22-A8012

22-A8012 PROGRAM POLICIES AND PROCEDURES

This regulation requires each DBH-licensed behavioral health program in DC to document its organizational structure, mission, staffing, and service philosophy, and to establish written policies and procedures covering admission criteria, discharge planning, infection control, crisis intervention, medication management, record confidentiality, individuals' rights, grievances, and quality improvement. Programs must ensure placement 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. These are broad operational standards applicable across DBH-licensed programs rather than a single level of care.

8012 PROGRAM POLICIES AND PROCEDURES

8012.1 Each program must document the following:

(a) Organization and program mission statement, philosophy, purpose, and 
values;

(b) Organizational and leadership structure;

(c) Staffing;

(d) Relationships with parent organizations, affiliated organizations, and 
organizational partners;

(e) Treatment philosophy and approach;

(f) Services provided;

(g) Characteristics and needs of the population served;

(h) Performance metrics, including intended outcomes and process methods;

(i) Contract services, if any;

(j) Affiliation agreements, if any;

(k) The scope of volunteer activities and rules governing the use of 
volunteers, if any; and

(l) Location of service sites and specific designation of the geographic area to 
be served.

8012.2 Each program shall establish written policies and procedures subject to review by the Department to ensure each of the following:

(a) Service provision based on the individual’s needs;

(b) Consideration of special needs of the individual served and the program's 
population of focus;

(c) Placement of individuals in the least restrictive setting necessary to address the acuity of the individual’s presenting illness and circumstances; and

(d) Facilitation of access to other more appropriate services for individuals who do not meet the criteria for admission into a program offered by the provider.

8012.3 Each program shall develop and document policies and procedures subject to review by the Department related to each of the following:

(a) Program admission and exclusion criteria;

(b) Termination of treatment and discharge or transition criteria;

(c) Infection control procedures and use of universal precautions, addressing at least those infections that may be spread through contact with bodily fluids;

(d) Volunteer utilization, recruitment, and oversight;

(e) Crisis intervention and medical emergency procedures;

(f) Safety precautions and procedures for participant volunteers, employees, 
and others;

(g) Record management procedures in accordance with "Confidentiality of Substance Use Disorder Patient Records" (“42 CFR Part 2”), as applicable, the Health Insurance Portability and Accountability Act (“HIPAA”) (42 U.S.C. §§ 1320d et seq., and the regulations promulgated under HIPAA, including 45 CFR Part 160, 162 and 164), the D.C. Mental Health Information Act of 1978, effective March 3, 1979 (D.C. Law 2-136; D.C. Official Code §§ 7-1201.01 et seq.), this chapter, and any other Federal and District laws and regulations regarding the confidentiality of individuals’ records;

(h) The on-site prohibition on use of tobacco, alcohol, and other substances;

(i) Individuals’ rules of conduct and commitment to treatment regimen, including restrictions on carrying weapons and specifics of appropriate behavior while in or around the program;

(j) Individuals’ rights;

(k) Addressing and investigating major unusual incidents;

(l) Addressing individuals’ grievances;

(m) Addressing issues of an individual’s non-compliance with established treatment regimen and/or violation of program policies and requirements; 

(n) 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); 

(o) Selecting and hiring staff; and

(p) Quality improvement. 

8012.4 Gender-specific programs shall ensure that staff of that specific gender is in attendance at all times when individuals are present in the program.

SOURCE: Final Rulemaking published at 68 DCR 1623 (February 5, 2021).

District of Columbia Municipal Regulations

 Mental Health
22-A DCMR § 8012