Section 441.24.3. Standards for organizational activities.

         24.3(1) Performance improvement system.

            a.                Performance benchmark. The organization has a systematic, organizationwide, planned approach to designing, measuring, evaluating, and improving the level of its performance.

            b.                Performance indicators. The organization:

             (1)             Annually measures and assesses organizational activities and services accredited in this chapter.

             (2)             Gathers information from individuals using the services, from staff, and from family members.

             (3)             Implements an internal review of individual records for those services accredited under this chapter. For outpatient psychotherapy and counseling services, the organization:

            1.      Reviews the individual’s involvement in and with treatment.

            2.      Ensures that treatment activities are documented and are relevant to the diagnosis or presenting problem.

             (4)             Reviews the organization’s response to incidents reported under subrule 24.4(5) for necessity, appropriateness, effectiveness and prevention. This review includes analysis of incident data at least annually to identify any patterns of risk to the health and safety of consumers.

             (5)             Reviews the organization’s response to any situation that poses a danger or threat to staff or to individuals using the services for necessity, appropriateness, effectiveness, and prevention.

             (6)             Identifies areas in need of improvement.

             (7)             Has a plan to address the areas in need of improvement. Where applicable, the organization establishes a plan to resolve the problem of patients missing appointments.

             (8)             Implements the plan and documents the results.

         24.3(2) Leadership.

            a.                Performance benchmark. Organization leaders provide the framework for the planning, designing, directing, coordination, provision and improvement of services that are responsive to the individuals using the services and the community served by the organization.

            b.                Performance indicators.

             (1)             There are clearly articulated mission and values statements that are reflected in the long-range organizational plans and in organization policies.

             (2)             The annual and long-range budgeting process involves appropriate governing and managing levels of leadership and reflects the organization’s mission and values. An independent auditor or other person as provided by law performs an annual financial audit.

             (3)             Individuals using the services or family members of individuals using the services are represented on the organization’s governing board or on an advisory board.

             (4)             The organization’s decision-making process, including policy decisions affecting the organization, reflects involvement of the various levels of leadership and responsiveness to staff.

             (5)             Organization leaders solicit input from leaders of the various community groups representing individuals served by the organization in designing responsive service delivery systems.

             (6)             Organization leaders develop and implement a service system appropriate to the needs of the individuals served by the organization.

             (7)             Organization leaders make educational information, resources, and service consultation available to community groups.

         24.3(3) Management information system.

            a.                Performance benchmark. Information is obtained, managed, and used in an efficient and effective method to document, enhance, and improve organizational performance and service delivery.

            b.                Performance indicators.

             (1)             The organization has a system in place to maintain current individual-specific information documenting the provision and outcomes of services and treatments provided.

             (2)             The organization has a system in place to maintain the confidentiality and security of information that identifies specific individuals using the services, including mail, correspondence, and electronic files.

         24.3(4) Human resources.

            a.                Performance benchmark. The organization provides qualified staff to support the organization’s mission and facilitate the provision of quality services.

            b.                Performance indicators. The organization:

             (1)             Has a job description in the personnel file of each staff member that clearly defines responsibilities and qualifications.

             (2)             Has a process to verify qualifications of staff, including degrees, licenses, medication management training, and certification as required by the position, within 90 days of the staff person’s employment. For staff hired after July 1, 2006, personnel files contain evidence that verification of professional licenses and college degrees at the bachelor’s level or higher, as required by the position, was obtained from the primary source.

             (3)             Evaluates staff annually.

             (4)             Includes a plan for staff development for each staff member in the annual evaluation.

             (5)             Provides training and education to all staff relevant to their positions.

             (6)             Provides for approved training on child and dependent adult abuse reporter requirements to all organization staff who are mandatory abuse reporters. The organization documents in personnel records training on child and dependent adult abuse reporter requirements.

             (7)             Has staff members sign a document indicating that they are aware of the organization’s policy on confidentiality and maintains these documents in the personnel files.

             (8)             Provides an initial orientation to new staff and documents this orientation in the employee’s personnel file.

             (9)             Has mechanisms in place that afford staff the right to express concerns about a particular care issue or to file a grievance concerning a specific employment situation.

             (10)            Completes criminal and abuse record checks and evaluations as required in Iowa Code section 135C.33(5) before employment for any employee who meets with individuals using the services in the individuals’ homes.

             (11)            Establishes and implements a code of ethics for all staff addressing confidentiality, individual rights, and professional and legal issues in providing services and documents in the personnel records that the code of ethics in effect at the time of review has been reviewed with each staff member.

         24.3(5) Organizational environment.

            a.                Performance benchmark. The organization provides services in an organizational environment that is safe and supportive for the individuals being served and the staff providing services.

            b.                Performance indicators.

             (1)             The environment enhances the self-image of the individual using the service and preserves the individual’s dignity, privacy, and self-development.

             (2)             The environment is safe and accessible and meets all applicable local, state, and federal regulations.

             (3)             The processes that service and maintain the environment and the effectiveness of the environment are reviewed within the organization’s monitoring and improvement system.

             (4)             The organization establishes intervention procedures for behavior that presents significant risk of harm to the individual using the service or others. The interventions also ensure that the individual’s rights are protected and that due process is afforded.

             (5)             The organization meets state and federal regulations in the way it implements the safe storage, provision, administration, and disposal of medication when used within the service.

             (6)             All toys and other materials used by children are clean and safe.