Section 72521 - Administrative Policies and Procedures(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.(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.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).