Pennsylvania Code & Bulletin

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 54 Pa.B. 488 (January 27, 2024).

Pennsylvania Code



5320.21.    Contracted services.
5320.22.    Governing body.
5320.23.    Access.
5320.24.    Access by Pennsylvania Protection and Advocacy.
5320.25.    Provider records.
5320.26.    Confidentiality.

§ 5320.21. Contracted services.

 To meet the needs of residents, some services are provided under agreements with outside sources. The provider shall have a written agreement with each outside source to furnish the necessary services as stipulated by the County Administrator/Provider Letter of Agreement. The provider is responsible for upholding service stipulations contained in the Letter of Agreement between the county administrator and the provider, even if the provider subcontracts for that service. The LTSR provider agreement with outside providers shall do the following:

   (1)  Set forth the responsibilities, functions, objectives, scope, cost and nature of the service and other terms agreed to by both parties.

   (2)  Contain a statement that the LTSR recognizes that it is responsible for ensuring that the contracted services meet the standards specified in this chapter.

§ 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).

§ 5320.23. Access.

 The provider shall permit community legal services, advocacy groups, mental health consumer and family organizations and authorized Federal, State or local government agents reasonable access to the facility and its residents. The provider shall review requests by generic community service organizations to access the facility on a case-by-case basis.

§ 5320.24. Access by Pennsylvania Protection and Advocacy.

 The provider shall permit access by employes and legal counsel of Pennsylvania Protection and Advocacy (PPA) to the facility and its records, residents and staff under the Protection and Advocacy for Mentally Ill Individuals Amendments Act of 1988 (42 U.S.C.A. § §  10801—10851).

§ 5320.25. Provider records.

 Provider records shall, at a minimum, contain copies of the following:

   (1)  Required inspection reports, certifications or licenses by State and local agencies.

   (2)  Contracts with outside service providers.

   (3)  Affirmative action and nondiscrimination policies.

   (4)  Policies and procedures required by this chapter.

   (5)  Preemployment and biennial physical examinations and screening results for direct-care and dietary support staff. These shall be kept in a separate confidential file.

   (6)  Job descriptions for all staff.

   (7)  Credentials or qualifications of direct-care staff as required by this chapter and evidence of verification of credentials.

   (8)  Records of all staff orientation and training as required under §  5320.45 (relating to staff orientation and training).

   (9)  Staff work schedules, including payroll records and time sheets.

   (10)  Provider/resident contracts as described in §  5320.33 (relating to resident/provider contract; information on resident rights).

   (11)  The LTSR’s ‘‘house’’ rules.

   (12)  A schedule of allowable resident fees or charges signed, as approved, by the county administrator or a designee. The County Administrator/Provider Letter of Agreement shall include a definition of the service items included in the per diem cost of care, including room and board, treatment, rehabilitation and personal care services, personal hygiene items and laundry services. See §  5320.11(3) (relating to prerequisites to licensure).

   (13)  Resident activity schedules. Current schedules shall be posted in a resident accessible area and outdated schedules shall be kept in provider records for 1 year.

   (14)  Other records mandated by Federal, State and local statutes and regulations.

§ 5320.26. Confidentiality.

 Providers of LTSR services shall be responsible for ensuring that confidentiality of individual mental health records is maintained in accordance with § §  5100.31—5100.39 (relating to confidentiality of mental health records).

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