Section 140.301 - Administrative Records(A) Each clinic shall maintain current, complete, and accurate administrative records in a safe location. The clinic shall make all administrative records available promptly to any agent of the Department seeking to determine compliance with 105 CMR 140.000.(B) Administrative records shall include: (1) Updated articles of organization and bylaws, partnership agreement or trust instrument, as appropriate. The documents shall specify the organizational structure of the governing body and the methods of the selection of its members.(2) Updated lists of the names and addresses of the persons set forth in 105 CMR 104.102(B)(1)(a) through (d).(3) Minutes of meetings of the governing body and of the members.(4) An organizational chart for the entire organization.(5) Written policies and procedures designed to safeguard the health and safety of patients and staff. These policies and procedures shall be reviewed and updated annually. At a minimum the policies shall address:(a) Selection of personnel and the qualifications for each position. A job description for each position must be included in the administrative records.(b) Employee health policies ensuring employees are free of communicable disease.(c) Patient treatment criteria.(d) The provision of emergency care and the retention of emergency equipment appropriate to the clinic's patient population.(e) Obtaining informed consent for surgical procedures and other treatment where required by law.(f) A policy for off-hour coverage posted conspicuously in the clinic and any of its satellite clinics. The policy must ensure compliance with 105 CMR 140.315(B).(g) The disposal of hazardous and infectious waste.(i) Services that the clinic provides.(j) Smoking on the premises.(k) Procedures for complying with laws and regulations relating to reportable diseases and conditions.(l) Procedures for ensuring all patients of a clinic providing mobile services at host locations are provided with written information clearly identifying the clinic, and not the host location, as the licensed health care facility responsible for the service provided.(m) Policies and procedures for documenting clinical supervision of health care staff by licensed staff members.(6) Personnel records for each employee, including evidence of any required license or registration number; documentation of any specialty certification, education and job experience.Amended by Mass Register Issue 1443, eff. 5/14/2021.