Section 158.030 - Administration(A) The licensee shall be responsible for compliance with all applicable laws and regulations.(B) Each licensee shall establish by-laws or policies which describe the organizational structure, establish authority and responsibility of the Program, and identify the goals and service components of the Program.(C) The licensee shall appoint a qualified Program Director who is responsible for establishing and implementing policies and procedures regarding the management and operation of the Program.(D) The licensee shall ensure the Program is open at least Monday through Friday and is non-residential.(E) The licensee shall ensure that all required records, reports, and other materials required by 105 CMR 158.000 are complete, accurate, current, and available within the Program.(F) The licensee shall ensure the Program is administered in a manner that uses its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each participant.(G) The licensee shall make participant records and copies of participant records available to the Commissioner or his or her designee upon request.(H)Personnel. (1) The licensee shall be responsible for procurement of competent personnel. The licensee and the Program Director shall each be responsible for the direction and supervision of personnel.(2) The licensee and Program Director shall establish and maintain written policies and procedures regarding personnel that promote quality care of participants.(3) The licensee shall: (a) Maintain accurate time records for all personnel;(b) Maintain payroll records, timesheets, and staffing schedules for at least seven years;(c) Post, and make accessible to participants and their families, staffing schedules; and(d) Maintain a written job description for each position that includes title, reporting authority, qualifications, duties, and responsibilities.(4) The licensee shall maintain a personnel record for each employee and volunteer that is current, accurate, and available on the premises for seven years. Personnel records shall contain: (a) Pertinent information regarding identification, including maiden name, if applicable;(b) Social Security number, photo copy of a government issued photo identification, professional registration number or competency determination (if applicable), and year of original licensure, registration, or competency determination;(c) Cardiopulmonary resuscitation and first aid certifications;(d) Names and addresses of educational institutions attended, dates of graduation, degrees or certificates conferred, and name at the time of graduation;(e) Employment history including experience, training, names and addresses of previous employers, dates of employment, and reasons for terminating previous employment;(f) Completed and signed job application forms;(h) Performance evaluations;(i) A pre-employment physical examination completed within 12 months of employment and a physical examination completed at least once every two years during the period of employment;(j) A pre-employment Tuberculosis (TB) history and risk assessment with additional screening as indicated within three months prior to employment in accordance with Department Bureau of Infectious Disease guidelines;(k) An annual TB risk assessment, symptom review, and education with additional screening as indicated in accordance with Department Bureau of Infectious Disease guidelines;(l) For food service personnel, any documentation required by 105 CMR 590.000: State Sanitary Code Chapter X - Minimum Sanitation Standards for Food Establishments;(m) Training attendance records; and(n) Records of illnesses, incidents, and complaints involving personnel while on duty.(5) Prior to hiring staff or approving volunteers, a Program shall perform a background check that includes the candidate's references, job history, Criminal Offender Records Information (CORI), and the Nurse Aide Registry, established under M.G.L. c. 111, § 72J.(6) A Program shall conduct an annual performance evaluation for each employee which includes a face-to-face meeting.(7) A Program shall have an organized orientation program for all new employees that explains job responsibilities, duties, conditions of employment, and relevant participant care policies. All new personnel shall attend orientation training.(8) A Program shall provide a minimum of 12 hours of relevant in service training per year for personnel who interact with participants. The in-service training shall be relevant to the participant population and to the services provided by the Program.(9) A Program shall ensure that all personnel are knowledgeable about the types of medical and behavioral conditions of participants and their cultural diversity, including, but not limited to, race, ethnicity, sexual orientation and gender identity, such that personnel are able to provide care that is appropriate to participants' needs.(10) A Program shall ensure that all personnel are adequately trained to understand, respond to, and address the needs of participants with Alzheimer's disease and related disorders. Training regarding Alzheimer's disease and related disorders shall include: (a) Knowledge about Alzheimer's disease and related disorders;(b) Behavior management skills necessary to respond appropriately to participant behaviors and non-verbal communications; and(c) Group process skills in working with special need populations.(11) No individual may be employed, allowed to work, or allowed to volunteer, if he or she is infected with a contagious disease that might endanger the health of participants or personnel.(12) The Department shall be notified in writing within two business days of the resignation or dismissal of the Program Director and the name and qualifications of the new Program Director or interim Program Director.(13) A Program shall require all persons, including students, who examine, observe, or treat a participant to wear an identification badge that readily discloses the first name, licensure status, if any, and staff position of the person so examining, observing, or treating a participant.(I) In order to promote appropriate placements, a Program shall exchange information regarding resources and services with other agencies and institutions that provide health care or community care in the geographic area of the Program.(J)Participant and Family Advisory Council.(1) A Program shall establish a Participant and Family Advisory Council to advise the Program on matters including, but not limited to, participant and provider relationships, community services and needs, quality improvement initiatives, and participant education related to safety and quality.(2) A Program operating prior to January 2, 2015 shall establish a Participant and Family Advisory Council on or before May 1, 2015.(3) Membership of the Participant and Family Advisory Council shall, to the extent possible, reflect the cultural diversity of the community served, and at least 50% of the Council members shall be current or former participants and their family members, legal representatives or caregivers; at least one member shall be the Program Director or designee; members may include health care professionals from outside the Program who work with the target population.(4) A Program shall develop and implement written policies and procedures for the Participant and Family Advisory Council, which shall include:(a) The Council's purposes and goals;(b) Membership of the Council including qualifications, selection, retention, and term of service;(c) Orientation, training, and continuing education for members of the Council on topics related to Council membership and community health care services; and(d) Responsibilities of members of the Council.(5) The Participant and Family Advisory Council shall: (a) Advise on participant quality of life, quality of care, safety issues and, if the participant or participant's family and/or legally authorized representative seeks the Council's advice, specific grievances;(b) Advise the Program Director on physical plant and program related matters;(c) Review and advise on the Program's QAPI semi-annual report and make recommendations as applicable;(d) Review and advise on the Program's written policies and procedures;(e) Convene meetings at least one time every four months;(f) Maintain minutes of Council meetings and accomplishments for at least five years; and(g) Submit Council meeting minutes to the licensee and Program Director.(6)Reporting Requirements.(a) At least one time per year, a Program shall prepare a written report documenting the Program's compliance with 105 CMR 158.030(J) and describing the Participant and Family Advisory Council's accomplishments during the preceding year.(b) A Program shall make the written reports required by 105 CMR 158.030(J) available to the Department within seven days upon request.(7) In the event a Program's bylaws or organizational structure require it to be overseen by a Board of Directors, the Board of Directors may assume the roles and responsibilities of the Participant and Family Advisory Council and may operate in lieu of such a Council, provided that the Board of Directors otherwise complies with all requirements specified in 105 CMR 158.030(J). The composition of the Board of Directors need not be reconfigured to comply with 105 CMR 158.030(J)(3) if the Board has participant, family, or caregiver representation on the Board; otherwise, in lieu of reconfiguration, the Board may establish a Participant and Family Advisory subcommittee to the Board.(K)Program Director.(1) A Program with a licensed program capacity of 35 or fewer participants shall employ a qualified Program Director for at least ten hours per week to manage the Program.(2) A Program with a licensed program capacity of 36 to 72 participants shall employ a qualified Program Director for at least 20 hours per week to manage the Program.(3) A Program with a licensed program capacity of 73 or more participants shall employ a qualified Program Director for at least 35 hours per week.(4) The Program Director shall be on-site and available to staff, participants, and legally authorized representatives for at least a portion of each week during the hours of operation. A senior staff person may be designated to assume temporary responsibility for a Program Director in the event that the Program Director requires an absence longer than a full week. If the Program Director also serves the Program as a registered nurse, then the temporary designee may only act in the capacity of a Program Director, and may not act in the capacity as a registered nurse, unless the temporary designee is also a registered nurse, or licensed nurse acting as a relief nurse pursuant to 105 CMR 158.032(B)(2).(5) A Program Director shall be a suitable and responsible person, 21 years of age or older, who has: (a) A high school diploma or its equivalent;(b) At least two years' experience working with adults in a health care setting in a professional or volunteer position; and(c) At least two years of related managerial experience.(6) A licensed nurse may not simultaneously serve in the capacity of the Program Director and as a nurse required to satisfy minimum staffing requirements in 105 CMR 158.032.(7) A Program shall post, and make available to staff, the name and telephone numbers of the Program Director.(8) The Program Director shall be responsible to the licensee and shall operate the Program to ensure that services required by participants are available and are provided in accordance with professional standards of care, the Program's written policies and procedures, and 105 CMR 158.000.(9) The responsibilities of a Program Director shall include:(a) Direction and supervision of all aspects of the Program;(b) Management of personnel;(c) Ensuring appropriate supervision and evaluation of all personnel;(d) Overseeing Program safety and emergency evacuation plans;(e) Managing the fiscal administration of the Program;(f) Establishing collaborative relationships with community services to ensure that necessary support services are available to participants and their families;(g) Notifying the participant or his or her legally authorized representative in the event of change in a participant's charges, billings, benefit status, or other administrative matters;(h) Delegating responsibility for managing the day-to-day operations of the Program during any short term absence of the Program Director;(i) Overseeing the quality assessment and performance improvement program, as described at 105 CMR 158.046; and(j) Immediately informing the participant, consulting with the participant's primary care provider, and immediately notifying the participant's legally authorized representative or contact person in the following circumstances:1. An emergency, serious incident, or fire;2. Severe illness involving the participant;3. An incident involving the participant which resulted in injury or which required medical intervention;4. A significant change in the participant's status;5. A need to alter the participant's treatment significantly;6. A significant revision of the participant's plan of care; or7. A decision to transfer the participant from the Program.(k) Immediately notifying the participant, the participant's primary care provider, and the participant's legally authorized representative or contact person, upon a decision to discharge the participant from the Program as specified in 105 CMR 158.034.(L)Requirement for Personnel to Be Vaccinated against Influenza Virus. (1) Definitions. (a) For purposes of 105 CMR 158.030(L), personnel means an individual or individuals who either work at or come to the licensed program site and who are employed by or affiliated with the program, whether directly, by contract with another entity, or as an independent contractor, paid or unpaid including, but not limited to, employees, members of the medical staff, contract employees or staff, students, and volunteers, whether or not such individual(s) provide direct care.(b) For purposes of 105 CMR 158.030(L), the requirement for influenza vaccine or vaccination means immunization by either influenza vaccine, inactivated or live; attenuated influenza vaccine including seasonal influenza vaccine pursuant to 105 CMR 158.030(L).(c) For purposes of 105 CMR 158.030, mitigation measures mean measures that personnel who are exempt from vaccination take to prevent viral infection and transmission.(2) Each program shall ensure all personnel are vaccinated annually with seasonal influenza vaccine, consistent with any guidelines of the Commissioner, unless an individual is exempt from vaccination in accordance with 105 CMR 158.030(L)(6).(3) Each program also shall ensure all personnel are vaccinated against other pandemic or novel influenza virus(es) as specified in guidelines of the Commissioner, unless an individual is exempt from vaccination in accordance with 105 CMR 158.030(L)(6). Such guidelines may specify:(a) The categories of personnel to be vaccinated and the order of priority of vaccination of personnel, with priority for personnel with responsibility for direct care;(b) The influenza vaccine(s) to be administered;(c) The dates by which personnel must be vaccinated; and(d) Any required reporting and data collection relating to the personnel vaccination requirement of 105 CMR 158.030(L)(3).(4) Each program shall provide all personnel with information about the risks and benefits of influenza vaccine.(5) Each program shall notify all personnel of the influenza vaccination requirements of 105 CMR 158.030(L) and shall, at no cost to any personnel, provide or arrange for vaccination of all personnel who cannot provide proof of current immunization against influenza unless an individual is exempt from vaccination in accordance with 105 CMR 158.030(L)(6).(6)Exemptions. (a) Subject to the provisions set forth in 105 CMR 158.030(L)(6)(b), a program shall not require an individual to receive an influenza vaccine pursuant to 105 CMR 158.030(L)(2) or (3) if the individual declines the vaccine.(b) F or any individual subject to the exemption, a program may require such individual take mitigation measures, consistent with guidance from the Department.(c) An individual who is exempt from vaccination shall sign a statement certifying that they are exempt from vaccination and they received information about the risks and benefits of influenza vaccine.(7)Unavailability of Vaccine. A program shall not be required to provide or arrange for influenza vaccination during such times the vaccine is unavailable for purchase, shipment, distribution or administration by a third-party or when complying with an order of the Commissioner restricting the use of the vaccine. A program shall obtain and administer influenza vaccine in accordance with 105 CMR 158.030(L) as soon as vaccine becomes available.(8)Documentation.(a) A program shall require and maintain for each individual proof of current vaccination against influenza virus pursuant to 105 CMR 158.030(L)(2) and (3), or the individual's exemption statement pursuant to 105 CMR 158.030(L)(6).(b) Each program shall maintain a central system to track the vaccination status of all personnel.(c) If a program is unable to provide or arrange for influenza vaccination for any individual, it shall document the reasons such vaccination could not be provided or arranged for.(9)Reporting and Data Collection. Each program shall report information to the Department documenting the facility's compliance with the personnel vaccination requirements of 105 CMR 158.030(L), in accordance with reporting and data collection guidelines of the Commissioner.(10)105 CMR 158.030(L) establishes requirements for influenza vaccination of adult day health program personnel. Nothing in 105 CMR 158.000 shall be read to prohibit programs from establishing policies and procedures for influenza vaccination of personnel that exceed the requirements set forth in 105 CMR 158.030(L).(M)Requirement for Personnel to Be Vaccinated against Coronavirus Disease 2019 (COVID-19) Caused by the Virus SARS-CoV-2.(1)Definitions.(a) For purposes of 105 CMR 158.030(M), personnel means an individual or individuals who either work at or come to the licensed program site and who are employed by or affiliated with the program, whether directly, by contract with another entity, or as an independent contractor, paid or unpaid including, but not limited to, employees, members of the medical staff, contract employees or staff, students, and volunteers, whether or not such individual(s) provide direct care.(b) For purposes of 105 CMR 158.030(m), COVID-19 vaccination means being up to date with COVID-19 vaccines as recommended by the Centers for Disease Control and Prevention (CDC).(c) For purposes of 105 CMR 158.030(M), mitigation measures mean measures that personnel who are exempt from vaccination take to prevent viral infection and transmission.(2) Each program shall ensure all personnel have received COVID-19 vaccination in the timeframe specified in Department guidelines, unless an individual is exempt from vaccination in accordance with 105 CMR 158.030(M)(5).(3) Each program shall provide all personnel with information about the risks and benefits of COVID-19 vaccination.(4) Each program shall notify all personnel of the COVID-19 vaccination requirements of 105 CMR 158.030(M) and shall, at no cost to any personnel, provide or arrange for vaccination of all personnel who cannot provide proof of current vaccination against COVID-19 unless an individual is exempt from vaccination in accordance with 105 CMR 158.030(M)(5).(5)Exemptions. (a) Subject to the provisions set forth in 105 CMR 158.030(M)(5)(b), a program shall not require an individual to receive a COVID-19 vaccine pursuant to 105 CMR 158.030(M)(2) if the individual declines the vaccine.(b) F or any individual subject to the exemption, a program may require such individual take mitigation measures, consistent with guidance from the Department.(c) An individual who is exempt from vaccination shall sign a statement certifying that they are exempt from vaccination and they received information about the risks and benefits of COVID-19 vaccine.(6)Unavailability of Vaccine. A program shall not be required to provide or arrange for COVID-19 vaccination during such times the vaccine is unavailable for purchase, shipment, distribution, or administration by a third-party or when complying with an order of the Commissioner restricting the use of the vaccine. A program shall obtain and administer COVID-19 vaccine in accordance with 105 CMR 158.030 (M) as soon as vaccine becomes available.(7)Documentation.(a) A program shall require and maintain for each individual proof of current vaccination against COVID-19 virus pursuant to 105 CMR 158.030(M)(2), or the individual's exemption statement pursuant to 105 CMR 158.030(M)(5).(b) Each program shall maintain a central system to track the vaccination status of all personnel.(c) If a program is unable to provide or arrange for COVID-19 vaccination for any individual, it shall document the reasons such vaccination could not be provided or arranged for.(8)Reporting and Data Collection. Each program shall report information to the Department documenting the program's compliance with the personnel vaccination requirements of 105 CMR 158.030(M) in accordance with reporting and data collection guidelines of the Commissioner.(9)105 CMR 158.030(M) establishes requirements for COVID-19 vaccination of adult day health program personnel. Nothing in 105 CMR 158.000 shall be read to prohibit programs from establishing policies and procedures for COVID-19 vaccination of personnel that exceed the requirements set forth in 105 CMR 158.030(M).Adopted by Mass Register Issue 1277, eff. 1/2/2015.Amended by Mass Register Issue 1349, eff. 10/6/2017.Amended by Mass Register Issue 1505, eff. 9/29/2023.