Section 440IAC1.5-3-1. Governing board

   (a) The private mental health institution shall have a governing board.

  (b) The purpose of the governing board is to:

(1) make policy; and

(2) assure the effective implementation of the policy.

  (c) The duties of the governing board include the following:

(1) Meeting on a regular basis.

(2) Employing a chief executive officer for the private mental health institution who is delegated the authority and responsibility for managing the private mental health institution.

(3) Delineating in writing the responsibility and authority of the chief executive officer.

(4) Ensuring the following:

(A) All workers, including contract and agency personnel, for whom a license, registration, or certification is required, maintain their current license, registration, or certification.

(B) The facility retains the documentation of the same.

(C) The documentation is available within a reasonable period of time.

(D) Orientation and training programs are provided to all employees, and each employee has a periodic performance evaluation, which includes the following:

(i) A competency evaluation.

(ii) An individualized education plan.

(5) Evaluating the performance of the chief executive officer. An evaluation must be conducted at least every other year.

(6) Establishing and enforcing prudent business and fiscal policies for the private mental health institution.

(7) Developing and enforcing written policies governing private mental health institution operations.

(8) Developing and implementing an ongoing strategic plan that:

(A) identifies the priorities of the governing board; and

(B) considers community input and consumer assessment of programs and services offered.

(9) Assuring that minutes of all meetings:

(A) are maintained; and

(B) accurately reflect the actions taken.

(10) Conducting an annual assessment that includes the following:

(A) A review of the business practices of the private mental health institution to ensure the following:

(i) Appropriate risk management procedures are in place.

(ii) Prudent financial practices are used.

(iii) Professional practices are maintained in regard to the following:

(AA) Information systems.

(BB) Accounts receivable.

(CC) Accounts payable.

A plan of corrective action shall be implemented for any identified deficiencies in the private mental health institution's business practices.

(B) A review of the programs of the private mental health institution shall assess whether the programs are:

(i) well-utilized;

(ii) cost-effective; and

(iii) clinically effective.

A plan of corrective action shall be implemented for any identified deficiencies in the private mental health institution's current program practices.

  (d) The governing board is responsible for the conduct of the medical or professional staff. The governing board shall do the following:

(1) With the advice and recommendations of the medical or professional staff, and in accordance with state law, determine the categories of practitioners who are eligible candidates for appointment to the medical or professional staff.

(2) Ensure the following:

(A) The requests of practitioners for appointment or reappointment to practice in the private mental health institution are acted upon with the advice and recommendation of the medical or professional staff.

(B) Reappointments are acted upon at least biennially.

(C) Practitioners are granted privileges consistent with their individual training, experience, and other qualifications.

(D) The above processes are accomplished within a reasonable period of time, as specified by the medical or professional staff bylaws.

(E) The medical or professional staff has approved bylaws and rules, which are reviewed and approved at least triennially. The governing board shall not unreasonably withhold approval of medical or professional staff bylaws and rules.

(F) The medical or professional staff is accountable and responsible to the governing board for the quality of care provided to consumers.

(G) The criteria for the selection of the medical and professional staff members include individual:

(i) character;

(ii) competence;

(iii) education;

(iv) training;

(v) experience; and

(vi) judgment.

(H) The granting of medical or professional staff membership or professional privileges in the private mental health institution is not solely dependent upon certification, fellowship, or membership in a specialty body or society.

(Division of Mental Health and Addiction; 440 IAC 1.5-3-1; filed Oct 11, 2002, 11:26 a.m.: 26 IR 737; filed Aug 11, 2008, 3:40 p.m.: 20080910-IR-440070875FRA; readopted filed Nov 5, 2008, 3:50 p.m.: 20081119-IR-440080742RFA; readopted filed Aug 11, 2014, 11:21 a.m.: 20140910-IR-440140240RFA)