Rule 5122-26-03 | Governing body and governance.
(A) Each provider is to have a leadership structure. The leadership structure is to identify who is responsible for managing all of the following:
(1) Governance;
(2) Provider administration (i.e., planning, management, and operational activities); and
(3) The provision of certifiable services or supports.
(B) With respect to a provider that is a nonprofit corporation, governance of the provider is to be managed by a board of directors. The board is to develop written bylaws, policies, or a code of regulations covering all of the following:
(1) The selection of board members. The composition of the board is to reflect the demographics of the community the provider serves;
(2) The number of board members constituting a quorum;
(3) The terms of office for board members; and
(4) A ban on conflicts of interest between a board member and the provider.
(C) A board of directors of a provider that is a nonprofit corporation has all of the following duties:
(1) To organize and deliver an orientation program for new board members that includes information on governing structure, duties, responsibilities, and provider operations.
(2) To provide financial oversight and approve the provider's annual budget and plan for services.
(3) To conduct board meetings at least quarterly. Each board meeting is to include all of the following:
(a) A review of the most recent annual summary of quality assurance and risk management activities and documentation of the board actions taken as a result of the review;
(b) Approval of the performance improvement plan; and
(c) A review of the most recent annual summary of client rights activities and documentation of the board actions taken as a result of the review.
(4) To maintain board meeting minutes that include all of the following components:
(a) The date, time, and place of the meeting;
(b) The names of the board members who attended the meeting; and
(c) The topics discussed at the meeting and actions taken as a result of the meeting.
(5) To establish procedures for the selection of the provider's chief executive officer, executive director, or equivalent official.
(6) To establish the duties and responsibilities of the individual described in paragraph (C)(5) of this rule.
(7) To select the individual described in paragraph (C)(5) of this rule.
(8) To conduct an annual review and evaluation of the individual described in paragraph (C)(5) of this rule.
(9) To identify who is responsible for leading the provider in the absence of the individual described in paragraph (C)(5) of this rule.
(10) To establish, review, and update, as necessary, the provider's policies and document that this review has occurred. The policies are to be reviewed in accordance with the schedule established by the provider's national accrediting organization, if applicable, or at least every four years.
(11) To ensure the provider has procured adequate malpractice and liability insurance for all of the following and to review that insurance coverage not less than annually: the board; advisory board, if applicable; and provider and provider staff.
(12) To ensure that opportunities for input on planning, evaluation, delivery and operation of certifiable services or supports, including opportunities to participate on the board, advisory groups, committees, and other bodies, are offered to both of the following:
(a) Individuals who are receiving or have received certifiable services or supports and their family members; and
(b) Individuals who collectively represent a wide range of community interests and demographics of the service district in categories such as race, ethnicity, primary spoken language, gender, and socioeconomic status.
(13) To ensure that the hours of operation for certifiable services or supports accommodate the needs of individuals served and their family members and significant others.
(14) To ensure that all certifiable services or supports are delivered, and employment practices are implemented, in accordance with nondiscrimination provisions in federal law.
(D) With respect to a provider that is not a nonprofit corporation, including a provider that is a government entity, the provider is to describe its governance structure (i.e., whether the provider has a board of directors or other type of governing body).
(E) The governing body described under paragraph (D) of this rule has all of the following duties:
(1) To provide financial oversight and approve the provider's annual budget and plan for services.
(2) At least annually, do all of the following:
(a) Conduct a review of the most recent annual summary of quality assurance and risk management activities and document board actions taken as a result of the review;
(b) Approve the quality assurance plan; and
(c) Conduct a review of the most recent summary of client rights activities and document the board actions taken as a result of the review.
(3) To establish the duties and responsibilities of the provider's chief executive officer, executive director, or equivalent.
(4) To select the individual described in paragraph (E)(3) of this rule.
(5) To conduct an annual review and evaluation of the individual described in paragraph (E)(3) of this rule.
(6) To identify who is responsible for leading the provider in the absence of the individual described in paragraph (E)(3) of this rule.
(7) To establish, review, and update, as necessary, the provider's policies and document that this review has occurred. The policies are to be reviewed in accordance with the schedule established by the provider's national accrediting organization, if applicable, or at least every five years.
(8) To ensure the provider has procured adequate malpractice and liability insurance for all of the following and to review that insurance coverage not less than annually: the provider's corporate membership; advisory board, if applicable; and provider and provider staff.
(9) To ensure that opportunities for input on planning, evaluation, delivery, and operation of certifiable services or supports, including opportunities to participate on the governing body, advisory groups, committees, and other bodies, are offered to both of the following:
(a) Individuals who are receiving or have received certifiable services or supports and their family members; and
(b) Individuals who collectively represent a wide range of community interests and demographics of the service district in categories such as race, ethnicity, primary spoken language, gender, and socioeconomic status.
(10) To ensure that the hours of operation for services and activities accommodate the needs of individuals served and their family members and significant others.
(11) To ensure that all certifiable services or supports are delivered, and employment practices are implemented, in accordance with nondiscrimination provisions in federal law.
(F) Each provider is to maintain a written table of organization or organization chart that documents the lines of responsibility of all of the following:
(1) The board of directors or governing body, as applicable;
(2) The chief executive officer, executive officer, or equivalent official;
(3) Administrative leadership; and
(4) Clinical oversight.
(G) Each provider is to designate an individual to serve as its compliance officer and be responsible for overseeing, coordinating, implementing, and monitoring the provider's compliance with applicable federal and state laws, regulations, rules, certification and licensure standards, accreditation standards, and organizational policies and procedures. The designation of a compliance officer does not relieve the provider, its board of directors or governing authority, or other personnel of their responsibility to comply with applicable legal, regulatory, certification, licensure, and contractual standards. The compliance officer's responsibilities include, at a minimum, oversight, coordination, implementation, and monitoring of compliance with all of the following:
(1) Standards of the department of behavioral health, including certification, licensure, and credential verification standards; criminal records check standards; training standards; clinical and service-delivery standards; incident reporting, review and analysis of reportable incidents, and performance improvement standards; health and safety standards; and other applicable department standards;
(2) Standards of other state and local regulatory agencies having jurisdiction over the provider's operations;
(3) Professional licensure and credentialing standards applicable to personnel providing services on behalf of the provider;
(4) Other applicable state and federal laws, regulations, and funding mandates; and
(5) Regulatory changes affecting the provider's operations, services, programs, or funding.
Last updated August 3, 2026 at 8:34 AM
Supplemental Information