§ 5320.22. Governing body.
An LTSR shall be operated by either a nonprofit corporation established under 15 Pa.C.S. Part I, Subpart C (relating to nonprofit corporations) or a for-profit corporation established under 15 Pa.C.S. Part I, Subpart B (relating to business corporations). The corporation’s governing body has legal responsibility for the operation of the facility. The governing body shall:
(1) Adopt written policies for its own operation which include:
(i) Criteria for the qualifications and methods of selection for governing body membership.
(ii) Frequency of meetings.
(iii) Procedures for conducting business.
(iv) Provisions for disclosure by members of conditions that may create a conflict of interest and procedures for dealing with conflict of interest situations.
(2) Select a program director qualified under § 5320.42 (relating to staffing levels) who shall supervise the LTSR in accordance with the policies of the governing body and be officially responsible to the governing body.
(3) Conduct an annual review and evaluation of the LTSR’s program activities, policies, procedures and program goals. This annual review and evaluation shall be documented.
(4) Adopt written program goals and objectives, including measurable anticipated outcomes.
(5) Develop and document the organizational structure.
(6) Administer funds needed to meet the written program goals and objectives.
(7) Develop, review and approve the annual budget and its modifications. These activities shall be documented.
(8) Develop and maintain written personnel policies for all staff.
(9) Develop written policies prohibiting discrimination against residents, prospective residents and all staff on the basis of age, race, sex, religion, handicap or disability, ancestry and ethnic origin, economic status or sexual preference, subject to applicable State and Federal statutes, including Chapter 5100 (relating to mental health procedures), section 504 of the Rehabilitation Act of 1973 (29 U.S.C.A. § 794) and the Americans with Disabilities Act of 1990 (42 U.S.C.A. § § 12101—12213).
(10) Develop written policies to maintain a clean, healthful and therapeutic environment.
(11) Document provisions made to meet the laundry, food service, housekeeping and maintenance requirements of this chapter.
(12) Oversee the provision of services specified in this chapter.
(13) Adopt written policies for the operation of the LTSR which shall include:
(i) The protection of residents’ rights as set forth in § § 5100.51—5100.56 (relating to patient rights).
(ii) A resident grievance procedure guaranteeing a written response to the resident by the program director when informal methods of resolving complaints are unsuccessful.
(iii) Site specific policies and schedules for fire and emergency evacuation drills.
(iv) Medication policies consistent with § 5320.53 (relating to medication).
(v) Policies covering the investigation and reporting of allegations of resident abuse.
(14) Develop written policies regarding the resident/provider contract as specified in § 5320.33 (relating to resident/provider contract; information on resident rights).
(15) Review and document reported allegations of violations of resident rights in the LTSR and report the results of the review to the county administrator.
(16) Maintain copies of policies applicable to the LTSR onsite, and make them readily available to residents, family members and visitors.
(17) Comply with § 5100.11(a) (relating to adequate treatment), which requires compliance with other relevant statutes, regulations and professional standards.
(18) Comply with this chapter when there is a conflict or inconsistency with the provision of any other regulation.
Cross References This section cited in 55 Pa. Code § 6000.1003 (relating to definitions).
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