) Personnel qualifications;

(F) Quality assurance activities;

(G) Standards of care;

(H) Professional issues especially as they relate to the delivery of service and findings of the quality assurance program.

(3) The professional advisory committee shall hold at least two (2) meetings annually.

(4) Written minutes shall document dates of meetings, attendance, agenda and recommendations. The minutes shall be presented, read and accepted at the next regular meeting of the governing authority of the agency following the professional advisory committee meeting. These minutes shall be available at any time to the commissioner.

(d) Administrator:

(1) There shall be a full-time agency administrator appointed by the governing authority of the agency.

(2) The administrator shall have full authority and responsibility delegated by the governing authority to plan, staff, direct and implement the programs and manage the affairs of the agency. The administrator's responsibilities include, but are not limited to:

(A) Interpretation and execution of the policies of the governing authority;

(B) Program planning, budgeting, management and evaluation based upon

(C) Maintenance of ongoing liaison among the governing authority, its committees, the professional advisory committee and staff;

(D) Employment of qualified personnel, evaluation of staff performance per agency policy, provision of planned orientation and inservice education programs for agency personnel;

(E) Development of a record system and statistical reporting system for program documentation, planning and evaluation, which includes at least the data specified in these regulations;

(F) Preparation of a budget for the approval of the governing authority and implementation of financial policies, accounting system and cost controls;

(G) Assurance of an accurate public information system;

(H) Maintenance of the agency's compliance with licensure regulations and standards;

(I) Distribution of a written plan for the delegation of administrative responsibilities and functions in the absence of the administrator.

(3) An administrator's absence of longer than one month shall be reported to the commissioner.

(e) Supervisor of Clinical Services;

(1) An agency shall employ one full-time supervisor of clinical services for each fifteen (15), or less, full-time or full-time equivalent professional direct service staff.

(2) The supervisor of clinical services shall have primary authority and responsibility for maintaining the quality of clinical services.

(3) The supervisor's responsibilities include, but are not limited to:

(A) Coordination and management of all services rendered to patients and families by direct service staff under his/her supervision;

(B) Supervision of assigned nursing personnel in the delivery of nursing services to patients and families;

(C) Direct evaluation of the clinical competence of assigned nursing personnel and participation with appropriate supervisory staff in the evaluation of other direct service staff;

(D) Participation in or development of all agency objectives, standards of care, policies and procedures affecting clinical services;

(E) Participation in direct services staff recruitment, selection, orientation and inservice education;

(F) Participation in program planning, budgeting and evaluation activities related to the clinical services of the agency.

(4) The supervisor of clinical services may also serve as the administrator in agencies with six (6) or less full-time or full-time equivalent professional direct service staff.

(5) Any absence of the supervisor of clinical services for longer than one month must be reported to the commissioner. A registered nurse who has at least two (2) years' experience in a home health care agency, shall be designated, in writing, to act during any absence of the supervisor of clinical services whenever patient care personnel are serving patients.

(Effective June 21, 1983)