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determination, the center will receive written notification.
4.Correction of a violation or a deficiency which is the basis for the denial, revocation, or non-renewal, shall not be a basis for the administrative appeal.

AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and 40:2120.41-46.

HISTORICAL NOTE:Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 34:2181 (October 2008).

§4221.Complaint Surveys

A.The department shall conduct complaint surveys in accordance with R.S. 40:2009.13 et seq.

B.Complaint surveys shall be unannounced surveys.

C.A follow-up survey will be conducted for any complaint survey where deficiencies have been cited to ensure correction of the deficient practices.

D.The department may issue appropriate sanctions including, but not limited to civil monetary penalties, directed plans of correction, and license revocations for deficiencies and noncompliance with any complaint survey.

E.DHH surveyors and staff shall be given access to all areas of the facility and all relevant files during any complaint survey. DHH surveyors and staff shall be allowed to interview any provider staff and participant as required to conduct the survey.

AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and 40:2120.41-46.

HISTORICAL NOTE:Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 34:2182 (October 2008).

§4223.Statement of Deficiencies

A.Any statement of deficiencies issued by the department to the ADHC provider shall be posted in a conspicuous place on the licensed premises.

B.Any statement of deficiencies issued by the department to the ADHC provider shall be available for disclosure to the public 30 days after the provider submits an acceptable plan of correction to the deficiencies or 90 days after the statement of deficiencies is issued to the provider, whichever occurs first.

AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and 40:2120.41-46.

HISTORICAL NOTE:Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 34:21482 (October 2008).

Subchapter B.Administration and Organization

§4225.Governing Body

A.The center shall have a governing body with responsibility as an authority over the policies and activities of the center.

1.The center shall have documents identifying the following information regarding the governing body:
a.names and addresses of all members;
b.terms of membership, if applicable;
c.officers of the governing body, if applicable; and
d.terms of office of all officers, if applicable.
2.When the governing body is composed of more than one person, formal meetings shall be held at least twice a year.
3.The governing body shall have by-laws specifying frequency of meetings and quorum requirements.
4.The center shall have written minutes of all formal meetings of the governing body.
5.A single person or owner may govern a privately owned and operated center. This person would assume all responsibilities of the governing body.

B.Governing Body Responsibilities. The governing body of an ADHC center shall:

1.ensure the center's compliance and conformity with the center's charter;
2.ensure the center's continual compliance and conformity with all relevant federal, state, parish and municipal laws and regulations;
3.ensure that the center is adequately funded and fiscally sound;
4.review and approve the center's annual budget;
5.ensure that the center is housed, maintained, staffed and equipped appropriately considering the nature of the program;
6.designate a person to act as the director and delegate sufficient authority to this person to manage the center and to insure that all services provided are consistent with accepted standards of practice;
7.formulate and annually review, in consultation with the director, written policies concerning the center's philosophy, goals, current services, personnel practices and fiscal management;
8.annually evaluate the director's performance;
9.have the authority to dismiss the director;
10.meet with designated representatives of DHH whenever required to do so; and
11.inform designated representatives of DHH prior to initiating any substantial changes in the program, services or physical plant of the center.

AUTHORITY NOTE:Promulgated in accordance with R.S. 36:254 and 40:2120.41-46.

HISTORICAL NOTE:Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 34:2182 (October 2008).

§4227.Policy and Procedures

A.An ADHC center shall have a written program plan describing the services and programs that it furnishes.

B.The center shall have written policies and procedures governing all areas of care and services provided by the center that are available to staff, participants, and/or sponsors. These policies and procedures shall:

1.ensure that each participant receives the necessary care and services to promote his/her highest level of functioning and well-being;
2.reflect awareness of the medical and psychosocial needs of participants as well as provisions for meeting those

Louisiana Register   Vol. 34, No. 10   October 20, 2008

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