Each agency licensed by the department to provide any behavioral health service must develop, implement, and maintain policies and procedures that address all of the applicable licensing and certification requirements of this chapter including administrative and personnel policies and procedures. Administrative policies and procedures must demonstrate the following, as applicable:

(1) Ownership. Documentation of the agency's governing body, including a description of membership and authorities, and documentation of the agency's:

(a) Articles and certificate of incorporation and bylaws if the owner is a corporation;

(b) Partnership agreement if the owner is a partnership; or

(c) Sole proprietorship if one person is the owner.

(2) Licensure. A copy of the agency's master business license that authorizes the organization to do business in Washington state that lists all addresses where the entity performs services.

(3) Organizational description. An organizational description detailing all positions and associated licensure or certification, updated as needed.

(4) Agency staffing. Documentation that shows the agency has adequate staffing to provide treatment in accordance with regulations relevant to their specialty or specialties and registration, certification, licensing, and trainee or volunteer status.

(5) Interpreter services for individuals with limited-English proficiency (LEP) and individuals who have sensory disabilities. Documentation that demonstrates the agency's ability to provide or coordinate services for individuals with LEP and individuals who have sensory disabilities. This means:

(a) Certified interpreters or other interpreter services must be available for individuals with LEP and individuals who have sensory disabilities; or

(b) The agency must have the ability to effectively provide, coordinate or refer individuals in these populations for appropriate assessment or treatment.

(6) Reasonable access for individuals with disabilities. A description of how reasonable accommodations will be provided to individuals with disabilities.

(7) Nondiscrimination. A description of how the agency complies with all state and federal nondiscrimination laws, rules, and plans.

(8) State and federal rules on confidentiality. A description of how the agency implements state and federal rules on individuals' confidentiality consistent with the service or services being provided.

(9) Reporting and documentation of suspected abuse, neglect, or exploitation. A description how the agency directs staff to report and document suspected abuse, neglect, or exploitation of a child or vulnerable adult consistent with chapters 26.44 and 74.34 RCW.

(10) Reporting of impaired practitioners in accordance with chapters 18.130 RCW and 246-16 WAC.

(11) Protection of youth. Documentation of how the agency addresses compliance with service-specific rules and the protection of youth participating in group or residential treatment with adults and how the agency will follow the requirements of chapter 71.34 RCW when an adolescent seeks treatment for themselves and for family initiated treatment of an adolescent.

(12) Completing and submitting reports. A description of how the agency directs staff to complete and submit in a timely manner, all reports required by entities such as the courts, department of corrections, department of licensing, the department of social and health services, the health care authority, and the department of health.

(13) Reporting critical incidents. A description of how the agency directs staff to report to the department within forty-eight hours any critical incident that occurs involving an individual, and actions taken as a result of the incident. A critical incident is a serious or undesirable outcome that occurs in the agency including:

(a) Allegations of abuse, neglect, or exploitation;

(b) Death, including death by suicide;

(c) Injuries resulting in admission to a hospital as an inpatient; or

(d) Outbreak of communicable disease within the agency.

(14) A smoking policy. Documentation that a smoking policy consistent with chapter 70.160 RCW, and in compliance with applicable county ordinances, is in effect.

(15) Evacuation plan. Documentation that the residential or inpatient agency has an evacuation plan consistent with chapter 246-320, 246-322, 246-324, or 246-337 WAC. For a nonresidential agency, documentation of an evacuation plan for use in the event of a disaster or emergency that addresses:

(a) Different types of disasters or emergencies;

(b) Placement of posters showing routes of exit;

(c) The need to mention evacuation routes at public meetings;

(d) Communication methods for individuals, staff, and visitors, including persons with a visual or hearing impairment or limitation;

(e) Evacuation of mobility impaired individuals; and

(f) Evacuation of children if child care is offered.

(16) Individual rights. A description of how the agency has individual participation rights and policies consistent with WAC 246-341-0600.

(17) Individual complaints. A description of how the agency addresses an individual's right to report an alleged violation of chapter 70.41, 71.05, 71.12, 71.24, or 71.34 RCW, and this chapter consistent with WAC 246-341-0605;

(18) Personnel policies and procedures must address the following:

(a) Background checks and disclosure statements. Identification of how the agency conducts Washington state background checks and obtains disclosure statements on each agency employee with unsupervised access to individuals receiving services, consistent with RCW 43.43.830 through 43.43.842.

(b) Drug-free workplace. Identification of how the agency provides for a drug-free workplace that includes:

(i) Agency program standards of prohibited conduct; and

(ii) Actions to be taken in the event a staff member misuses alcohol or other drugs, including referral to a department-approved impaired practitioner or voluntary substance use monitoring program.

(c) Supervision. Identification of how supervision is provided to assist clinical and nonclinical staff and volunteers to increase their skills and improve quality of services to individuals and families.

(d) Staff training. A description of how the agency provides training initial orientation and annual training thereafter in accordance with WAC 246-341-0510.