5122-26-03 Governing body and governance.

(A) Each provider shall have a leadership structure. The leadership structure shall identify who is responsible for:

(1) Governance;

(2) Provider administration, i.e. planning, management and operational activities; and,

(3) Provision of services.

(B) Each corporation for non-profit shall have a governing body. For the purposes of this rule, governing body shall have the same meaning as governing board. The governing body shall guide, plan and support the achievement of the provider's mission, vision and goals. The governing body shall develop written by-laws, a code of regulation, or policies for the following:

(1) Selection of members of the governing body. The composition of the governing body shall reflect the demographics of the community it serves ;

(2) Provisions for orienting new members of the board of directors;

(3) The number of members of the governing body needed for a quorum;

(4) Terms of office for the members of the governing body; and,

(5) Provisions guarding against the development of, and prohibiting the existence of, a conflict of interest between a governing body member and the provider.

(C) The governing body shall:

(1) Provide for orientation of its new members, including providing information about governing structure, duties, responsibilities and operations of the organization;

(2) Provide financial oversight and approve the annual budget and plan for services;

(3) Conduct meetings of the governing body at least quarterly, which shall include:

(a) Review an annual summary of quality assurance and risk management activities and document governing body actions taken as a result of this review;

(b) Approve the quality assurance plan;

(c) Review an annual summary of client rights activities and document governing body actions taken as a result of this review.

(4) Maintain minutes of meetings of the governing body including, but not limited to:

(a) Date, time and place of the meeting;

(b) Names of members who attended; and

(c) Topics discussed and actions taken.

(5) Establish procedures for selecting the chief executive officer, executive director or equivalent;

(6) Establish duties and responsibilities of the executive director;

(7) Select the executive director;

(8) Conduct an annual review and evaluation of the executive director;

(9) Identify responsibility for leadership in the absence of the executive director;

(10) Establish, review and update as necessary the provider's policies, and document that this review has occurred. The policies shall be reviewed in accordance with the schedule established by the provider's national accrediting body, if applicable, or a minimum of every five years;

(11) Ensure adequate malpractice and liability insurance protection for its corporate membership, governing body, advisory board if applicable, provider and provider staff, and review such protection annually;

(12) Ensure that opportunity is offered for input regarding the planning, evaluation, delivery, and operation of certified services, which shall include but not be limited to the opportunity to participate in the activities of or participate on the governing body, advisory groups, committees, or other provider bodies, to:

(a) Persons who are receiving or have received certified services, and their family members; and

(b) Persons who collectively represent a wide range of community interests and demographic characteristics of the service district in categories such as race, ethnicity, primary spoken language, gender and socio-economic status;

(13) Ensure that the hours of operation for services and activities accommodate the needs of persons served, their families and significant others; and,

(14) Ensure that all services provided and employment practices are in accordance with non-discrimination provisions of all applicable federal laws and regulations.

(D) A government provider shall identify its governance structure for the purpose of meeting the requirements of this rule. Each provider which is not a corporation for non-profit and therefore not subject to the provisions of paragraphs (B) and (C) of this rule shall have a written description of its governance structure, and identify whether the owner shall assume sole responsibility for the activities required in this rule, or whether the provider is governed by a governing body, board of directors, or other governance body. Provider governance shall:

(1) Provide financial oversight and develop an annual budget and plan for services;

(2) At least annually:

(a) Review a summary of quality assurance and risk management activities and document governing body actions taken as a result of this review; and

(b) Approve the annual quality assurance plan; and,

(c) Review client rights activities and document governing body actions taken as a result of this review;

(3) Establish duties and responsibilities of the executive director, chief executive officer or equivalent;

(4) Select the executive director;

(5) Conduct an annual review and evaluation of the executive director;

(6) Identify responsibility for leadership in the absence of the executive director;

(7) Establish, review and update as necessary the provider's policies, and document that this review has occurred. The policies shall be reviewed in accordance with the schedule established by the provider's national accrediting body, if applicable, or a minimum of every five years;

(8) Ensure adequate malpractice and liability insurance protection for its corporate membership, advisory board if applicable, provider and provider staff, and review such protection annually;

(9) Ensure that opportunity is offered for input regarding the planning, evaluation, delivery, and operation of mental health and addiction services, which shall include but not be limited to the opportunity to participate in the activities of or participate on the governing body, advisory groups, committees, or other provider bodies, to

(a) Persons who are receiving or have received mental health and addiction services, and their family members; and

(b) Persons who collectively represent a wide range of community interests and demographic characteristics of the surrounding community, such as race, ethnicity, primary spoken language, gender, and socio-economic status;

(10) Ensure that the hours of operation for services and activities accommodate the needs of persons served, their families and significant others; and

(11) Ensure that all services provided and employment practices are in accordance with non-discrimination provisions of all applicable federal laws and regulations.

(E) Each provider shall maintain a written table of organization or organization chart which documents the lines of responsibility of:

(1) Governing body, if applicable;

(2) Executive director;

(3) Administrative leadership; and

(4) Clinical oversight.

Effective: 4/1/2016
Five Year Review (FYR) Dates: 06/29/2015 and 04/01/2021
Promulgated Under: 119.03
Statutory Authority: 5119.36
Rule Amplifies: 5119.36
Prior Effective Dates: 5/10/79, 1/1/91, 4/18/91, 7/1/11