This regulation requires each DBH-licensed behavioral health program to document its organizational structure, mission, staffing, services, and population characteristics, and to establish written policies and procedures covering admission criteria, discharge, crisis intervention, infection control, medication management, client rights, grievances, and confidentiality. Programs must ensure services are tailored to individual client needs, place clients in the least restrictive appropriate setting, and facilitate referrals when a client does not meet admission criteria. Gender-specific programs must maintain staff of the corresponding gender whenever clients are present.
View official source6313 PROGRAM POLICIES AND PROCEDURES Each program must document the following: Organization and program mission statement, philosophy, purpose, and values; Organizational structure; Leadership structure; Program relationships; Staffing; Relationships with parent organizations, affiliated organizations, and organizational partners; Treatment philosophy and approach; Services provided; Characteristics and needs of the population served; Performance metrics, including intended outcomes and process methods; Contract services, if any; Affiliation agreements, if any; The scope of volunteer activities and rules governing the use of volunteers, if any; Location of service sites and specific designation of the geographic area to be served; and Hours and days of operation of each site. Each program shall establish written policies and procedures to ensure each of the following: Service provision based on the individual needs of the client; Consideration of special needs of the client and the program’s population of focus; Placement of clients in the least restrictive setting necessary to address the acuity of the client’s presenting illness and circumstances; and Facilitation of access to other more appropriate services for clients who do not meet the criteria for admission into a program offered by the provider. Each program shall develop and document policies and procedures subject to review by the Department related to each of the following: Program admission and exclusion criteria; Termination of treatment and discharge or transition criteria; Outreach; Infection control procedures and use of universal precautions, addressing at least those infections that may be spread through contact with bodily fluids; Volunteer utilization, recruitment, and oversight; Crisis intervention and medical emergency procedures; Safety precautions and procedures for participant volunteers, employees, and others; Record management procedures in accordance with “Confidentiality of Substance Use Disorder Patient Records” (“42 CFR Part 2”), this chapter, and any other Federal and District laws and regulations regarding the confidentiality of client records; The on-site limitations on use of tobacco, alcohol, and other substances; Clients’ rules of conduct and commitment to treatment regimen, including restrictions on carrying weapons and specifics of appropriate behavior while in or around the program; Clients’ rights; Addressing and investigating major unusual incidents; Addressing client grievances; Addressing issues of client non-compliance with established treatment regimen and/or violation of program policies and requirements; and The purchasing, receipt, storage, distribution, return, and destruction of medication, including accountability for and security of medications located at any of its service site(s) (“Medication Policy”). Gender-specific programs shall ensure that staff of that specific gender is in attendance at all times when clients are present. SOURCE: Final Rulemaking published at 62 DCR 12056 (September 4, 2015); as amended by Final Rulemaking published at 67 DCR 011585 (October 9, 2020). District of Columbia Municipal Regulations Mental Health 22-A DCMR § 6313