Sec. 10.21.02.08. Organizational and Administrative Structure

A. Any corporation delivering day treatment services shall have a valid charter of incorporation.

B. Every day treatment program shall have a mechanism to assure community and consumer participation in the establishment of policies and procedures related to the operation of the program and for continuing review and evaluation of the implementation of these policies. Participation may be provided by inclusion of consumer and community representatives in the membership of the board of directors, if one exists, or by an advisory board whose members include consumer and community representatives. Existing boards of directors or advisory boards of sponsoring agencies may perform this function if consumer and community interests are appropriately represented.

C. Standards for Administration of Day Treatment Programs.

(1) There shall be an organizational chart clearly showing intra-organizational relationships and lines of authority.

(2) Every program shall have a policies-and-procedures manual which, among other elements, describes its mission, its geographic service area, its target population, its organizational structure, its clinical policies, its operating procedures, types of services provided, with responsibility for supervision clearly defined.

(3) There shall be a personnel policy manual which shall include written job descriptions for all staff positions, policies and procedures for personnel evaluation, and grievance procedures.

(4) Every program shall have an itemized budget showing all sources of income and the services being funded.

(5) All programs shall maintain a generally accepted accounting system.

D. Patient Rights.

(1) Written policies describing patient rights shall be made available to persons admitted to the service.

(2) All patient information, verbal and written, shall be held confidential and restricted to staff members engaged in the treatment of the patient, to individuals authorized to participate in quality assurance and utilization review of records, and to designated representatives of authorized funding, licensing, and certifying agencies which must evaluate programs in order to carry out their responsibilities. With proper authorization from the patient, relevant information may be disclosed to staff members of agencies providing necessary social and other support services to the patient.

(3) Program staff shall provide the patient in writing with a description of the program, including admissions and discharge policies, and an explanation of charges and methods of determining fees.

(4) Program staff shall establish mechanisms to assure the patient of the opportunity to be consulted and informed on procedures related to his care. The leader of the patient's treatment team shall give him, on request, current information in regard to his treatment and condition.

(5) Program staff shall inform patients receiving chemotherapy of the effects of the medication, including benefits and possible side effects.

(6) Program staff shall establish mechanisms for patients to register grievances and for appeal and review.