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016.05.4-100. Governing Board/Organization/Leadership

AR ADC 016.05.4-100Arkansas Administrative Code

West's Arkansas Administrative Code
Title 016. Department of Human Services
Division 05. Division of Developmental Disabilities Services
Rule 4. Certification Standards for Early Intervention Services
Ark. Admin. Code 016.05.4-100
016.05.4-100. Governing Board/Organization/Leadership
Currentness
Guiding Principles: The Governing Board/organization/Leadership is that body of people who have been chosen by the corporation and vested with legal authority to be responsible for directing the business and affairs of the corporation. The responsibilities assured by each Board/organization member by their acceptance of membership are to provide effective and ethical governance leadership on behalf of its owners'/stakeholders' interest to ensure that the organization focuses on its purpose and outcomes for persons served, resulting in the organization's long-term success and stability.
The mission statement of the organization is based on the Board/organization's philosophical motivations, the services provided, and values of the members. The mission statement should identify the population to be served and the services to be provided. This description shall be nondiscriminatory by reason of sex, age, disability, creed, marital status, ethnic, or national membership.
NOTE: See Arkansas Code Ann. §§ 20-48-201 - 20-48-211 for examples of Board/organization responsibilities.
All information regarding your organization shall be readily available to staff, consumers, referral and funding sources, and the interested public, pursuant to the Freedom of Information Act.
101 The organization shall be legally incorporated under the appropriate federal, state or local statues as defined by its official Articles of Incorporation and registered to do business in the State of Arkansas.
A. The governing body should periodically review the appropriateness of its governing documents. (Ark. Code Ann. §§ 20-48-201 - 20-48-211). This shall include the organizations mission statement as filed with the Secretary of State, and the Articles of Incorporation.
B. Any changes in the Articles of Incorporation must be filed with the Secretary of State. This includes name changes, amendments, or any reconstitution of the Governing Board/organization. The organization shall provide copies of any changes to DDS upon filing.
102 Bylaws shall be established which govern the internal affairs of the organization and will address each of the following areas as applicable:
A. Composition of Board
1. This shall include the number of Board members and the eligibility criteria (i.e. citizenship and residency).
2. Selection of Board members
a. Twenty percent (20%) consumer and advocate representation on the Board is required. (Note: defined as a consumer, immediate family member or guardian of a consumer receiving services or has received services at the organization or person in a qualified position that advocates on behalf of the population served)
B. Term of membership:
1. Number of years as dictated by the organization's Articles of Incorporation.
Note: It is recommended that membership on the governing body be rotated periodically.
C. Replacement/removal of directors:
1. Refers to written criteria for Board membership. Shall include any contingency to include but not be limited to resignation of Board/organization members and removal for non-attendance or other reasons.
D. Election of officers and directors:
1. Describe the election process
E. Duties and responsibilities of Board officers are described in writing
1. Must document each position's purpose, structure, responsibilities, authority, if any, and the relationship of the advisory committee of Board members to other entities involved with the organization.
F. Appointment of committees, if applicable;
1. Duties and functions of standing committees are described in writing, if applicable.
G. Meetings of the Board/organization and its committees. All meetings shall be planned, organized, and conducted in accordance with the organization's by-laws, policies, procedures, applicable statutes, or other appropriate regulations. In no event shall the full Board/organization meet less than four times per year.
Note: The Board/organization and its committees should meet with a frequency sufficient to discharge their responsibilities effectively.
H. The Board/organization shall adopt written procedures to guide the conduct of its meetings (i.e. Parliamentary Procedure, Robert's Rules of Order, etc.);
I. The Board/organization shall maintain minutes of all actions taken by the Board/organization for review by DDS. Minutes shall accurately document all members present and any action taken at the committee meetings to include any committee recommendations to the Board/organization.
1. Written minutes of previous Board/organization meetings should be made available by posting the adopted minutes in a location convenient to the staff and individuals served, and made available to members of the public upon request, as required under the Freedom of Information Act.
103 The Board/organization shall establish a procedural statement addressing nepotism as it relates to Board/organization and staff positions.
103.1 The Board/organization shall establish a procedural statement addressing conflict of interest
Note: The intent of the standard does not rule out a business relationship, but does call for the governing body to decide in advance what relationships are in the best interest of the organization.
A. Paid employees may not serve as Board/organization members. (Note: This DOES NOT include individuals receiving services.)
B. Directors of organizations may serve as non-voting ex officio Board/organization members.
104 Board/organization meetings and public meetings as defined by Ark. Code Ann. §§ 25-19-106 shall be conducted at a time and place which make the meetings accessible to the public. Specifically, except as otherwise specifically provided by law, all meetings, formal or informal, special or regular, of the governing bodies of all municipalities, counties, townships, and school districts and all boards, bureaus, commissions, or organizations of the State of Arkansas, except grand juries, supported wholly or in part by public funds or expending public funds, shall be public meetings.
A. Board/organization meetings and Executive sessions shall be announced to be in compliance with Ark. Code Ann. §§ 25-19-101 - 25-19-107 “Freedom of Information Act”
B. All local media are to be notified one week in advance and a notice posted in a prominent place by the organization. Called meetings shall be announced to the local media and others who have requested notification at least two hours in advance of meeting. Documentation of Notification may include newspaper clippings, copy of item posted on bulletin board, radio contact forms, etc.
D. If the meetings are held each month at the same time and location, one notification and posting shall be sufficient...
105 The Board/organization of Directors shall adopt a mission statement to guide its activities and to establish goals for the organization. The plan shall show evidence of participation by stakeholders (evidence of open meeting, letters of input, survey, questionnaire, etc.).
105.1 The Board of Directors shall review the mission statement annually and shall make changes as necessary to ensure the overall goals and objectives of the organization are reflected in its mission.
106 The Board/organization maintains a plan which shall identify annual and long range goals; the plan should address community needs and target populations and should be reviewed and updated annually.
A. Each Board/organization will develop and implement a long-range plan of action for that organization. Examples include, but are not limited to starting a new component, accessing individualized services in the community, etc.
B. Development and implementation of the plan shall include stakeholder input. The organization shall maintain evidence of this input (i.e., letters of input, minutes of open meetings, questionnaires, surveys, etc.)
C. The plan shall be reviewed annually and updated as needed. The Board/organization shall approve the initiation, expansion, or modification of the organization's program based on the needs of the community and the capability of the organization to have an effect upon those needs within its established goals and objectives.
Note: The Board of Directors, at its discretion, may assign this responsibility to staff.
107 The Board/organization shall demonstrate corporate social responsibility while maintaining overall accountability for the administration and direction of the organization, and shall delegate authority and responsibility to executive leadership as deemed appropriate by the organization.
A. The organization shall identify:
1. Its leadership structure.
2. The roles and responsibilities of each level of leadership.
B. The identified leadership shall guide the following:
1. Establishment of the mission and direction of the organization.
2. Promotion of value/achievement of outcomes in the programs and services offered.
3. Balancing the expectations of both the persons served and other stakeholders, as defined by the organization's policies.
4. Financial solvency.
5. Compliance with insurance and risk management requirements.
6. Ongoing performance improvement.
7. Development and implementation of corporate responsibilities.
8. Compliance with all legal and regulatory requirements.
C. The organization shall respond to the diversity of its stakeholders with respect to:
1. Culture.
2. Age.
3. Gender.
4. Sexual orientation.
5. Spiritual beliefs.
6. Socioeconomic status.
7. Language.
108 The Board/organization shall create a mechanism for monitoring the decisions and operations of the organization's programs which includes provisions for the periodic review and evaluation of its program in relation to the program goals. Documentation of the review must be maintained on file for review. Documentation may include but not be limited to Board/organization minutes, reports, etc.
Guiding Principle: An organized training program for Board/organization Members prepares them for their responsibilities and assures that they are kept up-to-date on issues concerning services offered to individuals with a developmental disability.
109 The Board/organization shall maintain a general plan for Board/organization training and will ensure that all items listed as required topics are covered in the required three-hour training.
A. Training shall be provided for all Board/organization members. Where the Board, because of its size, lacks sufficient resources to conduct a training program, it will make arrangements with another Board, organization, agency, appropriate community resource, or training organization to provide such training.
109.1 New Board Members must participate in a minimum of three hours of training.
A. The following topics shall be required during the first year of service
1. Functions and Responsibilities of the Board
2. Composition and Size of the Board
3. Legal Responsibilities
4. Funding Sources and Responsibilities,
5. Equal Employment Opportunity/Affirmative Action,
6. Due Process
7. Ark. Code Ann. §§ 25-19-101 - 25-19-107 “Freedom of Information Act of 1967”
8. U. S. C. § 12101 et. seq. “Title 42 THE PUBLIC HEALTH AND WELFARE--CHAPTER126--EQUAL OPPORTUNITY FOR INDIVIDUALS WITH DISABILITIES--§ 12101. Findings and purpose”
9. DDS Service Policy 3004-I Maltreatment Prevention, Reporting and Investigation;
10. DHS Policy 1090, Incident Reporting.
11. DDS Administrative Policy 1077
12. Chemical Right to Know
13. The Health Insurance Portability and Accountability Act (HIPAA)
NOTE: POSSIBLE TRAINING RESOURCES INCLUDE ASPEN PUBLICATIONS, WHICH HAS MATERIALS ON BOARD/ORGANIZATION AND ADMINISTRATOR TRAINING. (WWW.ASPENPUBLISHERS.COM) Resources or additional information should be obtained from DDS Licensure.
B. All new Board members as they begin service shall participate in training. Board members may disseminate training information to new Board members if they are unable to attend formal training sessions. Documentation of the information provided, date provided and the board member(s) involved must be maintained for review by DDS. (Note: Training may be documented in Board minutes or by Certificates of Attendance.)
109.2 All Board members shall complete a minimum of three hours annual training. Topics may be selected by the Board of Directors and must be germane to the annual plan and services provided. Training should be documented in Board minutes, by Certificates of Attendance or sign in sheets from approved training.
110 Board members shall visit service components of the organization during operating hours yearly.
A. All components of the organization must be observed annually. If on-site observations to each physical location are not feasible, at least 1 physical site from each program component must be observed during the calendar year. The sites must be rotated yearly. Committees or individual Board Members may be appointed to visit specific components and report back to the other Board members on observations. Documentation of reports in Board minutes shall be accepted as verification.
111 The Board/organization shall establish and approve policies and procedures which define Eligibility criteria, Readmission criteria, and transition/discharge/exit criteria
112 The Board/organization shall establish policy regarding financial oversight of the organization that addresses the following:
A. The organization's financial planning and management activities reflect strategic planning designed to meet:
1. Established outcomes for the persons served.
2. Organizational performance objectives.
B. Budgets are prepared that:
1. Include:
a. Reasonable projections of revenues and expenditures.
b. Input from various stakeholders, as required.
c. Comparison to historical performance.
2. Are disseminated to:
a. Appropriate personnel.
b. Other stakeholders, as appropriate.
3. Are written.
C. Actual financial results are:
1. Compared to budget.
2. Reported to:
a. Appropriate personnel.
b. Persons served, as appropriate.
c. Other stakeholders, as required.
3. Reviewed at least quarterly.
D. The organization identifies and reviews, at a minimum:
1. Revenues and expenses.
2. Internal and external:
a. Financial trends.
b. Financial challenges.
c. Financial opportunities.
d. Business trends.
e. Management information.
3. Financial solvency, with the development and implementation of remediation plans, if appropriate.
113 For-profit organizations or organizations who receive less that $10,000 in compensation for services under this program shall submit a compilation report that includes a balance sheet and statement of revenue and expense to DDS at the close of each financial period.
Note: Sections 102 & 104 do not apply to organizations that are not governed by a Board of Directors
PERSONNEL POLICIES AND PROCEDURES
114 The organization shall maintain written personnel procedures that are approved by the Board and are reviewed annually and which conform to state and federal laws, rules and regulations.
NOTE: DDS SHALL NOT BECOME DIRECTLY INVOLVED IN PERSONNEL ISSUES UNLESS IT DIRECTLY IMPACTS CONSUMER CARE AND/OR SAFETY.
114.1 Personnel procedures shall be clearly stated and available in written form to employees as required by 42 U.S.C. § 2000a - 2000 h-6 “Title VI of the Civil Rights Act of 1964” and U.S.C. § 1201 et. Seq. Americans with Disabilities Act. These include but are not limited to:
A. Hiring and promotional procedures which are nondiscriminatory by reason of sex, age, disability, creed, marital status, ethnic, or national membership
B. A procedure for discipline, suspension and/or dismissal of staff which includes opportunities for appeal
C. An appeals procedure allowing for objective review of concerns and complaints
114.2 One copy of the organization's Personnel procedures must be available in the personnel or administrator's office. This copy must be readily accessible to each employee.
114.3 The organization shall develop and implement steps to voice grievances within the organization. All grievances are subject to review by the Governing Board and Court of Law (29 U.S.C. §§ 706(8), 794 - 794(b), the “Rehabilitation Act of 1973 Section 504; 20 U.S.C. § 1400 et. Seq. Section 615 “The Individual Disabilities Education Act”.
A. All steps in the Grievance Procedure should be time-bound and documented, including initial filing of grievance.
114.4 The organization shall develop and implement policies regarding whether pre-employment and random drug testing will be required. If the organization chooses to do drug testing they must establish guidelines for actions to be taken when the drug test results are obtained, whether positive or negative. (The organization may contact Arkansas Transit Association for further information on drug testing)
115 Prior to employment, a completed job application must be submitted which includes the following documents.
A. The organization shall obtain and verify PRIOR to employment and maintain documentation of the following:
1. The credentials required
2. That required credentials remain current
3. The applicant has completed a statement related to criminal convictions
4. A criminal background check has been initiated. Refer to DDS Policy 1087.
5. Declaration of truth of statement on job application.
6. A release to complete reference checks is signed and reference checks have been completed
7. Results of pre-employment drug screen, if required by organization.
NOTE: THE ITEMS IN 202A.5 AND 202A.6 WILL NOT BE RATED FOR EMPLOYEES HIRED PRIOR TO JULY 1, 1986.
B. The organization shall obtain and verify within 30 days of employment and maintain documentation of the following:
1. Adult Maltreatment Central Registry Ark. Code Ann. §§ 5-28-201 has been completed and the response is filed, or a second request submitted
2. Arkansas Child Maltreatment Central Registry Ark. Code Ann. §§ 12-12-501 - 12-12-515 has been completed and the response is filed, or a second request submitted. This check will provide documentation that prospective employee's name do not appear on the statewide Central Registry.
a. The organization should adopt policy requiring subsequent criminal checks and registry checks. The organizations that provide licensed daycare services must adhere to Child Care Licensing regulations regarding Criminal background checks and central registry checks.
Note: Staff holding professional licenses may be used in lieu of criminal background and adult and child maltreatment checks.
3. TB skin test
a. Renewed yearly for ALL STAFF.
4. Hepatitis B series or signed declination
5. The results of criminal background check of the will be on file.
6. Employment reference verification and signed release
a. On file within thirty (30) days of hire date
C. The organization shall obtain and verify information in 202 A and B in response to information received (i.e., a complaint is received that a person's license has lapsed or a person has been convicted of a crime since they were hired).
116 The agency shall ensure sub-contractor's services meet all applicable standards and will assess performance on a regular basis.
A. The organization shall ensure that sub-contractors providing direct care services are in compliance with DDS policies and must have verification and documentation of all applicable items listed in 202A.
Note: Staff holding professional licenses may be used in lieu of criminal background and adult and child maltreatment checks.
B. The organization shall demonstrate:
1. Reviews of all contract personnel utilized by the organization that:
a. Assess performance of their contracts
b. Ensure all applicable policies and procedures of the organization are followed
c. Ensure they conform to DDS standards applicable to the services provided
d. Are performed annually
117 The organization shall develop, implement and monitor policies and procedures for staff recruitment and retention so that sufficient staff is maintained to ensure the health and safety of the individuals served, according to their plans of care.
A. The organization must ensure there are an adequate number of personnel to:
1. Meet the established outcomes of the persons served.
2. Ensure the safety of persons served.
3. Deal with unplanned absences of personnel.
4. Meet the performance expectations of the organization.
B. The organization shall demonstrate:
1. Recruitment efforts.
2. Retention efforts.
3. Identification of any trends in personnel turnover.
118 The organization shall develop and implement procedures governing access to staff members' personnel file.
A. An access sheet shall be kept in front of the file to be signed and dated by those who are examining contents, with stated reasons for examination.
B. The policy shall clearly state who, when, and what is available concerning access to personnel files and be in compliance with the Federal Privacy Act and Freedom of Information Act. At no time shall the policy allow access that violates the provisions of the Health Insurance Portability and Accountability Act (HIPAA).
119 The organization shall develop written job descriptions which describe the duties, responsibilities, and qualifications of each staff position.
A. The organization shall:
1. Identify the skills and characteristics needed by personnel to:
a. Assist the persons served in the accomplishment of their established outcomes.
b. Support the organization in the accomplishment of its mission and goals.
2. Assess the current knowledge and competencies of personnel at least annually.
3. Provide for the orientation and training needs of personnel.
4. Provide the resources to personnel for learning and growth.
5. Identify the supervisor of the position and the positions to be supervised.
B. Performance management shall include:
1. Job descriptions that are reviewed and/or updated annually.
2. Promotion guidelines.
3. Job posting guidelines.
4. Performance evaluations for all personnel directly employed by the organization shall be:
a. Based on measurable objectives that tie back to specific duties as listed in the Job Description.
b. Evident in personnel files.
c. Conducted in collaboration with the direct supervisor with evidence of input from the personnel being evaluated.
d. Used to:
1. Assess performance related to objectives established in the last evaluation period.
2. Establish measurable performance objectives for the next year.
e. Performed annually.
120 The organization shall establish policies/practices for students, interns, volunteers and trainees utilized by the organization who have regular, routine contact with consumers.
A. The organization shall define who has and what constitutes regular, routine contact with consumers.
B. If students, interns, volunteers or trainees are used by the organization, the following shall be in place:
1. A signed agreement.
a. If professional services are provided, standards or qualifications applied to comparable positions must be met.
2. Identification of:
a. Duties.
b. Scope of responsibility.
c. Supervision.
3. Orientation and training.
4. Assessment of performance.
5. Policies and written procedures for dismissal.
6. Confidentiality policies.
7. Background checks, when required.
121 For-profit organizations or organizations who receive less that $10,000 in compensation for services under this program shall submit a compilation report that includes a balance sheet and statement of revenue and expense to DDS at the close of each financial period.
Current with amendments received through February 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 016.05.4-100, AR ADC 016.05.4-100
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