(1) The agency administrator is responsible for the day-to-day operation of the agency's provision of certified behavioral health treatment services, including:

(a) All administrative matters;

(b) Individual care services; and

(c) Meeting all applicable rules, policies, and ethical standards.

(2) The administrator must:

(a) Delegate to a staff person the duty and responsibility to act in the administrator's behalf when the administrator is not on duty or on call;

(b) Ensure administrative, personnel, and clinical policies and procedures are adhered to and kept current to be in compliance with the rules in this chapter, as applicable;

(c) Employ sufficient qualified personnel to provide adequate treatment services and facility security;

(d) Ensure all persons providing clinical services are credentialed for their scope of practice as required by the department;

(e) Identify at least one person to be responsible for clinical supervision duties;

(f) Ensure that there is an up-to-date personnel file for each employee, trainee, student, volunteer, and for each contracted staff person who provides or supervises an individual's care; and

(g) Ensure that personnel records document that Washington state patrol background checks consistent with chapter 43.43 RCW have been completed for each employee in contact with individuals receiving services.

(3) The administrator must ensure the agency develops and maintains a written internal quality management plan/process that:

(a) Addresses the clinical supervision and training of clinical staff;

(b) Monitors compliance with the rules in this chapter, and other state and federal rules and laws that govern agency licensing and certification requirements; and

(c) Continuously improves the quality of care in all of the following:

(i) Cultural competency;

(ii) Use of evidence based and promising practices; and

(iii) In response to:

(A) Critical incidents;

(B) Complaints; and

(C) Grievances and appeals.