Conn. Agencies Regs. § 17-226d-5

Current through August 9, 2024

Section 17-226d-5 - Organization and administration

(a)Governing authority

(1) Each awardee shall have a governing authority which shall be ultimately responsible for ensuring the awardee's compliance with Commission requirements.

(2) The governing authorities of nonprofit organizations shall be boards of directors, which shall be representative of the community and the target population which the awardee serves. Awardees shall endeavor to include former service recipients among the board membership and each board of directors shall include at least one health care professional knowledgable about the treatment or prevention of substance abuse.

(3) Each awardee's board of directors shall have by-laws which shall include, but need not be limited to:

(A) a list of the officers of the board;

(B) a description of the officer's duties;

(C) a description of the way in which the board conducts business; and,

(D) the terms of office of board members and officers and the method by which each are chosen.

(4) The board shall provide an orientation program for all new board members which shall familiarize them with the awardee's operations and their duties, responsibilities and potential liabilities as members of the board.

(5) Each board of directors shall meet at least quarterly and shall keep written minutes of each meeting.

(b)Governing authority responsibilities

The responsibilities of each awardee's governing authority shall include, but need not be limited to overseeing and approving:

(1) establishment of the awardee's philosophy, goals and objectives which shall be formulated to demonstrate the awardee's awareness of the demographic characteristics of the population it proposes to serve;

(2) establishment of accounting policies and procedures which fulfill the requirements of section 17-226d-4 and include, but are not necessarily limited to:

(A) listing the type of records to be kept;

(B) accounting procedures;

(C) procurement policies;

(D) the method of inventory control;

(E) guidelines for controlling expenditures;

(F) fulfilling Commission accounting requirements;

(G) a method for preparing financial statements;

(H) responsibility for the budget preparation process; and,

(I) responsibility for the chart of accounts.

(3) management and use of, and accounting for, the awardee's assets;

(4) control and approval of the awardee's activities and major financial transactions;

(5) review and approval of the awardee's annual budget and any revisions thereof;

(6) review and approval of awardee's executive director's salary increases;

(7) fund-raising efforts;

(8) review and approval of the awardee's policies and procedures;

(9) appointment, review and evaluation of the awardees executive directors and assignment of the executive director's duties;

(10) designation of two or more persons to act as signatories on checks as required by section 17-226d-4(e) (3); and,

(11) yearly planning, review and revision of the awardee's goals and objectives.

(c)Organizational chart

Each awardee shall have an organizational chart which shall be reviewed and updated annually. Such charts shall illustrate the organizational structure, lines of authority and all staff positions within the awardee's organization.

(d)Philosophy and policy

(1) Each awardee shall include in its philosophy a statement of the awardee's philosophical approach to services which shall include, but need not be limited to:

(A) a description of the relationship between the needs of the persons served by the awardee and the awardee's approach to treatment; and,

(B) a description of the relationship between community needs and the awardee's approach to treatment.

(2) Each awardee shall have a written description of its treatment or service policy which shall be used in inservice training, staff recruitment and orientation and as a basis for relationships with the community and shall be reviewed at least annually and updated when necessary.

(e)Nondiscrimination policy

(1) No awardee shall discriminate or permit discrimination against any person or group of persons in outreach, admission or treatment activities on the basis of race, color, religious creed, age, marital status, national origin, sex, sexual preference, mental retardation or physical disability, including but not limited to blindness.

(2) Each awardee shall have and utilize a written policy on nondiscriminatory practices.

(3) A program which has been established to provide services to a specific target population shall not be deemed to be in violation of subsection (1) of this section provided such program refers any individual found ineligible for admission to the program to an appropriate facility.

(4) No person shall be denied admission to a Commission funded program or service solely or jointly because of:

(A) the inability to pay all or part of the cost of services, directly or through third party reimbursement.

(B) the number of prior admissions to treatment, except where the programs admission criteria requires a certain number of prior admissions.

(C) the length of time since last treatment.

(D) the location of last treatment.

(E) a refusal to undergo previous treatment.

(f)Confidentiality

Each awardee shall have and utilize a written policy and procedure for ensuring the confidentiality and security of service recipient records and identifying information which conforms to the requirements of state and federal confidentiality law and regulations including, Connecticut General Statutes Section 17-155bb and 42 CFR 2. Such policy shall include, but need not be limited to:

(1) a description of the process and requirements for disclosure of confidential information;

(2) copies of forms for documenting the disclosure of confidential information and for obtaining the written consent of the service recipient when such consent is required; and,

(3) staff training in the requirements of state and federal laws related to confidentiality of client records.

(g)Awardee's executive director

Each awardee shall appoint an executive director whose duties and qualifications shall be established by the awardee's governing authority and who shall be responsible for day-to-day operations.

(h)Personnel requirements

(1) Each awardee shall have and follow written personnel policies for all staff and consultants which shall be included in a Personnel Policies' and Procedures' Manual which shall include but need not be limited to:

(A) a description of the methods and procedures to be used to supervise all personnel;

(B) A job description for each staff or consulting position which includes at least a description of:

(i) the credentials required for employment in the position;

(ii) the duties and responsibilities of the position;

(iii) the minimum levels of education and training required for the position;

(iv) related work experience required for the position;

(v) reporting and supervisory responsibilities of the position;

(vi) salary range of position; and,

(C) A description of policies covering at least the following topics:

(i) recruitments, benefits, promotion;

(ii) training and staff development;

(iii) employee assistance available to the awardee's staff;

(iv) disciplinary systems, suspension and termination policies;

(v) performance review;

(vi) rules of conduct;

(vii) wages, hours and salary administration;

(viii) grievance mechanisms; and

(ix) equal employment opportunity and affirmative action policies.

(2) Each person hired or promoted by the awardee shall meet the qualifications of the position to which that person is appointed, and the various disciplines represented on the program staff shall meet any state or federal legal requirements for certification, licensing and/or registration within their respective disciplines.

(3) All counselors providing counseling services to clients in each awardee's program shall receive direct supervision at least one hour per week from a senior member of the awardee's clinical staff.

(4) The awardee shall maintain a personnel record for each employee. Such records shall be kept confidential. Each personnel record shall include, but need not be limited to:

(A) a copy of the employee's application for employment;

(B) verification of the employee's credentials or certification;

(C) verification of the employee's education and training;

(D) the employee's salary history;

(E) appraisals of the employee's performance;

(F) a record of any disciplinary action taken against the employee within the preceeding two year period and the reasons for such action;

(G) commendations of the employee; and,

(H) incident and accident reports involving the employee and the results of any investigations taken in response to such reports.

(5) Awardees shall not discriminate against any person or group of persons in hiring or promotion of employees on the basis of race, color, religious creed, age, marital status, national origin, sex, sexual preference, mental retardation or physical disability, including but not limited to blindness, unless it is shown by such Awardee that such disability prevents performance of the work involved in any manner prohibited by the laws of the United States or of the State of Connecticut, and shall provide the Commission on Human Rights and Opportunities with such information requested by that Commission concerning the employment practices and procedures of the Awardee as relate to the provisions of Section 4-114a of the Connecticut General Statutes, as amended. The awardee shall make reasonable efforts to take into account the composition of service recipients and the community when hiring and promoting employees.

(6) Awardees shall have and use a plan for staff development and training which shall include training in the requirements of state and federal laws which are applicable to the awardee's program and training in emergency medical care for staff providing direct services to clients.

(7) Awardees shall employ sufficient clinical staff with documented experience and training in substance abuse to adequately meet the treatment goals for each of the persons serviced by the awardee's program or programs and to meet the awardee's goals and objectives.

(i)Conflict of interest

(1) No person shall serve as a member of an awardee's governing authority or be employed by an awardee if a conflict of interest exists between the person's responsibilities as a member of the governing authority or employee and his personal financial interests or those of any member of his immediate family.

(2) Business dealings for profit between the awardee and a member of the awardee's governing authority, a paid employee of the awardee or a member of the immediate family of either; are deemed a conflict of interest unless an open bid system is used, the basis for accepting the bid is documented in the program's financial records and, if a member of the governing authority or member of the immediate family is involved, the member of the governing authority refrains from voting on the issue.

(3) Whenever an employee or member of the governing authority sells goods or services to the awardee at cost, the actual cost shall be documented in the awardee's financial records.

(j)Policies and procedures

(1) Every awardee shall have a written policies' and procedures' manual which shall include, at a minimum, all written policies and procedures required by sections 17-266d-1 through 17-266d-11, which shall be written in language understandable to the average person, and shall be reviewed at least annually and revised as needed.

(2) The manual shall be available upon request to staff, volunteers, service recipients, members of the community and Commission staff and shall be routinely used in orientation and training programs for new members of the governing authority, staff and volunteers.

(k)Volunteers

The services of volunteers may be utilized by awardees provided:

(1) the volunteers are supervised by qualified paid staff;

(2) the use of volunteers is in accordance with the provisions of a written volunteer plan;

(3) all volunteers receive training and a thorough orientation to program rules, operations, all program policies and procedures and federal confidentiality regulations and client's rights before beginning to work in the program.

Conn. Agencies Regs. § 17-226d-5

Effective September 20, 1984