L&P Services, Inc. Policy & Procedures. Date: March Policy and Procedures Page 1

Transcription

1 Policy & Procedures Date: March 2012 Policy and Procedures Page 1

2 Policy & Procedures Table of Contents Policy & Procedures Section A: Intro Policy, Procedures, and Plans... 7 Vision, Mission, and Values... 8 Accessibility Policy... 9 Client Rights & Grievances for Drug and Alcohol Grievance Procedure Client Rights & Grievances for Mental Health Section B: Privacy/HIPPA Notice of Privacy Practices Use or Disclosure of Protected Health Information for Treatment, Payment or Health Care Operations Purposes Individuals Rights Related to Protected Health Information (PHI) Provision of Privacy Notice Protected Health Information Business Associate Amendment Management and Protection of Personal Health Information Accounting for Disclosures of Protected Health Information Administrative Requirements for the Implementation of HIPAA Authorization for Use or Disclosure of Protected Health Information Business Associate Agreements Workforce Confidentiality Agreement Records of Disclosure Authorized by Law Collateral Information Policy Section C: Records Control Records Control Listing of Components of Clinical Records Policy and Procedures Page 2

3 Section D: Ethics Code of Ethics Drug Theft Research Section E: Client Treatment Authorization to Release Information Consent for Treatment Diagnostic Assessment Diagnostic Assessment Service Individualized Service Plan and Progress Notes Medication/Somatic Algorithms Medication/Somatic Pharmacotherapy Handling Storage, and Dispensing of Medication Counseling and Psychotherapy Service Community Support Program Service Client Transfer Client No Show/Cancellations Agency Termination of Services Discharge of Clients Policy and Procedure regarding Self Harm Crisis Intervention Intensive Home Based Treatment Services Abuse and Neglect Urinalysis Section F: Safety Physical Plant and Safety Emergency Physical Intervention Procedure Tobacco Free Policy Incident Reporting (Incident Notification and Risk Management) Client Safety Policy ODADAS MAJOR UNUSUAL INCIDENT (MUI) REPORT FORM Infection Control Policy and Procedures Page 3

4 Infection Control Committee Infectious Waste Management Medical Emergency Plan Bomb Threat Procedures Fire Emergency Procedures Natural Disasters & Power Failure Procedures Section G: Waiting List Management Waiting List Management Referral and Information Service Interagency Referral Individualized Service Plan and Progress Notes Section H: Staff Guidelines for Legal Involvement Clinical Supervision Staff Credentialing Staff Re Credentialing Staff Recruitment Personnel Qualifications Cultural Competency Cultural Competency Plan Duty to Protect Clinical Management Alcohol & Drug Addiction Services Section I: Affiliation Agreements Affiliation Agreements Section J: Business Governing Body Table of Organization Contractual Relationships Service Evaluation Performance Improvement Risk Management Policy and Procedures Page 4

5 Corporate Compliance Policy & Procedure Governing Authority Corporate Compliance Technology and Information Policy and Procedure Budget Management and Control for Cash Disbursements Management and Control for Cash Receipts Human Resources Management Policy and Procedures Page 5

6 Section A: Intro Policy & Procedures Table of Contents Vision, Mission, and Values... 8 Accessibility Policy... 9 Client Rights & Grievances for Drug and Alcohol Grievance Procedure Client Rights & Grievances for Mental Health Policy and Procedures Page 6

7 Policy, Procedures, and Plans Effective: 9/06/05 By: Brent Phipps, CEO Purpose: To establish guidelines and procedures for the creation, approval and implementation of all Policies, Procedures, and Plans for L & P Services, Inc. Policy: It is the policy of L & P Services, Inc. that all Policies, Procedures, and Plans be reviewed and approved at least annually by the President. This includes, but is not limited to, Policies and Procedures regarding service delivery, the Employee Policy and Procedure Manual, Affirmative Action Plan, Cultural Competency Plan, Accessibility Plan, and the Quality Improvement Plan. Procedures: The President empowers the Chief Executive Officer to create, and/or revise, and implement any and all Policies and Procedures that he/she may find necessary. The President may elect to review the Policies and Procedures individually, in a timely manner, or may elect to review the aggregate Policies, Procedures, and Plans at scheduled dates. The President will review, amend if necessary, and approve all Policies, Procedures, and Plans at least annually and empowers the Chief Executive Officer to implement all such policies, procedures, and plans at the Executive Director's discretion pending either individual or annual review of such policies, procedures, and plans. Policy and Procedures Page 7

8 Vision, Mission, and Values Effective: 9/16/2006 Revised: 03/04/09 By: Brent Phipps, CEO Vision: It is the vision of L & P Services, Inc. that every person in our community lives in such a manner that they fulfill their potential as an individual and a member of the community if they so choose. Mission/Purpose: It is the mission/purpose of L & P Services, Inc. to help individuals and families to maintain their independence and gain and maintain the highest quality of life. Values: L & P Services, Inc. is committed to integrating the values of Respect, Integrity, Dedication, Quality, and Professionalism into every activity and service provided. Objective: The objective of L & P Services, Inc. is to provide diagnostic, home based, and outpatient therapies as well as medical/somatic services in order to fulfill our Vision, Mission, and Values. L & P Services, Inc. is a collaborative organization working closely with other community providers and the Washington County Mental Health Board. Policy and Procedures Page 8

9 Accessibility Policy Effective: 9/16/2006 Revised: 03/04/09 By: Brent Phipps, CEO Purpose: That clear written admission criterion shall exist for the agency as a whole and, more specifically, for each separate service. These program guidelines shall also stipulate any exclusionary criteria specific to that service. Basis for exclusion will reside solely in the defined application, ethical and/or professional practice code or legal restrictions pertaining to that service (such as diagnostic treatment indications, age and least restrictive setting considerations, etc.). To ensure that agency services shall be accessible, available, appropriate and acceptable to the persons served. This policy assures that services are appropriate and include but are not limited to provision of services in the least restrictive setting, delivery of services in the natural environment of the person receiving services, continuity of therapeutic relationships, perceived needs of the person receiving services, and culturalogical assessment. Policy: No otherwise eligible family or client shall be denied access to services based on age, race, creed, color, ethnicity, gender, sexual orientation, marital status, national origin, religion, prior legal, medical or psychiatric history or ability to pay. The agency assures compliance with relevant state and federal regulations including section 504 of the Rehabilitation Act of Reasons for not accepting an applicant will be contained in the referral note or (for a specific program), after an evaluation, in the assessment or subsequent case notes. Unusual or uncertain cases will be reviewed by the CEO pending final decision. Special accommodations to increase access to services will include: TTY (provided by SBC), foreign language translation services, handicapped accessibility, evening hours, staff trained in cultural sensitivity, assessments and (as necessary) select services provided on location at community, juvenile justice or home settings. Specially scheduled weekend service hours and arrangements for transportation assistance due to geographical issues are assessed by request and determined on a case by case basis. These services are provided at no additional cost to the client. Foreign language translation and services for the hearing impaired can be accessed through Marietta College and Washington State Community College respectively and ensures that services are provided in a manner whereby interpreters are fluent in the first vernacular language of the person served. Financial inability to pay does not necessarily disqualify persons for service and waivers may be issued by the CEO. A contract or sub contract may be established with the local community mental health board in order to qualify some persons for service. Treatment planning services and service delivery are culturally and ethnically sensitive utilizing information obtained in the diagnostic assessment to ensure these are utilized in these processes. Policy and Procedures Page 9

10 Services are not denied based on refusal to accept other services recommended by the agency. Services promote freedom of choice among therapeutic alternatives as evidenced in the consent for treatment. Services are available at a convenient site and are offered in the client s natural environment. L & P Services Inc. coordinates discharge planning and mental health services for persons leaving state operated inpatient settings and participate in discharge planning for persons leaving private inpatient psychiatric settings. Those referred to the agency from an inpatient psychiatric setting will be assured of continuity of services through the provision of necessary services as determined by the agency in consultation with the person served and the referral source. Such necessary services shall be provided upon discharge, whenever possible and no later than two weeks post discharge if it has been concluded that these services are required within two weeks. Outreach to residents, community stakeholders, public and private education, business, youth, church, and community groups and special activities to increase accessibility by advertising the availability of our services in general or to acquaint targeted groups with specific services is an ongoing priority of L & P Services, Inc. Communication of specific outreach targets is a function of the CEO or their designee and is responsive to individual staff input. It also occurs through direct community request and at the initiative of management. A summary of these services is created annually. Information concerning accessibility is solicited in direct format such as interviews of service users in our recent community plan, in our annual consumer satisfaction survey, in the type of outreach described in the paragraph above, and through informal networks. L & P Services has a history of and is committed to being responsive to such input. It has, where possible, created or transposed new programs and service formats directly upon request by the community. L & P Services is committed to proactively pursue the identification and reduction of: environmental, architectural, attitudinal, fiscal, communication, transportation, employment or any other feasible barrier to its services' accessibility. Organizational channels of input have been established which insure information to executive management through the Performance Improvement process regarding such concerns including an employee problem form, meetings with staff at site staff meeting with executive staff, staff meeting minutes, Interagency survey, Consumer satisfaction data, and an open door policy which provides direct access to the President on issues effecting service access. Requests for accommodations are considered a priority which will receive immediate review by executive staff, and board of director staff, if applicable, in order, to reach a decision. Such requests from persons in our service population will receive a substantive response within 10 working days. In general, employees of L&P Services, Inc. should strive for and consumers should expect the following quality guidelines regarding client access and service delivery: Phone calls should be answered within 3 rings. Clients should be scheduled for assessments within 3 working days. Policy and Procedures Page 10

11 Assessments should be complete within 7 working days. Assessments should include information from significant others, family members, legal guardians, (when applicable). Assessment updates may be completed within the course of treatment by all direct service providers at a minimum every two years or upon change of condition and circumstance and the results will be communicated to the client and or Guardian. Individual service plans should be completed within 30 days for mental health clients and 7 days for substance abuse clients from time of first appointment. Service plans should be updated upon change of condition, addition of services, or change in providers. If pharmacotherapy services are indicated depending on priority and severity, client should be scheduled within 30 working days with the physician. Clients may come and tour the facility and meet with staff prior to a decision to engage in services. L & P Service s executive staff will issue a report for each new identified barrier which provides an action plan to address the problem within a realistic identified time line. These reports will be summarized in an annual status report by June 30 th of each year identifying all known improvable barriers to services. The report will include timelines for the removal of each barrier, progress made in that direction and areas in need of improvement. It may include, besides the description of the barrier and plan to remove it, a description of equivalent facilitation that is to be provided until the barrier is removed. It may also include specific responsible staff, dates and timelines as well as actual completion dates. The effectiveness of this policy will be part of the performance improvement process and annual evaluation of the agency. Policy and Procedures Page 11

12 Client Rights & Grievances for Drug and Alcohol Accountability: Client Rights Officer; CEO Effective Date: By: Brent Phipps, CEO Revised: ; Purpose: To protect and ensure the rights of persons seeking or receiving mental health services by guaranteeing specific rights of clients, with procedures for responsive and impartial resolution for all grievances either from the client themselves or on behalf of the client by the guardian, next of kin, or special representative. The overall purpose is to ensure clients are free from abuse, financial or other exploitation, humiliation, and neglect and ensure that there is no retaliation for exercising any of the rights or for filing a grievance. Definitions: 1. Client an individual applying for or receiving mental health services from a qualified person from this agency. 2. Client Rights Officer the person designated by L & P Services, Inc. with responsibility for assuring compliance with the Client Rights and Grievance Procedure rule as implemented. 3. Grievance a written complaint initiated, either verbally or in writing, by the client or any other person or agency on behalf of the client regarding denial or abuse of the client's rights. Client Rights: 1. The right to be treated with kindness, consideration, and respect for personal dignity, autonomy, and privacy. 2. The right to receive service in a humane setting which is the least restrictive possible, as defined in the treatment plan. 3. The right to be told of one's own condition, of planned or present services, treatment or therapies, and of the alternative of requesting and evaluation by an independent professional. 4. The right to agree to or refuse any service, treatment, or therapy upon full explanation of the expected consequences. 5. The right to a current, written treatment plan that addresses one's own mental and physical health, social and economic needs, and that specifies the provision of appropriate and adequate services as available, either directly or indirectly. 6. The right to active and informed participation in the development, periodic review, and rereview of the treatment plan as well as a copy of it. 7. The right to freedom from unnecessary or excessive medication. 8. The right to freedom from unnecessary restraint or seclusion. 9. The right to participate in any appropriate and available Agency service regardless of refusal of one or more other services, treatment or therapies, or regardless of relapse from earlier treatment, unless there is a valid and specific necessity which precludes and/or requires the client's participation in the other services. This will be explained to the client and will be Policy and Procedures Page 12

13 recorded in the client's treatment plan. 10. The right to be informed of, and to refuse, any unusual or hazardous treatment procedure. 11. The right to be told of and to refuse observation techniques such as one way mirrors, taperecording, television, movies, or photographs. 12. The right to request and have the opportunity to consult with independent treatment specialists or legal counsel at one's own expense. 13. The right to confidentiality of communications and of all personally identifying data within the limitations and requirements for disclosure of various and/or certifying sources, State or federal statutes, unless release of information is specifically authorized by the Client, parent, or legal guardian of a minor client or court appointed guardian of the person of an adult client in accordance with Rule 5122: of the Administrative Code. 14. The right to have access to one's own client record, unless access to particular identified items of information is specifically restricted for that individual client for clear treatment reasons, as cited in the service plan. "Clear Treatment Reasons" shall be understood to mean only severe emotional damage to the client and/or if dangerous or self injurious actions are an imminent risk. This action must be explained in detail to the client and other persons authorized by the client. The restriction must be renewed at least annually to remain valid. Any person authorized by the client has unrestricted access to all information. Clients will be informed in writing of Agency policies and procedures for reviewing or obtaining copies of all personal records. 15. The right to be told in advance of the reason (s) for termination of services and to be involved in planning for the consequences of that event. 16. The right to receive an explanation of the reason for denial of service. 17. The right not to be discriminated against in the delivery of services on the basis of religion, race, color, creed, sex, national origin, age, lifestyle, sexual orientation, physical or mental handicap, developmental disability, or inability to pay. 18. The right to know the cost of the services. 19. The right to be fully informed of all rights. 20. The right to exercise any and all rights without reprisal in any form, including continued, uncompromised access to services. 21. The right to file a grievance in accordance with agency procedures. 22. The right to have oral and written instruction for filing a grievance. Client Rights Procedure: L & P Services, Inc. will distribute to each applicant or client at the scheduled diagnostic evaluation, or following subsequent appointment, a copy of the Client Rights Policy & Procedure. If the client continues to receive services beyond one year, the client rights policy will be reviewed with the client by a staff person on an annual basis. The Client Rights Officer is available upon request. It is the Client Rights Officer s responsibility to accept and oversee the processing of any and all grievances filed by a client or other person or agency on behalf of a client. The Client Rights Officer will also be available to explain any and all aspects of client rights and grievance procedures. Policy and Procedures Page 13

14 In a crisis or emergency situation, the Clients Rights Officer shall advise the client of at least the immediate pertinent rights to consent to, or to refuse, the offered treatment and the consequences of that agreement or refusal. Under these circumstances, the written copy and full verbal explanation of the client s rights policy may be delayed to a subsequent meeting. A copy of the client rights policy will be distributed to each applicant or client and will be posted in a conspicuous location at each building operated by L & P Services, Inc. All staff persons at the Board, including both administrative and support staff, will be familiarized with all specific client rights and grievance policies and procedures. Policy and Procedures Page 14

15 Grievance Procedure Purpose To establish guidelines of the timely processing of client grievances as they pertain to the agency's Client Rights Policy. Policy It is the policy of L&P Services, Inc. to insure that the program participants have the right to file grievances concerning the services they receive while a program participant. It shall further be the policy of L & P Services, Inc. Inc. to fully support the appointed Client Rights Officer to take all necessary steps to assure compliance with the following procedures: 1. All clients will receive a copy of the Client Rights Grievance procedure at intake. The procedure will be explained by a staff member and upon acceptance of the procedure will the sign the form to verify understanding of and receipt of the Client Grievance Procedure. 2. If a program participant has a grievance they shall be provided with a formal grievance form on which the nature of the complaint, all individuals involved, and the date(s) of the occurrences shall be documented. This form shall be signed and dated by the participant and submitted to the Client Rights Officer. If the Client Rights Officer is away from the office for more than a one week period, the Client Rights Officer will designate another qualified agency staff person to serve in this capacity in their absence. ODADAS standards state the grievance must be in writing. 3. The Client Rights Officer will provide assistance in filing the grievance, investigate the grievance on behalf of the griever, and will represent the griever at the hearing on the grievance at all levels, if requested to do so by the griever. 4. Upon receipt of the grievance, the Client Rights Officer shall collect pertinent information and document the information on the Client Rights Grievance Log. The Client Rights Officer shall serve as representative for the griever. If resolved at this time, a written statement of results will be given to the client and the procedure shall end. The Client Rights Officer will respond to the grievance within five (5) working days. 5. The Client Rights Officer will also present to the griever the option to initiate a complaint with any of several outside entities, if a satisfactory resolution cannot be reached at the Board level. Specifically, the Ohio Department of Mental Health, the Ohio Legal Rights Services, the U.S. Department of Health and Human Services and/or appropriate professional licensing or regulatory associations. The client's relevant addresses and telephone numbers, copies of the presenting grievances and resolutions to any or all of the above agencies, if requested to do so, in writing by the griever. 6. A written acknowledgement of receipt of the grievance will be provided to each grievant. Such acknowledgement will be provided within three (3) working days from receipt of the grievance. The written acknowledgement shall include, but not be limited to, the following: a. Date grievance was received b. Summary of grievance Policy and Procedures Page 15

16 c. Overview of grievance investigation process d. Timetable for completion of investigation and notification of resolution e. Treatment provider contact name, address and telephone number In the event that a grievance is filed against the Client Rights Officer, the client will then be assisted through the entire grievance procedure by the CEO. All written documents relating to the grievance itself will remain confidential at the administrative level and the resolution of the grievance will only be shared with the Client Rights Officer with permission of the client. This agency shall keep records of grievances it receives for a minimum of two years from resolution that include, at minimum: a. A copy of grievance b. Documentation reflecting the process used and resolution/remedy of the grievance c. Documentation, if applicable, of extenuating circumstances for extending the time period for resolving the grievance beyond the five (5) calendar days. The agency will also summarize annually its records to include the number of grievances received, types of grievances and resolution status for each. At all times, the grievance process shall operate in accordance with Title VI. No person in the agency shall on the grounds of RACE, COLOR, RELIGION, SEX, AGE, NATIONAL ORIGIN, OR HANDICAP be excluded from participation in, be denied the benefits of, or otherwise be subject to discrimination under any program or activity for which the applicant received federal financial assistance. Client Rights Officer Anita Meek PO Box 4006 Marietta, Ohio Can be reached 9 5 M F by calling the above number, if not available they or their designee will return call within 1 business day. Washington County Behavioral Health Board, 344 Muskingum Drive, Marietta, Ohio Phone Fax U.S. Department of Human Services, Office of Civil Rights, Washington, D.C. (202) Ohio Legal Rights Service, 8 E. Long Street, Suite 500, Columbus, Ohio T.T.Y Ohio Department of Alcohol and Drug Addiction Services, Two Nationwide Plaza, 280 N. High Street, 12th Floor, Columbus, OH Phone (614) , Deaf Communication (TDD) (TDY) (614) , ODADAS FAX (614) Policy and Procedures Page 16

17 All clinical records remain strictly confidential and program staff shall not convey to a person outside the program that a client attends or receives services from the program or disclose any information identifying a client as an alcohol or other drug services client unless the client consents in writing for the release of information, the disclosure is allowed by a court order, or the disclosure is made to a qualified personnel for a medical emergency, research, audit, or program evaluation purpose. Federal laws and regulations do not protect any threat to commit a crime, any information about a crime committed by a client either at the program or against any person who works for the program. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities. Policy and Procedures Page 17

18 Client Rights & Grievances for Mental Health Accountability: Client Rights Officer; CEO Effective Date: By: Brent Phipps, CEO Revised: ; Purpose: To protect and ensure the rights of persons seeking or receiving mental health services by guaranteeing specific rights of clients, with procedures for responsive and impartial resolution for all grievances either from the client themselves or on behalf of the client by the guardian, next of kin, or special representative. The overall purpose is to ensure clients are free from abuse, financial or other exploitation, humiliation, and neglect and ensure that there is no retaliation for exercising any of the rights or for filing a grievance. Definitions: 1. Client an individual applying for or receiving mental health services from a qualified person from this agency. 2. Client Rights Officer the person designated by L & P Services, Inc. with responsibility for assuring compliance with the Client Rights and Grievance Procedure rule as implemented. 3. Grievance a written complaint initiated, either verbally or in writing, by the client or any other person or agency on behalf of the client regarding denial or abuse of the client's rights. 4. Mental Health Services any of the services, programs, or activities listed/defined in Rule 5122: of the Administrative Code. Mental health services include both direct client services and community services. Direct client services are listed and defined in paragraph (D) (1) to (D) (10) of Rule 5122: Community services are listed and defined in paragraph (D) (11) to (D) (15) of the same rule. Client Rights: 1. The right to be treated with kindness, consideration, and respect for personal dignity, autonomy, and privacy. 2. The right to receive service in a humane setting which is the least restrictive possible, as defined in the treatment plan. 3. The right to be told of one's own condition, of planned or present services, treatment or therapies, and of the alternative of requesting and evaluation by an independent professional. 4. The right to agree to or refuse any service, treatment, or therapy upon full explanation of the expected consequences. 5. The right to a current, written treatment plan that addresses one's own mental and physical health, social and economic needs, and that specifies the provision of appropriate and adequate services as available, either directly or indirectly. 6. The right to active and informed participation in the development, periodic review, and rereview of the treatment plan. 7. The right to freedom from unnecessary or excessive medication. Policy and Procedures Page 18

19 8. The right to freedom from unnecessary restraint or seclusion. 9. The right to participate in any appropriate and available Agency service regardless of refusal of one or more other services, treatment or therapies, or regardless of relapse from earlier treatment, unless there is a valid and specific necessity which precludes and/or requires the client's participation in the other services. This will be explained to the client and will be recorded in the client's treatment plan. 10. The right to be informed of, and to refuse, any unusual or hazardous treatment procedure. 11. The right to be told of and to refuse observation techniques such as one way mirrors, taperecording, television, movies, or photographs. 12. The right to request and have the opportunity to consult with independent treatment specialists or legal counsel at one's own expense. 13. The right to confidentiality of communications and of all personally identifying data within the limitations and requirements for disclosure of various and/or certifying sources, State or federal statutes, unless release of information is specifically authorized by the Client, parent, or legal guardian of a minor client or court appointed guardian of the person of an adult client in accordance with Rule 5122: of the Administrative Code. 14. The right to have access to one's own psychiatric, medical or other treatment records, unless access to particular identified items of information is specifically restricted for that individual client for clear treatment reasons, as cited in the service plan. "Clear Treatment Reasons" shall be understood to mean only severe emotional damage to the client and/or if dangerous or selfinjurious actions are an imminent risk. This action must be explained in detail to the client and other persons authorized by the client. The restriction must be renewed at least annually to remain valid. Any person authorized by the client has unrestricted access to all information. Clients will be informed in writing of Agency policies and procedures for reviewing or obtaining copies of all personal records. 15. The right to be told in advance of the reason (s) for termination of services and to be involved in planning for the consequences of that event. 16. The right to receive an explanation of the reason for denial of service. 17. The right not to be discriminated against in the delivery of services on the basis of religion, race, color, creed, sex, national origin, age, lifestyle, sexual orientation, physical or mental handicap, developmental disability, or inability to pay. 18. The right to know the cost of the services. 19. The right to be fully informed of all rights. 20. The right to exercise any and all rights without reprisal in any form, including continued, uncompromised access to services. 21. The right to have oral and written instruction for filing a grievance. Client Rights Procedure: L & P Services, Inc. will distribute to each applicant or client at the scheduled diagnostic evaluation, or following subsequent appointment, a copy of the Client Rights Policy & Procedure. If the client continues to receive services beyond one year, the client rights policy will be reviewed with the client by a staff person on an annual basis. Policy and Procedures Page 19

20 The Client Rights Officer is available upon request. It is the Client Rights Officer s responsibility to accept and oversee the processing of any and all grievances filed by a client or other person or agency on behalf of a client. The Client Rights Officer will also be available to explain any and all aspects of client rights and grievance procedures. In a crisis or emergency situation, the Clients Rights Officer shall advise the client of at least the immediate pertinent rights to consent to, or to refuse, the offered treatment and the consequences of that agreement or refusal. Under these circumstances, the written copy and full verbal explanation of the client s rights policy may be delayed to a subsequent meeting. All clients or recipients of the type of mental health services specified as "Community Services" (Information and referral, consultation services, mental health education service, training) may have a copy and explanation of the client rights policy upon request. A copy of the client rights policy will be distributed to each applicant or client and will be posted in a conspicuous location at each building operated by L & P Services, Inc. All staff persons at the Board, including both administrative and support staff, will be familiarized with all specific client rights and grievance policies and procedures. Grievance Procedure Purpose: To establish guidelines of the timely processing of client grievances as they pertain to the agency's Client Rights Policy. Policy: It is the policy of L & P Services, Inc. to insure that the program participants have the right to file grievances concerning the services they receive while a program participant. It shall further be the policy of L & P Services, Inc. Inc. to fully support the appointed Client Rights Officer to take all necessary steps to assure compliance with the following procedures: 1. All clients will receive a copy of the Client Rights Grievance procedure at intake. The procedure will be explained by a staff member and upon acceptance of the procedure will the sign the form to verify understanding of and receipt of the Client Grievance Procedure. 2. If a program participant has a grievance they shall be provided with a formal grievance form on which the nature of the complaint, all individuals involved, and the date(s) of the occurrences shall be documented. This form shall be signed and dated by the participant and submitted to the Client Rights Officer. This may be done verbally with the client; it is not mandated that the client complete a written form in order to file a grievance. If the Client Rights Officer is away from the office for more than a one week period, the Client Rights Officer will designate another qualified agency staff person to serve in this capacity in their absence. 3. The Client Rights Officer will provide assistance in filing the grievance, investigate the grievance on behalf of the griever, and will represent the griever at the hearing on the grievance at all levels, if requested to do so by the griever. Policy and Procedures Page 20

21 4. Upon receipt of the grievance, the Client Rights Officer shall collect pertinent information and document the information on the Client Rights Grievance Log. The Client Rights Officer shall serve as representative for the griever. If resolved at this time, a written statement of results will be given to the client and the procedure shall end. The Client Rights Officer will respond to the grievance within five (5) working days. 5. The Client Rights Officer will also present to the griever the option to initiate a complaint with any of several outside entities, if a satisfactory resolution cannot be reached at the Board level. Specifically, the Ohio Department of Mental Health, the Ohio Legal Rights Services, the U.S. Department of Health and Human Services and/or appropriate professional licensing or regulatory associations. The client's relevant addresses and telephone numbers, copies of the presenting grievances and resolutions to any or all of the above agencies, if requested to do so, in writing by the griever. In the event that a grievance is filed against the Client Rights Officer, the client will then be assisted through the entire grievance procedure by the CEO. All written documents relating to the grievance itself will remain confidential at the administrative level and the resolution of the grievance will only be shared with the Client Rights Officer with permission of the client. Client Rights Officer Anita Meek PO Box 4006 Marietta, OH (740) Can be reached 9 5 M F by calling the above number, if not available they or their designee will return call within 1 business day. Washington County Behavioral Health Board, 344 Muskingum Drive, Marietta, OH Phone (740) Fax (740) Ohio Department of Human Services, Office of Civil Rights, Washington, D.C. (202) Ohio Department of Mental Health, 30 E. Broad Street, Columbus, OH (614) Ohio Legal Rights Service, 8 E. Long Street, Suite 500, Columbus, OH TTY This agency shall keep records of grievances it receives, the subject of the grievances, the resolution of each and shall ensure the availability of these records for review by the Department of Mental Health upon request. The agency will also summarize annually its records to include the number of grievances received, types of grievances and resolution status for each. At all times, the grievance process shall operate in accordance with Title VI. No person in the agency shall on the grounds of RACE, COLOR, RELIGION, SEX, AGE, NATIONAL ORIGIN, OR HANDICAP be Policy and Procedures Page 21

22 excluded from participation in, be denied the benefits of, or otherwise be subject to discrimination under any program or activity for which the applicant received federal financial assistance. Policy and Procedures Page 22

23 Section B: Privacy/HIPPA Policy & Procedures Table of Contents Notice of Privacy Practices Use or Disclosure of Protected Health Information for Treatment, Payment or Health Care Operations Purposes Individuals Rights Related to Protected Health Information (PHI) Provision of Privacy Notice Protected Health Information Business Associate Amendment Management and Protection of Personal Health Information Accounting for Disclosures of Protected Health Information Administrative Requirements for the Implementation of HIPAA Authorization for Use or Disclosure of Protected Health Information Business Associate Agreements Workforce Confidentiality Agreement Records of Disclosure Authorized by Law Collateral Information Policy Policy and Procedures Page 23

24 Notice of Privacy Practices I. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. H. Our Duty to Safeguard Your Protected Health Information. Individually identifiable information about your past, present, or future health or condition, the provision of health care to you, or payment for the health care is considered "Protected Health Information" ("PHI"). We are required to extend certain protections to your PHI, and to give you this Notice about our privacy practices that explains how, when and why we may use or disclose your PHI. Except in specified circumstances, we must use or disclose only the minimum necessary PHI to accomplish the intended purpose of the use or disclosure. We are required to follow the privacy practices described in this Notice, though we reserve the right to change our privacy practices and the terms of this Notice at any time. If we do so, we will post a new Notice in the lobby at all office locations. You may request a copy of the new notice from L & P Services, Inc. PO Box 4006, Marietta, Ohio IH. How We May Use and Disclose Your Protected Health Information. We use and disclose PHI for a variety of reasons. We have a limited right to use and/or disclosure your PHI for purposes of treatment, payment or our health care operations. For uses beyond that, we must have your written authorization unless the law permits or requires us to make the use or disclosure without your authorization. If we disclose your PHI to an outside entity in order for that entity to perform a function on our behalf, we must have in place an agreement from the outside entity that it will extend the same degree of privacy protection to your information that we must apply to your PHI. However, the law provides that we are permitted to make some uses/disclosures without your consent or authorization. The following offers more description and some examples of our potential uses/disclosures of your PHI. Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations. Generally, we may use or disclose your PHI as follows: For treatment: We may disclose your PHI to doctors, nurses, and other health care personnel who are involved in providing your health care. For example, your PHI will be shared among members of your treatment team, or with other agency staff on a need to know basis. Your PHI may also be shared with outside entities performing ancillary services relating to your treatment, such as lab work or for consultation purposes, or ADAMH/CMH Boards and/or community mental health agencies involved in provision or coordination of your care. To obtain payment: We may use/disclose your PHI in order to bill and collect payment for your health care services. For example, we may contact your employer to verify employment status, and/or release portions of your PHI to the Medicaid program, the ODMH central office, the local ADAMH/CMH Board and/or a private insurer to get paid for services that we delivered to you. For health care operations: We may use/disclose your PHI in the course of operating our mental health services. For example, we may use your PHI in evaluating the quality of services provided, or Policy and Procedures Page 24

25 disclose your PHI to our accountant or attorney for audit purposes. Since we are an integrated system, we may disclose your PHI to designated staff in our central office or our Office of Support Services for similar purposes. Release of your PHI to the Multi Agency Community Services Information System [MACSIS] and/or state agencies might also be necessary to determine your eligibility for publicly funded services. All of these will be on a need to know basis. Appointment reminders: Unless you provide us with alternative instructions, we may send appointment reminders, billings, and other similar materials to your home. Uses and Disclosures Requiring Authorization: For uses and disclosures beyond treatment, payment and operations purposes we are required to have your written authorization, unless the use or disclosure falls within one of the exceptions described below. Authorizations can be revoked at any time to stop future uses/disclosures except to the extent that we have already undertaken an action in reliance upon your authorization. Uses and Disclosures of PHI from Mental Health Records Not Requiring Consent or Authorization: The law provides that we may use/disclose your PHI from mental health records without consent or authorization in the following circumstances: When required by law: We may disclose PHI when a law requires that we report information about suspected abuse, neglect or domestic violence, or relating to suspected criminal activity, or in response to a court order. We must also disclose PHI to authorities that monitor compliance with these privacy requirements. For public health activities: We may disclose PHI when we are required to collect information about disease or injury, or to report vital statistics to the public health authority. For health oversight activities: We may disclose PHI to our central office, the protection and advocacy agency, or another agency responsible for monitoring the health care system for such purposes as reporting or investigation of unusual incidents. Relating to decedents: We may disclose PHI relating to an individual's death to coroners, medical examiners or funeral directors, and to organ procurement organizations relating to organ, eye, or tissue donations or transplants. For research purposes: In certain circumstances, and under supervision of a privacy board, we may disclose PHI to our central office research staff and their designees in order to assist medical/psychiatric research. To avert threat to health or safety: In order to avoid a serious threat to health or safety, we may disclose PHI as necessary to law enforcement or other persons who can reasonably prevent or lessen the threat of harm. For specific government functions: We may disclose PHI of military personnel and veterans in certain situations, to correctional facilities in certain situations, to government benefit programs relating to eligibility and enrollment, and for national security reasons, such as protection of the President. Policy and Procedures Page 25

26 Uses and Disclosures of PHI from Alcohol and Other Drug Records Not Requiring [Consent or] Authorization: The law provides that we may use/disclose your PHI from alcohol and other drug records without consent or authorization in the following circumstances: When required by law: We may disclose PHI when a law requires that we report information about suspected child abuse and neglect, or when a crime has been committed on the program premises or against program personnel, or in response to a court order. Relating to decedents: We may disclose PHI relating to an individual's death if state or federal law requires the information for collection of vital statistics or inquiry into cause of death. For research, audit or evaluation purposes: In certain circumstances, we may disclose PHI for research, audit or evaluation purposes. To avert threat to health or safety: In order to avoid a serious threat to health or safety, we may disclose PHI to law enforcement when a threat is made to commit a crime on the program premises or against program personnel. Uses and Disclosures Requiring You to have an Opportunity to Object: In the following situations, we may disclose a limited amount of your PHI if we inform you about the disclosure in advance and you do not object, as long as the disclosure is not otherwise prohibited by law. However, if there is an emergency situation and you cannot be given your opportunity to object, disclosure may be made if it is consistent with any prior expressed wishes and disclosure is determined to be in your best interests. You must be informed and given an opportunity to object to further disclosure as soon as you are able to do so. IV. Your Rights Regarding Your Protected Health Information. You have the following rights relating to your protected health information: To request restrictions on uses/disclosures: You have the right to ask that we limit how we use or disclose your PHI. We will consider your request, but are not legally bound to agree to the restriction. To the extent that we do agree to any restrictions on our use/disclosure of your PHI, we will put the agreement in writing and abide by it except in emergency situations. We cannot agree to limit uses/disclosures that are required by law. Under most situations we will expressly ask for your authorization in writing to release information outside our agency. To choose how we contact you: You have the right to ask that we send you information at an alternative address or by an alternative means. We must agree to your request as long as it is reasonably easy for us to do so. To inspect and copy your PHI: Unless your access is restricted for clear and documented treatment reasons, you have a right to see your protected health information upon your written request. We will respond to your request within 30 days. If we deny your access, we will give you written reasons for the denial and explain any right to have the denial reviewed. If you want copies of your PHI, a charge for copying may be imposed, depending on your circumstances. You have a right to choose what portions of Policy and Procedures Page 26

27 your information you want copied and to have prior information on the cost of copying. To request amendment of your PHI: If you believe that there is a mistake or missing information in our record of your PHI, you may request, in writing, that we correct or add to the record. We will respond within 60 days of receiving your request. We may deny the request if we determine that the PHI is: (i) correct and complete; (ii) not created by us and/or not part of our records, or; (iii) not permitted to be disclosed. Any denial will state the reasons for denial and explain your rights to have the request and denial, along with any statement in response that you provide, appended to your PHI. If we approve the request for amendment, we will change the PHI and so inform you, and tell others that need to know about the change in the PHI. To find out what disclosures have been made: You have a right to get a list of when, to whom, for what purpose, and what content of your PHI has been released other than instances of disclosure: for treatment, payment, and operations; to you, your family, or the facility directory; or pursuant to your written authorization. The list also will not include any disclosures made for national security purposes, to law enforcement officials or correctional facilities, or disclosures made before April, We will respond to your written request for such a list within 60 days of receiving it. Your request can relate to disclosures going as far back as six years. There will be no charge for up to one such list each year. There may be a charge for more frequent requests. To receive this notice: You have a right to receive a paper copy of this Notice and/or an electronic copy by upon request. V. How to Complain about our Privacy Practices: If you think we may have violated your privacy rights, or you disagree with a decision we made about access to your PHI, you may file a complaint with the person listed in Section VI. Below. You also may file a written complaint with the Secretary of the U.S. Department of Health and Human Services at 200 Independence Avenue, S.W., Washington, D.C (202) We will take no retaliatory action against you if you make such complaints. VI. Contact Person for Information, or to Submit a Complaint: If you have questions about this Notice or any complaints about our privacy practices, please contact: Privacy Officer, PO Box 4006, Marietta, Ohio (740) VII. Effective Date: This Notice was effective on Date: 9 / 16 /05 VIII. Acknowledgment: I have received a copy of this Notice. Printer Name Signature. Date Policy and Procedures Page 27

28 Use or Disclosure of Protected Health Information for Treatment, Payment or Health Care Operations Purposes Effective: By: Brent Phipps, CEO Purpose: To issue instructions to all L & P Services, Inc. offices, facilities, programs and workforce members regarding the use and disclosure of protected health information (PHI) and necessary documentation of authority for such use or disclosure, for purposes of treatment, payment and health care operations (TPO). Applicability: This policy applies to all L & P Services, Inc. offices, facilities, and programs, and to all L & P Services, Inc. workforce members ("entities"). Definitions: Protected Health Information (PHI) means individually identifiable information relating to the past, present or future physical or mental health or condition of an individual, provision of health care to an individual, or the past, present or future payment for health care provided to an individual. Treatment, Payment and Health Care Operations (TPO) includes all of the following: Treatment means the provision, coordination, or management of health care and related services, consultation between providers relating to an individual, or referral of an individual to another provider for health care. Payment means activities undertaken to obtain or provide reimbursement for health care, including determinations of eligibility or coverage, billing, collection activities, medical necessity determinations and utilization review. Health Care Operations include functions such as quality assessment and improvement activities, reviewing competence or qualifications of health care professionals, conducting or arranging for medical review, legal services, and auditing functions, business planning and development, and general business and administrative activities. Personal Representative means a person who has authority under applicable law to make decisions related to health care on behalf of an adult/guardian, or other person acting in locoparentis who is authorized under law to make health care decisions on behalf of an unemancipated minor, except where the minor is authorized by law to consent, on his/her own or via court approval, to a health care service, or where the parent, guardian or person acting in locoparentis has assented to an agreement of confidentiality between the provider and the minor. Policy: A. Generally: In compliance with 45 CFR Part 164 and Ohio law, an individual's authorization (or authorization from a personal representative) must be obtained prior to using or disclosing protected health information to carry out treatment, payment or health care operations, except as specified below. Policy and Procedures Page 28

29 B. Exceptions: Limited PHI [medication history, physical health status and history, summary of course of treatment, summary of treatment needs, and discharge summary] may be used or disclosed for TPO without authorization if disclosure is to CMH/ ADAMH Boards with which there is a current agreement for the individual's care or services, and an attempt has been made to obtain the individual's consent to the disclosure. (Reference MACSIS Enrollment/Authorization) Limited PHI [medication information, summary of diagnosis and prognosis, list of services and personnel available for assistance] may be disclosed to family members, other relatives or friends involved in the individual's care, or payment for that care, if the individual is notified and does not object to the disclosure. *In emergency treatment situations, necessary information for treatment may be disclosed if an attempt is made to obtain consent to the disclosure as soon as reasonably practical after the delivery of treatment. Policy and Procedures Page 29

30 Individuals Rights Related to Protected Health Information (PHI) Effective: By: Brent Phipps, CEO Purpose: To issue instructions regarding L & P Services, Inc. obligations relating to client's rights relating to access to and use/disclosure of their protected health information (PHI). Applicability: This policy applies to all L & P Services, Inc. offices, facilities, and programs and, as applicable, to all L & P Services, Inc. workforce members ("entities"). Definitions: Protected Health Information (PHI) means individually identifiable information relating to past, present or future physical or mental health or condition of an individual, provision of health care to an individual, or the past, present or future payment for health care provided to an individual. Designated Record Set means a group of records maintained by or for L & P Services, Inc., or one of its facilities or programs that includes medical, billing enrollment, payment, claims adjudication, and other records used to make decisions about an individual. Personal Representative means a person who has authority under applicable law to make decisions related to health care on behalf of an adult/guardian, or other person acting in locoparentis who is authorized under law to make health care decisions on behalf of the client, except where the client is authorized by law to consent, on his/her own or via court approval, to a health care service, or where the guardian or person acting in locoparentis has assented to an agreement of confidentiality between the provider and the client. Business Associate (BA) means a person or entity who, on behalf of L & P Services, Inc. or an office, program or facility of L & P Services, Inc., but not in the capacity of a workforce member, performs, or assists in the performance of, a function or activity involving the use or disclosure of PHI, or provides legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, or financial services involving disclosure of PHI. Privacy Notice means the notice of privacy practices relating to an entity's use and disclosure of PHI that is mandated under HIPAA regulations for distribution to all individuals whose information will be collected by or on behalf of the entity. Policy: A. INDIVIDUALS ACCESS TO PHI: Individuals have a right to access and a copy of their PHI and any information in their designated record set except as set forth below: Denial of Access without a right of review: Access may be denied where: Policy and Procedures Page 30

31 Information was compiled in anticipation of litigation; Care was provided under the direction of a correctional institution and provision of access would jeopardize health, safety, or rehabilitation; Information was collected in the course of research that includes treatment of the individual and the individual agreed to a suspension of the right of access during the research period; Access can be denied in accordance with the Clinical Laboratory Improvements Amendments of 1988 (CL1A) or the Privacy Act (5 USC 552a). Denial of Access with a right of review: Access may be denied, though denial is subject to review where: Access is determined by a licensed professional to be likely to endanger life or safety of the individual or another person; Access is requested by a Personal Representative and a licensed professional determines that such access is reasonably likely to cause substantial harm. Right of Review: If the basis for denial of access gives a right of review, the individual has a right to have the denial reviewed by another licensed professional who did not participate in the original denial decision. Such review must be completed within a reasonable period of time, and the agency or program must promptly: A. provide the individual with notice of the reviewer's decision, and B. comply with the determination to provide or deny access. Timely Review: The entity must act on a request for access no later than thirty (30) days after receipt unless the time period is extended as permitted below: If the information to be accessed is not maintained or accessible on site, the entity must act on the request no later than sixty (60) days after receipt. If the entity is unable to act on the request for access within the applicable 30 or 60 day period, it may extend the time for response by no more than thirty (30) days, provided that, within the original allotted time period, the entity gives the individual written notice of the reasons for the delay and the date by which a responsive action will be taken. Provision of Access: The entity must provide the individual with access to the information in the form or format requested if it is readily producible in such form or format, or in a readable hard copy or other form or format as mutually agreed to, either by arranging for a convenient time and place for inspection and copying, or mailing the information at the individual's request. If the information is maintained in more than one place, the information need only be produced once in response to a current request for access. The entity may provide a summary of the information in lieu of providing access, or may provide an explanation of the information to which access is provided if the individual, in advance, agrees. The entity may impose a reasonable, cost based fee for copying, or preparing a summary or explanation of the information provided that the fee includes only the cost of copying supplies, postage, and labor for preparing the summary or explanation as agreed to by the individual. Policy and Procedures Page 31

32 Denial of Access: The entity must provide a timely, written denial of access to the individual, written in plain language, explain the basis for the denial, and any applicable right of review, and describe how the individual may complain to the entity (including name or title of contact, and phone number) or the U.S. Secretary of Health and Human Services. To the extent possible, the individual must be given access to any information requested after excluding the information for which the entity has grounds for denying access. If the entity does not maintain the information for which access has been requested, but knows where it is maintained, the entity must inform the individual where to direct the request for access. Documentation: The entity must document and retain for six years from the date of its creation the designated record sets subject to access and the names or titles of persons responsible for receiving and processing requests for access. B. RIGHT TO REQUEST RESTRICTIONS ON USES/DISCLOSURES OF PHI, AND TO REQUEST CONFIDENTIAL COMMUNICATIONS: Requests for Restrictions on Uses/Disclosures: The entity must permit an individual to request that the entity restrict uses and disclosures of PHI made for TPO or disclosures to family or others involved in the individual's care, though the entity does not have to agree to the restriction requested. If the entity agrees to the requested restriction(s), it must document the agreed upon restriction in writing, and abide by the restriction unless the individual is in need of emergency treatment, the information is needed for the treatment, and the disclosure is to another provider only for purposes of such treatment. The entity must request that the provider agree not to further disclose the PHI. The entity cannot agree to a restriction that prevents uses or disclosures permitted or required to the individual, for a facility directory, or where the use or disclosure does not require the individual's permission. The entity may terminate an agreed upon restriction if the individual so agrees, as documented in writing, or the entity informs the individual and the termination is only effective as to PHI created or received after such notice. Requests for Confidential Communications: The record keeping entity must permit individuals to request to receive communications of PHI by alternative means or at alternative locations, and must accommodate all reasonable requests. C. RIGHT TO REQUEST AMENDMENT OF PHI: Requests for Amendment of PHI: An individual has the right to have the entity amend PHI or other information in the designated record set for as long as the entity maintains the information. The entity must act on the request within sixty (60) days of receipt, or within ninety (90) days if the Policy and Procedures Page 32

33 entity notifies the individual within the first 60 days of the reasons for delay and the date by which action will be taken. The entity may deny the request if it determines that the record: was not created by the entity (unless the individual provides reasonable basis to believe that the originator of the records is no longer available to act on the request); is not part of the designated record set; would not be available for inspection; or is accurate and complete. Accepting the Amendment: If the entity accepts the amendment, in whole or in part, it must: Make the amendment by, at minimum, identifying the affected records and appending or otherwise providing a link to the location of the amendment; Timely inform the individual that the amendment is accepted, and obtain his/her identification of an agreement to have the entity notify relevant persons with a need to know; Make reasonable efforts to inform and timely provide the amendment to those persons and others, including business associates that the entity knows to have the affected PHI and that may have relied, or be foreseen to rely, on that information to the detriment of the individual. Denying the Amendment: If the entity denies the amendment, in whole or part, it must: Provide the individual with a timely denial, written in plain language and include: the basis for denial; notice of the individual's right to submit a written statement of disagreement, and instructions on how to file the statement, or to request that future disclosures of the PHI include copies of the request and the denial; and a description of how the individual may complain about the decision to the entity or to the U. S. Secretary of Health and Human Services; Permit the individual to submit a statement of disagreement (but entity may reasonably limit its length); Provide a copy of any rebuttal prepared to the individual; As appropriate, identify the part of the record subject to the disputed amendment and append or otherwise link the request, the denial, and any statement of disagreement or rebuttal to the record; For future disclosures of the record, include any statement of disagreement or, in response to the individual's request, the amendment request and the denial (or an accurate summary of either of the foregoing). If standard transaction format does not permit the appending of the additional information, it must be transmitted separately to the recipient of the standard transaction. *If the entity is informed by another covered entity about an amendment to the record, the entity must amend the information in its record by, at a minimum, identifying the affected records and appending or otherwise providing a link to the location of the amendment. *The entity must document the titles of the persons or offices responsible for receiving and processing requests for amendments. D. RIGHT TO AN ACCOUNTING OF DISCLOSURES: An individual has a right to receive an accounting of disclosures of his/her PHI in accordance with the policy "Accounting of Disclosures of Protected Health Policy and Procedures Page 33

34 Information." Policy and Procedures Page 34

35 Provision of Privacy Notice Effective: By: Brent Phipps Purpose: To issue instructions to all L & P Services, Inc.'s offices, facilities, workforce members and business associates regarding the provision of a notice of privacy practices to all patients and clients. Applicability: This policy applies to all L & P Services, Inc.'s offices, facilities and programs, and to all L & P Services, Inc.'s workforce members in provider settings ("entities"). Definitions: Covered Entity (CE) means a health plan that provides, or pays the cost of, medical care, a health care clearinghouse, or a health care provider. Protected Health Information (PHI) means individually identifiable information relating to the past, present or future physical or mental health or condition of an individual, provision of health care to an individual, or the past, present or future payment for health care provided to an individual. Treatment, Payment and Operations (TPO) includes all of the following: Treatment means the provision, coordination, or management of health care and related services, consultation between providers relating to an individual, or referral of an individual to another provider for health care. Payment means activities undertaken to obtain or provide reimbursement for health care, including determinations of eligibility or coverage, billing, collection activities, medical necessity determinations and utilization review. Operations includes functions such as quality assessment and improvement activities, reviewing competence or qualifications of health care professionals, conducting or arranging for medical review, legal services and auditing functions, business planning and development, and general business and administrative activities. Policy: A. Generally: In compliance with 45 CFR , an individual has a right to adequate notice of the uses and disclosures of their PHI that may be made by or on behalf of a CE, and of the individual's rights and the CE's legal duties with respect to their PHI. This right to a notice of privacy practices does not apply to inmates of correctional facilities. B. Content Requirements: The notice of privacy practices must be written in plain language and must contain the following elements: The following statement in a header or otherwise prominently displayed: THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY." A description, including at least one example, of the types of uses and disclosures that the CE is Policy and Procedures Page 35

36 permitted to make for purposes of treatment, payment and health care operations, with sufficient detail to place an individual on notice of the uses and disclosures permitted or required; A description of each of the other purposes for which the CE is permitted or required to use or disclose PHI without an individual's consent or authorization, with sufficient detail to place an individual on notice of the uses and disclosures permitted or required; A statement that other uses or disclosures will be made only with the individual's written authorization, and that the authorization may be revoked in accordance with the policy on authorizations; If provider intends to contact the individual for appointment reminders, treatment alternatives or other health related benefits, a separate statement describing such contacts; A statement of the individual's rights with respect to his/her PHI, and a brief description of how the individual may exercise those rights, including: the right to request restrictions on certain uses/disclosures of PHI, and the fact that the CE does not have to agree to such restrictions; the right to receive confidential communications of PHI; the right to inspect and copy PHI; the right to amend PHI; the right to receive an accounting of disclosures of PHI, and; the right to receive a paper copy of the privacy notice (each of the above in accordance with relevant policies); A statement of the CE's duties with respect to PHI, including statements: that the CE is required by law to maintain the privacy of PHI and to provide individuals with notice of its legal duties and privacy policies; that the CE is required to abide by the terms of the currently effective privacy notice, and that the CE reserves the right to change the terms of the notice and make the new notice provisions effective for all PHI maintained, along with a description of how the CE will provide individuals with the revised notice; A statement that individuals may complain to the CE and to the Secretary of the U.S. Department of Health and Human Services about privacy rights violations, including a brief statement about how a complaint may be filed and an assurance that the individual will not be retaliated against for filing a complaint; The name, or title, and telephone number of the person or office to contact for further information; the effective date of the notice, which may not be earlier than the date printed or published. C. Revisions to Notice: L & P Services, Inc. must promptly revise and distribute the privacy notice whenever there is a material change to the uses or disclosures, the individual's rights, the CE's legal duties, or other privacy practices described in the notice. Except when required by law, a material change to any term may not be implemented prior to the effective date of the notice reflecting the change. D. Provision of Notice; L & P Services, Inc. must provide individuals with the notice, and obtain the individual's written acknowledgement of receipt, or document attempts to obtain such acknowledgement, no later than the date of the first service delivery. Additionally, the notice in effect (original notice or any subsequent revisions) must be prominently posted and copies must be available for individuals to take at any service delivery sites. The privacy notice must also be prominently posted Policy and Procedures Page 36

37 in agency locations and available electronically from the web site, if available. E. Documentation Requirements: L & P Services, Inc. must retain copies of notices issued for a period of at least six years from the later of the date of creation or the last effective date. Policy and Procedures Page 37

38 Protected Health Information Business Associate Amendment As a business associate, or person providing contract services to L & P Services, Inc., I agree to the following conditions regarding Protected Health Information, hereafter known as PHI: I will not use or disclose the PHI except as authorized under the agreement or required by law. I will use safeguards to prevent unauthorized use or disclosure. I will report unauthorized uses or disclosures to L & P Services, Inc. I will pass on the same obligations relating to protection of PHI to any subcontractors or agents. I will make PHI available for access by the individual or his/her personal representative, in accordance with relevant law and policy. I will make PHI available for amendment, and incorporate any approved amendments to PHI, in accordance with relevant law and policy I will make internal practices, books and records relating to its receipt or creation of PHI available to the Office of the U.S. Secretary of Health and Human Services for purposes of determining the entity's compliance with HIPAA regulations. If feasible, return or destroy all PHI upon termination of contract; if any PHI is retained, continue to extend the full protections specified herein as long as the PHI is maintained. L & P Services, Inc. may terminate the contract and/or agreement immediately upon a material breach by the business associate. (Reference L & P Services, Inc. Notice of Privacy Practice)\ Signature of Contractor/Business Associate Date Signature Representing L & P Services Date Created 9/16/05 L & P Services Policy and Procedures Page 38

39 Management and Protection of Personal Health Information Effective: By: Brent Phipps, CEO Purpose: To issue instructions to all L & P Services, Inc.'s, facilities, programs and workforce members regarding the management and protection of individuals' health information. Applicability: This policy applies to all L & P Services, Inc.'s offices, facilities and programs, and all L & P Services, Inc.'s workforce members ("entities"). Definitions: Covered Entity (CE) means a health plan, a health care clearinghouse, or a health care provider that transmits any health information in any form relating to any covered transaction. Hybrid Entity means a single legal entity that is a CE whose covered functions are not its primary functions. Protected Health Information (PHI) means individually identifiable information relating to the past, present or future physical or mental health or condition of an individual, provision of health care to an individual, or the past, present or future payment for health care provided to an individual. Designated Record Set means a group of records maintained by or for a CE that is: the medical and billing records relating to an individual maintained by or for a health care provider; the enrollment, payment, claims adjudication, and case or medical management systems maintained by or for a health plan, or; used, in whole or in part, by or for a CE to make decisions about individuals. Treatment, Payment and Health Care Operations (TPO) includes all of the following: Treatment means the provision, coordination, or management of health care and related services, consultation between providers relating to an individual, or referral of an individual to another provider for health care. Payment means activities undertaken to obtain or provide reimbursement for health care, including determinations of eligibility or coverage, billing, collections activities, medical necessity determinations and utilization review. Health Care Operations includes functions such as quality assessment and improvement activities, reviewing competence or qualifications of health care professionals, conducting or arranging for medical review, legal services and auditing functions, business planning and development, and general business and administrative activities. Disclosure means the release, transfer, provision of access to, or divulging in any other manner of information outside the entity holding the information. Policy and Procedures Page 39

40 Use means, with respect to individually identifiable health information, the sharing, employment, application, utilization, examination, or analysis of such information within an entity that maintains such information. Personal Representative means a person who has authority under applicable law to make decisions related to health care on behalf of a client/guardian, or other person acting in locoparentis who is authorized under law to make health care decisions on behalf of the client, except where the client is authorized by law to consent, on his/her own or via court approval, to a health care service, or where the parent, guardian or person acting in locoparentis has assented to an agreement of confidentiality between the provider and the minor. Workforce Members means employees, volunteers, trainees, and other persons whose conduct, in the performance of work for the department, its offices, programs or facilities, is under the direct control of the department, office, program or facility, regardless of whether they are paid by the entity. Policy: For details on specific requirements, refer to the appropriate policies in the Policy and Procedure Manual of L & P Services, Inc. A. Generally: PHI shall not be used or disclosed except as permitted or required by law. B. Notice of Privacy Practices Required: Individuals served must be given a Privacy Notice outlining the uses and disclosures of PHI that may be made, and notifying them of their rights and our legal duties with respect to PHI. [Privacy Notice} C. Permitted and Required Uses and Disclosures: PHI may or shall be disclosed as follows: To the individual [Individuals' Rights Related to PHI]; To carry out TPO activities, within specified limits [Use or Disclosure of PHI for TPO Purposes]; Pursuant to and in compliance with a current and valid Authorization [Authorization for Use or Disclosure of PHI]; In keeping with a Business Associate arrangement [Business Associate Agreements]; As otherwise provided for in the HIPAA privacy regulations [Uses and Disclosures of PHI beyond TPO for which Authorization is Not Required. D. Minimum Necessary: Generally, when using or disclosing PHI, or when requesting PHI from another entity, reasonable efforts must be made to limit the PHI being used or disclosed to the minimum necessary to accomplish the purpose of the use/disclosure [Minimum Necessary Requirement]). E. Personal Representatives: A person acting in the role of personal representative must be treated as the individual regarding access to relevant PHI unless: The client authorized to give lawful consent, individual is an unemancipated minor, but is authorized to give lawful consent, or may obtain the health care without consent of the personal representative, and minor has not requested that the person be treated as a personal representative, or the personal representative has assented to agreement of confidentiality between the provider and the minor; Policy and Procedures Page 40

41 There is a reasonable basis to believe that the individual has been or may be subjected to domestic violence, abuse or neglect by the personal representative or that treating that person as a personal representative could endanger the individual, and, in the exercise of professional judgment, it is determined not to be in the best interests of the individual to treat that person as a personal representative. F. Agreed Upon Restrictions: An individual has a right to request a restriction on any uses or disclosures of his/her PHI, though a covered entity need not agree to the requested restriction, and cannot agree to a restriction relating to disclosures required under law (i.e., disclosures to the U. S. Secretary of Health and Human Services for HIPAA enforcement purposes). [Individuals' Rights Related to PHI] G. Confidential Communications: An individual has a right to request to receive communications of PHI by alternative means or at alternative locations, and reasonable requests must be accommodated. [Individuals' Rights Relating to PHI] H. Accounting for Disclosures: An individual has a right to an accounting of disclosures of his/her PHI for up to a six year period. [Accounting for Disclosures of PHI] I. De identified PHI: Health information may be considered not to be individually identifiable in the following circumstances: A person with appropriate knowledge and experience with generally acceptable statistical and scientific principles and methods determines that the risk is very small that the information could be used, alone or with other reasonably available information, to identify the individual who is the subject of the information; or the following identifiers of the individual (and relatives, employers or household members) is removed: names; information relating to the individual's geographic subdivision if it contains fewer than 20,000 people; elements of dates (except year) directly related to the individual, and all ages and elements of dates that indicate age for individuals over 89, unless aggregated into a single category of age 90 and older; telephone numbers; fax numbers; addresses; social security numbers; medical record numbers; health plan beneficiary numbers; account numbers; certificate or license numbers; vehicle identifiers and serial numbers, including license plate numbers; device identifiers and serial numbers; Web Universal Resource Locators (URLs); Internet Protocol (IP) address numbers; biometric identifiers; full face photographic images; and, any other unique identifying number, characteristic or code. J. Complaint Process: Each office, program or facility of the department must have in place a process for individuals to make complaints about the entity's HIPAA policies and procedures and/or the entity's compliance with those policies and procedures. K. Documentation: Each office, program or facility of the department must maintain written or electronic copies of all policies and procedures, communications, actions, activities or designations as are required to be documented under this manual for a period of six (6) years from the later of the date of creation or the last effective date. NOTE: This is the documentation requirement under HIPAA, but does not necessarily reflect any longer retention period for particular documentation that may be mandated by state or federal law on another basis. Policy and Procedures Page 41

42 Accounting for Disclosures of Protected Health Information Effective: 9/16/05 By: Brent Phipps, CEO Purpose: To issue instructions to all L & P Services, Inc. facilities, programs and workforce members regarding the provision of an accounting of disclosures of protected health information (PHI). Applicability: This policy applies to all L & P Services, Inc. workforce members ("entities"). Definitions: Protected Health Information (PHI) means individually identifiable information relating to the past, present or future physical or mental health or condition of an individual, provision of health care to an individual, or the past, present or future payment for health care provided to an individual. Treatment, Payment and Health Care Operations (TPO) includes all of the following: Treatment means the provision, coordination, or management of health care and related services, consultation between providers relating to an individual, or referral of an individual to another provider for health care. Payment means activities undertaken to obtain or provide reimbursement for health care, including determinations of eligibility or coverage, billing, collection activities, medical necessity determinations and utilization review. Health Care Operations include functions such as quality assessment and improvement activities, reviewing competence and qualifications of health care professionals, conducting or arranging for medical review, legal services, and auditing functions, business planning and development, and general business and administrative activities. Policy: A. Generally: In compliance with 45 CFR , an individual has a right to receive an accounting of disclosures of PHI by the entity during a time period specified up to six (6) years prior to the date of the request for an accounting except for disclosures: To carry out TPO as permitted under law; To the individual about his or her own information; For the facility directory or to persons involved in the individual's care, or other notification purposes permitted under law; Pursuant to the individual's authorization; For national security or intelligence purposes; To correctional institutions or law enforcement officials as permitted under law; That occurred prior to April 14, The individual's right to receive an accounting of disclosures of PHI to a health oversight Policy and Procedures Page 42

43 agency or law enforcement official must be suspended for the time period specified by such agency or official if the agency or official provides a written statement asserting that the provision of an accounting would be reasonably likely to impede the activities of the agency or official and specifying a time period for the suspension. Such a suspension may be requested and implemented based on an oral notification for a period of up to thirty (30) days. Such oral request must be documented, including the identity of the agency or official making the request. The suspension may not extend beyond thirty (30) days unless the written statement described herein is submitted during that time period. B. Content Requirements: The written accounting must meet the following requirements: Other than as excepted above, the accounting must include disclosures of PHI that occurred during the six (6) years (or such shorter time period as is specified in the request) prior to the date of the request, including disclosures by or to business associates; The accounting for each disclosure must include: Date of disclosure; Name of entity or person who received the pm, and, if known, the address of such entity or person; A brief description of the pm disclosed; A brief statement of the purpose of the disclosure that reasonably informs the individual of the basis for the disclosure, or in lieu thereof, a copy of the individual's authorization or the request for a disclosure; If, during the time period for the accounting, multiple disclosures have been made to the same entity or person for a single purpose, or pursuant to a single authorization, the accounting may provide the information as set forth above for the first disclosure, and then summarize the frequency, periodicity, or number of disclosures made during the accounting period and the date of the last such disclosure during the accounting period. C. Provision of the Accounting: The individual's request for an accounting must be acted upon no later than sixty (60) days after receipt, as follows: Provide the accounting as requested, or; If unable to provide the accounting within sixty (60) days, the time for response may be extended by no more than thirty (30) additional days, provided that: o Within the first sixty (60) days, the individual is given a written statement of the reasons for the delay and the date by which the accounting will be provided, and; o There are no additional extensions of time for response. The first accounting in any twelve month period must be provided to the individual without charge. A reasonable, cost based fee may be charged for additional accountings within the twelve month period, provided the individual is informed in advance of the fee, and is permitted an opportunity to withdraw or amend the request. D. Documentation Requirements: The entity must document and retain documentation, in written Policy and Procedures Page 43

44 or electronic format, for a period of six years: All information required to be included in an accounting of disclosures of PHI; All written accountings provided to individuals, and; Titles of persons or offices responsible for receiving and processing requests for an accounting from individuals. Policy and Procedures Page 44

45 Administrative Requirements for the Implementation of HIPAA Effective Date: By: Brent Phipps, CEO Purpose: To issue instructions regarding L & P Services, Inc.'s obligations relating to the implementation of the Health Insurance Portability and Accountability Act (HIPAA), 42 V.S.C. 1320d 1329d 8, and regulations promulgated there under, 45 CFR Parts 160,162 and 164. Applicability: This policy applies to all L & P Services, Inc.'s facilities and programs and, as applicable, to all L & P Services, Inc.'s workforce members ("entities"). Definitions: Protected Health Information (PHI) means individually identifiable information relating to past, present or future physical or mental health or condition of an individual, provision of health care to an individual, or the past, present or future payment for health care provided to an individual. Workforce Members means employees, volunteers, trainees, and other persons whose conduct, in the performance of work for the agency is under the direct control of the agency, regardless of whether they are paid by the agency. Business Associate (BA) means a person or entity that, on behalf of the agency but not in the capacity of a workforce member, performs or assists in the performance of, a function or activity involving the use or disclosure of PHI, or provides legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, or financial services involving disclosure of PHI. Privacy Notice means the notice of privacy practices relating to an entity's use and disclosure of PHI that is mandated under HIPAA regulations for distribution to all individuals whose information will be collected by or on behalf of the entity. Policy: A. Personnel Designations: The agency must designate and document designations of the following: Privacy Officer: The Agency must designate an individual to be the Senior Privacy Officer, responsible for the development and implementation of department wide policies and procedures relating to the safeguarding of PHI. The Privacy Officer may designate a Security Officer to assist in the implementation and oversight of technology and other related issues regarding the PHI. Contact Person or Office: The Agency shall designate an individual, position title, or office that will be responsible for receiving complaints that may result from disclosure of PHI under this and related HIPAA policies. B. Training Requirements: The agency must document the following training actions: On or before the effective date of the HIPAA privacy regulations [4/14/03], all agency employees and other workforce members must receive training on applicable policies and procedures relating to PHI as necessary and appropriate for such persons to carry Policy and Procedures Page 45

46 out their functions within the agency. Each new workforce member shall receive the training as described above within a reasonable time after joining the workforce. Each workforce member, whose functions are impacted by a material change in the policies and procedures relating to PHI, or by a change in position or job description, must receive the training as described above within a reasonable time after the change becomes effective. C. Safeguards: The agency must have in place appropriate administrative, technical, and physical safeguards to reasonably safeguard PHI from intentional or unintentional unauthorized use or disclosure. D. Complaint Process: The agency must have in place a process for individuals to make complaints about the entity's HIPAA policies and procedures and/or the entity's compliance with those policies and procedures, and must document all complaints received and the disposition of each complaint. E. Sanctions: The Human Resources administrator for the agency must have in place, must apply and must document application of appropriate sanctions against workforce members who fail to comply with HIPAA policies and procedures. [Note there are exceptions for disclosures made by workforce members who qualify as whistleblowers or certain crime victims.] F. Mitigation Efforts Required: The agency must mitigate, to the extent practicable, any harmful effects of unauthorized uses or disclosures of pm by the entity or any of its business associates. G. Intimidating or Retaliatory Acts and Waiver of Rights Prohibited: Prohibition on Intimidating or Retaliatory Acts: Neither the agency or workforce member shall intimidate, threaten, coerce, discriminate against, or take other retaliatory action against any individual for the exercise of their rights or participation in any process relating to HIPAA compliance, or against any person for filing a complaint with the Secretary of the U.S. Department of Health and Human Services, participating in a HIPAA related investigation, compliance review, proceeding or hearing, or engaging in reasonable opposition to any act or practice that the person in good faith believes to be unlawful under HIPAA regulations as long as the action does not involve disclosure of PHI in violation of the regulations. Prohibition on Waiver of Rights: The agency or workforce member of the agency shall not require individuals to waive any of their rights under HIPAA as a condition of treatment, payment, enrollment in a health plan or eligibility for benefits. H. Policies and Procedures: The agency and, as applicable, its offices, programs and facilities must document the following actions relating to its policies and procedures: Required Policies and Procedures: The agency and, as applicable, each office, program or facility of the agency shall design and implement policies and procedures to assure appropriate safeguarding PHI in its operations. Changes to Policies and Procedures: The agency must change its policies and procedures as necessary and appropriate to conform to changes in law or regulation. The entity also may make changes to policies and procedures at other times as long as the policies and Policy and Procedures Page 46

47 procedures are still in compliance with applicable law. Where necessary, the entity must make correlative changes in its Privacy Notice. The entity may not implement a change in policy or procedure prior to the effective date of the revised Privacy Notice. Documentation Requirements: The agency must maintain the required policies and procedures in written or electronic form, and must maintain written or electronic copies of all communications, actions, activities or designations as are required to be documented hereunder, or otherwise under the HIPAA regulations, for a period of six (6) years from the later of the date of creation or the last effective date. Policy and Procedures Page 47

48 Authorization for Use or Disclosure of Protected Health Information Effective: By: Brent Phipps, CEO Purpose: To issue instructions to all L & P Services, Inc. offices, facilities, programs and workforce members regarding the use and disclosure of protected health information (PHI), and necessary documentation of authority for such use or disclosure, when use/disclosure is for purposes outside of those permitted relating to treatment, payment or health care operations, or under other provisions of law. Applicability: This policy applies to all L & P Services, Inc. offices, facilities, and programs, and all L & P Services, Inc. workforce members ("entities"). Definitions: Protected Health Information (PHI) means individually identifiable information relating to the past, present or future physical or mental health or condition of an individual, provision of health care to an individual, or the past, present or future payment for health care provided to an individual. Treatment, Payment and Operations (TPO) includes all of the following: Treatment means the provision, coordination, or management of health care and related services, consultation between providers relating to an individual, or referral of an individual to another provider for health care. Payment means activities undertaken to obtain or provide reimbursement for health care, including determinations of eligibility or coverage, billing, collection activities, medical necessity determinations and utilization review. Operations includes functions such as quality assessment and improvement activities, reviewing competence or qualifications of health care professionals, conducting or arranging for medical review, legal services and auditing functions, business planning and development, and general business and administrative activities. Personal Representative means a person who has authority under applicable law to make decisions related to health care on behalf of an adult or the parent, guardian, or other person acting in locoparentis who is authorized under law to make health care decisions on behalf of a client, except where the client is authorized by law to consent, on his/her own or via court approval, to a health care service, or where the parent, guardian or person acting in locoparentis has assented to an agreement of confidentiality between the provider and the minor. Policy: A. Generally: In compliance with 45 CFR Part 164 and Ohio law, all uses and disclosures of PHI beyond those otherwise permitted or required by law require a signed authorization according Policy and Procedures Page 48

49 to the provisions of this rule. An authorization is required for each entity that is to receive PHI. The provision of treatment, payment, or eligibility for benefits may not be conditioned on the individual's provision of an authorization for the use or disclosure of PHI except: Relating to the provision of research related treatment; Relating to health care that is solely for the purpose of creating pm for disclosure to a third party. B. Content Requirements: Each authorization for the use or disclosure of an individual's PHI shall be written in plain language and shall include at least the following information: A specific and meaningful description of the information to be used or disclosed; The name or identification of the person or class of person(s) authorized to make the use or disclosure; The name or identification of the person or class of person(s) to whom the requested use or disclosure may be made; An expiration date, condition or event that relates to the individual or the purpose of the use or disclosure; the authorization shall state that it will expire after ninety days unless the individual has opted for a shorter or longer time. An individual may specify a longer period of time for the duration of the authorization only if the person: o Is part of an approved research study and has given authorization for a longer period of time, or; o Is expected to continue receiving services beyond ninety days and has given authorization for a longer period of time which may be up to one hundred and eighty days A statement of the individual's right to revoke the authorization in writing, and exceptions to the right to revoke, together with a description of how the individual may revoke the authorization. Upon written notice of revocation, further use or disclosure of PHI shall cease immediately except to the extent that the office, facility, program or employee has acted in reliance upon the authorization or to the extent that use or disclosure is otherwise permitted or required by law; A statement that the information may only be re released with the written authorization of the individual, except as required by law; The dated signature of the individual, and; If the authorization is signed by a personal representative of the individual, a description of the representative's authority to act on behalf of the individual. C. Requests to Use or Disclose pm for Own Purposes: If the authorization is requested by the ODMH office, facility, program or workforce member for its own use or disclosure of the PHI it maintains, for a purpose outside of TPO, health care oversight or public health activities, the following elements are required in addition to those specified in section B. above: Except in circumstances where it is allowed, a statement that treatment, payment and eligibility for benefits will not be conditioned upon the individual's provision of an authorization. A description of each purpose of the requested use or disclosure; Policy and Procedures Page 49

50 A statement that the individual may inspect or copy the pm to be used or disclosed; A statement that the individual may refuse to sign the authorization; If applicable, a statement that the use or disclosure will result in direct or indirect remuneration from a third party, and; The individual must be provided with a copy of the signed authorization. D. Requests for PHI from Others: If the authorization is requested for disclosures of pm by others, the following elements are required in addition to those specified in section B. above: A description of each purpose of the requested disclosure; Except in circumstances where it is allowed, a statement that treatment, payment and eligibility for benefits will not be conditioned upon the individual's provision of an authorization; A statement that the individual may refuse to sign the authorization; The individual must be provided with a copy of the signed authorization. Generally requires an authorization unless such use or disclosure is permitted pursuant to [cite policy re: research uses/disclosures]. Such authorizations must include the basic elements specified in sections B. and C. above, and also contain: o A description of the extent to which pm will be used to carry out treatment, payment or health care operations; o A description of any pm that will not be used or disclosed for purposes otherwise permitted, provided that the limitation may not preclude disclosures required by law or to avert serious threat to health or safety; The authorization must refer to any privacy notice expected to be given to the individual and must state that the statements in the privacy notice are binding, and; This authorization may be combined in the same document with the consent to participate in research, or the privacy notice. E. Retention: A written or electronic copy of the authorization must be retained for a period of six (6) years from the later of the date of execution or the last effective date. Policy and Procedures Page 50

51 Business Associate Agreements Effective: By: Brent Phipps, CEO Purpose: To issue instructions to all L & P Services, Inc.'s facilities, programs and workforce members regarding the necessity for and the required content of agreements with business associates (including in some cases other governmental entities) relating to the business associate's receipt of protected health information (PHI) from or on behalf of L & P Services, Inc.'s offices, facilities, programs or workforce members. Applicability: This policy applies to all L & P Services, Inc.'s offices, facilities, programs and workforce members ("entities"). Definitions: Business Associate (BA) means a person or entity who, on behalf of L & P Services, Inc., and other than in the capacity of a workforce member: performs or assists in the performance of a function or activity that involves the use or disclosure of protected health information (PHI), or; provides legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, or financial services. Protected Health Information (PHI) means individually identifiable information relating to the past, present or future physical or mental health or condition of an individual, provision of health care to an individual, or the past, present or future payment for health care provided to an individual. Policy: A. Generally: The entity may disclose PHI to a BA, or allow a BA to create or receive PHI on the entity's behalf, if the entity first obtains adequate assurance that the BA will appropriately safeguard the PHI. This requirement does not apply with respect to: disclosures made to a provider concerning the individual's treatment, or; uses or disclosures made to another governmental agency for purposes of public benefit eligibility or enrollment determinations where such agency is authorized by law to make these determinations. The entity must document these assurances through a written agreement or as follows. If the BA is another governmental entity, the entity may comply with this requirement by executing a Memorandum of Understanding or like document covering the required terms or, by relying on other law that imposes upon the BA the requirements specified herein. If the BA is required by law to perform a function, activity or service on behalf of the entity, the entity may disclose PHI to the extent necessary to comply with that mandate as long as the entity documents an attempt to obtain the required assurances and the reasons that such assurances could not be obtained. B. Content Requirements: The agreement between the entity and the BA must meet the following Policy and Procedures Page 51

52 requirements, as applicable: Establish permitted and required uses or disclosures of PHI that are consistent with those authorized for the entity, except that the agreement may permit the BA to use or disclose pm for its own management and administration if such use or disclosure is required by law or the BA obtains reasonable assurance that the confidentiality of the PHI will be maintained Provide that the BA will: Not use or disclose the PHI except as authorized under the agreement or required by law Use safeguards to prevent unauthorized use or disclosure. Report unauthorized uses or disclosures to the entity Pass on the same obligations relating to protection of PHI to any subcontractors or agents Make PHI available for access by the individual or his/her personal representative, in accordance with relevant law and policy Make PHI available for amendment, and incorporate any approved amendments to PHI, in accordance with relevant law and policy Make information available for the provision of an accounting of uses and disclosures in accordance with relevant law and policy Make its internal practices, books and records relating to its receipt or creation of PHI available to the Office of the U.S. Secretary of Health and Human Services for purposes of determining the entity's compliance with HIPAA regulations If feasible, return or destroy all PHI upon termination of contract; if any PHI is retained, continue to extend the full protections specified herein as long as the PHI is maintained Authorize termination of the agreement by the entity upon a material breach by the BA; this element of the agreement may be omitted if the BA is another governmental entity and the termination would be inconsistent with the statutory obligations of the entity or the BA C. Oversight Responsibilities: If the entity knows of a pattern or practice of the BA that amounts to a material violation of the agreement, the entity must attempt to cure the breach or end the violation, and if such attempt is unsuccessful, terminate the agreement, if feasible, and, if not, report the problem to the Office of U.S. Secretary of Health and Human Services. Policy and Procedures Page 52

53 Workforce Confidentiality Agreement I, understand that L & P Services, Inc. has a legal and ethical responsibility to maintain client and organizational privacy. As a condition of my employment/engagement/affiliation with L & P Services, Inc., I understand that I must sign and comply with this Agreement. Types of Confidential Information I understand that during the course of my employment/engagement/affiliation with L & P Services, Inc., I will utilize, see and hear confidential client information. I understand that I need this information to perform my functions for L & P Services, Inc. I understand that during the course of my employment/engagement/affiliation with L & P Services, Inc., I may see or hear other confidential information such as financial or operational information pertaining to this organization that I am obligated to keep confidential. I understand that any client information or organizational information that I access or view at work does not belong to me. My Agreement By signing this document, I understand and agree that: I will not disclose client information and/or confidential organizational information unless such disclosure is in compliance with the Provider's privacy policies and procedures and is required for the performance of my job. I will not access or view any client or organizational information other than is required to do my job. If I have any question about whether access to certain information is required for me to do my job, I will ask my supervisor or the Privacy Officer for clarification. I will not make inquiries about any Provider information for any individual or person or entity that does not have proper authority to have such information. If I have any question about whether certain persons or entities are permitted access to certain Provider information, I will ask my supervisor or the Privacy Officer for clarification. I will not discuss any information pertaining to the organization in an area where unauthorized individuals may hear such information (for example, in hallways, on staircases, on elevators, in the cafeteria, on public transportation, at restaurants or at social events). I understand that it is never acceptable to discuss any Provider information in public areas, even if specific information, such as client's names, is not used. I will not make any unauthorized transmissions, copies, disclosures, inquiries, modifications, or expungements of client information or Provider information. I will keep my personal access codes, user ID's, access keys and passwords used to access computer systems, buildings, records or other organizational systems or equipment confidential at all times. I will immediately return all property belonging to the organization at the conclusion of my employment/engagement/affiliation with L & P Services, Inc. This includes keys, documents, identification badges, pass cards, etc. Consequences for Violating this Agreement I understand that violation of this agreement may result in disciplinary action up to and including termination of my employment/engagement/affiliation with L & P Services, Inc. and/or suspension, restriction or loss of privileges in accordance with L & P Services, Inc. policies as well as potential Policy and Procedures Page 53

54 personal, civil and criminal penalties. Maintaining the Agreement I agree that my obligations under this Agreement regarding client information and organizational information will continue after the conclusion of my employment/engagement/affiliation with L & P Services, Inc. I have read the above Agreement and agree to comply with all its terms as a condition of my continuing employment/engagement/affiliation with L & P Services, Inc. WORKFORCE MEMBER Signature Date: Printed Name: Created 9/16/05 Policy and Procedures Page 54

55 Records of Disclosure Authorized by Law On information about (Date) was disclosed to (Client) for (Name of Person/Organization) as required (Purpose) By. (Law) The Following information was disclosed: Authorized Signature and Date Policy and Procedures Page 55

56 Collateral Information Policy Effective: 7/1/11 By: Brent Phipps Revised: Purpose: To issue a policy regarding receiving collateral information from friends, family, and other collateral contacts when a release of information may not be present. Policy: It is the policy of L & P Services, Inc. to not disclose information, including affirmation or denial, of a person being a client of L & P Services without a signed release by the client, notwithstanding Ohio and Federal Law regarding continuity of treatment or payment exceptions and ensuring drug and alcohol confidentiality regulations pertaining to CFR 42. Procedure: We may elect to receive information from a collateral source offering the information pertaining to an open, closed, or non client case. If it is by phone the front desk staff, or their designee, will take down the information and forward it to a supervisor. If the information received by the will be printed and forwarded to a supervisor. The sender of the will be notified of this policy and that is not an appropriate method of contact to our agency and that subsequent s may or may not be read or reviewed. All people leaving collateral information should be informed that the information provided will become part of the client record and accessible by the client upon request or the treatment provider (s) working with such a client may elect to go over the information and disclose the name and identity of the provider of information as well as the information its self at any time. Depending on the individual circumstances of each case L & P Services, Inc. may elect to not receive collateral information from a source until the client has had the opportunity to sign an authorization that allows L & P Services, Inc. to receive information from a particular entity or individual. Policy and Procedures Page 56

57 Section C: Records Control Policy & Procedures Table of Contents Records Control Listing of Components of Clinical Records Policy and Procedures Page 57

58 Records Control Effective Date: 9/16/06 By: Brent Phipps, CEO Revised: 3/4/2009 Purpose: To assure confidential, legal and efficient control of client records. Policy: It shall be this agency's policy to maintain control of all client records in compliance with ODMH Rule and to ensure accountability, safety, and security of client records. Procedures: Storage: Each service site will maintain ICR's in locked filing cabinets, in a secure area. The cabinet may be unlocked when the record secretary or their designee is present; at all other times it will remain locked. Inactive records from all programs and sites will be stored at the Colegate Drive or our off sight storage location. Only authorized persons shall be admitted to the area that is used to maintain ICR's at any of the agency sites. Any client record saved on portable electronic storage devises will be stored in a locked drawer until hard copies are produced. At which time client data will be deleted from floppy disks. Indexing: Each record shall be maintained and indexed alphabetically by the client's last name and, secondly, first name. Each client will also be assigned a client case number which may be utilized to enhance confidentiality as well as ensure identification around such issues as multiple admission, service at differing sites, etc. Internal indexing of the ICR's is contained in the agency's policy entitled: "Organization of Clinical Records". Report Deadlines: 1. The Individualized Service Plans must be completed and in client ICR's within 30 days of admission or within the first five sessions for mental health clients and within 7 days of admission for AOD clients. 2. Individualized service plan updates must be completed and in client ICR's upon change in condition, addition of services, or client request. 3. All therapy and other progress notes must be completed and turned into billing within 24 hours of the services provided. Filing should be completed within 72 hours of service. 4. All reports received from outside sources must be in ICR's within eight hours. Access: Employees of the agency, who work directly with a client in some capacity, supervise an employee who does, or carry responsibility to monitor, review or otherwise contribute to that ICR within the guidelines of the agency are granted access to specific records. When removing a record from the file they will complete the out guide, which remains at the file's vacant place as a record of its whereabouts. It is the responsibility of any employee accessing an ICR to return it entirely intact and in Policy and Procedures Page 58

59 proper order. Under normal conditions, a record is not to be removed from the facility where it is housed. Exceptions may include the ICR's relocation due to changed status, or other legitimate external requirements including reviews by licensing bodies, valid legal demands, etc. ICR's are not to be removed for casual reasons from a facility and when removed it becomes the exclusive responsibility of the barer to: 1. Establish that this removal is legitimate. 2. Protect the ICR and its contents against any unwarranted disclosure and to return the record as soon as possible to its proper place. 3. Transport the record in a closed secure file folder to the facility. 4. If the record is to be left in the car at any time unattended, it will be placed in the locked trunk compartment of the car. 5. The record will be signed for by either the site facility's program manager or their designee that the file has arrived at that site. If being transported to an auditing entity, i.e., Washington County Behavioral Health Board, then their representative will sign that they have received the file. This record of transfer and signatures will be kept in the file cabinet where the record is normally stored and will become part of the closed file when the case is terminated. If a client or ex client requests access to their clinical records, the request shall be submitted in writing to the CEO. The Clinical Supervisor shall schedule an appointment to review that file with the client within ten (10) working days of the CEO s approval. The client may review their file in the presence of the Clinical Supervisor only. Prior to the scheduled appointment for review, the Supervisor shall review the file and remove any parts that may be detrimental to the client's emotional well being. This action must be documented in the progress notes and items removed must be identified and the reasons for the removal must be indicated. A note must also be dated and signed in full by the Clinical Supervisor. At the scheduled review, the client may read the file and/or request a written summary in the presence of the Clinical Supervisor. An accounting of disclosures may be made to the client per Federal Law (see HIPAA Policies and Procedures). The client may not remove any part of the record but may request copies subject to Clinical Director review. (See HIPAA Policies and Procedures regarding access to records by client. Following the review, the client must sign a Record Review Form (addendum #13) indicating the date of the review and the purpose for reviewing. The Clinical Supervisor shall also sign the review form and verify that the review was conducted in their presence. The above policy and procedure is subject to any changes in Federal and State laws governing client's rights and confidentiality, and client access must always coincide with these regulations. Access to records by other entities should be conducted with strict adherence to the agency's Authorization to Release policy. Policy and Procedures Page 59

60 Reopening Case Files If a client has been discharged for less than six months, their files are reopened by: 1. Documenting the reason and/or purpose of reopening the file at this time. 2. Counselor assessment of information from previous case, which may be summarized as supportive information for the new case file. Files terminated longer than six (6) months shall remain closed and new files reopened, however, utilizing the same client number. The counselor shall be responsible for thorough and complete data collection and the administration of a new assessment if necessary. Disposal of ICR's will be maintained by this agency for seven years after the client's attainment of age of majority and then destroyed by shredding. Periodic review by the Chart Management Coordinator will determine which records are eligible for disposal. The CEO is the agency's designated administrator of the clinical records systems and Chart Management Coordinator. Disposal of Records Client records are maintained for a minimum of 7 years after the case is closed. Records after that time are destroyed by shredding by the Chart Coordinator. Any issuance of a court order or subpoena will suspend shredding of that client record eligible for disposal until the subpoena or court order is resolved. Terminated clinical records information must be retained for at least seven years from the official date of termination, for an adult client, age 18 years and older. Terminated clinical records information of a client less than 18 years of age, at the time of termination must be retained until age 25 years is reached or seven years past the age of majority, regardless of termination date. Annually, the Clinical Records Manager oversees the preparation of terminated clinical records, meeting the above requirements, by reviewing the registry identifying the names correlated with the destruction year. Records are pulled from the shelves in the Archive Room, the termination date and birth date double checked and prepared for destruction. Upon completion of pulling the records, the names are listed for destruction, and a final registry is compiled by Clinical Records Manager to submit to Chief Compliance Officer for final authorization for destruction. Records are destroyed off site, following written approval of the President and Chief Compliance Officer. The original Register of Destroyed Records, completed annually, is maintained by the Clinical Records Manager. Policy and Procedures Page 60

61 Listing of Components of Clinical Records Effective: By: Brent Phipps, CEO Purpose: To standardize the format for compiling the information contained in the clinical records. Policy: It shall be this agency's policy to maintain each clinical record in a consistent and orderly format in order to facilitate the retrieval of information contained therein and to assure that all components required in ODMH Regulations are included and ODADAS regulations 3793: Access to client records is limited to staff on a need to know basis and no staff shall access client records if it is not necessary for the treatment and/or financial issues related to client care. Procedures: Each clinical record shall have indexed sections identifying the information contained in that section. The following components will be included in each client record: 1. Client Identification and Social Demographic Information (intake) 2. A description of the client's presenting problem and circumstances leading to admission. (intake) 3. History relevant to treatment. (dx assessment) 4. A description of any problem observed or reported in cognitive affective or behavioral functioning upon the admission. (intake) 5. A drug use History including any non drug allergies or sensitivities. (dx assessment) 6. Reports of any psychological and/or psychiatric evaluations, consultation, referrals and any other information relevant to the client's treatment 7. A diagnostic impression (within 15 days of admission) 8. An Individualized Service Plan (within 7 days of admission for AOD clients and within 30 days of admission for MH clients) 9. Progress notes (24 hours) 10. Documentation of client transfer or movement within the system. 11. A medication record if the client receives medication as part of treatment 12. A periodic review summary. 13. A signed authorization for each specific request for release of information. 14. A closing summary (30 days after last visit) Each form, report or entry in the ICR shall contain the following information: 1. The clients full name or case number 2. Appropriate signatures and dates Policy and Procedures Page 61

62 3. The date, time and person receiving any calls regarding the client and the name of the caller, if given. All clinical records remain strictly confidential and program staff shall not convey to a person outside the program that a client attends or receives services from the program or disclose any information identifying a client as an alcohol or other drug services client unless the client consents in writing for the release of information, the disclosure is allowed by a court order, or the disclosure is made to a qualified personnel for a medical emergency, research, audit, or program evaluation purposes. Federal laws and regulations do not protect any threat to commit a crime, any information about a crime committed by a client either at the program or against any person who works for the program. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or local authorities. Clients may review their own records after requesting review of their clinical record in writing to the Clinical Supervisor who will review the record to determine if anything contained in the record may be harmful to the client. Staff will have access to charts that have been assigned to them and will use the client sign out log when taking a chart from the file cabinet. Individuals other than clients or staff may have access to records if there is a signed and completed authorization to release information form complete, there is a valid court order, or if the record is part of the covered services mandated under the Ohio Revised Code for either the Ohio Department of Mental Health or the Ohio Department of Alcohol Services. All records are stored in a locked file cabinet in an office which is locked. The records are kept in a safe and secure location on the agency premises according to 42 CFR. The agency shall maintain documentation for services provided. All documentation, except for case management services and non treatment services, such as client returning to program after attending alcoholics anonymous meeting, etc., completed by registered candidates, chemical dependency counselor assistants and student interns shall be counter signed by an individual qualified to be an alcohol and drug treatment services supervisor pursuant to rule 3793: of the Administrative Code. Destruction of client records to include the requirement that records be maintained for at least seven years after clients have been discharged from the program. Client records shall be destroyed to maintain client confidentiality as required by state and federal law. Policy and Procedures Page 62

63 Section D: Ethics Policy & Procedures Table of Contents Code of Ethics Drug Theft Research Policy and Procedures Page 63

64 Code of Ethics Effective: 9/16/06 By: Brent Phipps, CEO Accountability: Chief Executive Officer; Clinical Supervisor Purpose: To establish guidelines for employees and the agency that assures adherence to a Code of Ethics that will guide staff and the agency to fulfill their obligations in an ethical manner. Policy: L & P Services, Inc. is dedicated to the individual employee and the organization to adhere to sound ethical practices in all aspects of administration, business, marketing, direct service delivery, and fiscal management. It is the policy of L & P Services, Inc. that procedures be in place for reporting any unethical behaviors, including but not limited to, waste, fraud, abuse, and other questionable activities, with no reprisals against staff which may so report. Such reports will be communicated to the CEO or his designee (Chief Compliance Officer) and a timely response and action will be taken regarding such reports with the consent and involvement of the President. Code of Ethics L & P Services, Inc. Employees I, as an employee of L & P Services, Inc., affirm that: 1. I will not discriminate against or refuse professional services to anyone on the basis of race, color, creed, age, sex, religion, nationality, or sexual orientation. 2. I will not use my professional relationship to further my own interests. 3. I will evidence a genuine interest in all persons served and do hereby dedicate myself to their best interests and helping them help themselves. 4. I will respect the privacy of persons served and hold in confidence all information obtained in the course of professional service. 5. I will maintain confidentiality when storing or disposing of client records. 6. I will maintain a professional attitude which upholds confidentiality toward individuals served, colleagues, applicants and the L & P Services, Inc. 7. I, upon termination, will maintain client and co worker confidentiality, and I will hold as confidential any information I obtained concerning the L & P Services, Inc. 8. I will respect the rights and views of my colleagues, and treat them with fairness, courtesy, and good faith. 9. I will not exploit the trust of the public or my co workers. I will make every effort to avoid relationships that could impair my professional judgment and or be considered a conflict of interest. 10. I will not engage in or condone any form of harassment or discrimination. 11. I will not permit fellow employees to present themselves as competent or perform services beyond their training and/or level of experience. Policy and Procedures Page 64

65 12. I will respect the confidences of my co workers. 13. When I replace a colleague or am replaced I will act with consideration for the interest, character, and reputation of the other professional. 14. I will extend respect and cooperation to colleagues of all professions. 15. I will not assume professional responsibility for the clients of a colleague without appropriate consultation with that colleague. 16. If I see that the client of a colleague during a temporary absence or emergency, I will serve that client with the same consideration afforded any client. 17. If I have the responsibility for employing and evaluating staff performance I will do so in a responsible, fair, considerate, and equitable manner. 18. If I know that a colleague has violated ethical standards I will bring this to my colleagues attention. If this fails I will report the activity to my supervisor. 19. I will accurately represent my education, training, experience, and competencies as they relate to my profession. 20. I will correct, when possible, misleading or inaccurate information and representations made by others concerning my qualifications or services. 21. If serving as a supervisor I will make certain that the qualifications of persons I supervise are honestly represented. 22. I will abide by L & P Services, Inc.'s policies related to public statements. 23. I have total commitment to provide the highest quality of service to those who seek my professional assistance. 24. I will continually assess my personal strengths, limitations, biases, and effectiveness. 25. I will strive to become and remain proficient in professional practice and the performance of professional functions. 26. I will act in accordance with standards of professional integrity. 27. I will not advise on problems outside the bounds of my competence. 28. I will seek assistance for any problem that impairs my performance. 29. I understand that violation of this code may be grounds for dismissal. Organization The L & P Services, Inc. will adhere to the following Code of Ethics: 1. Will not represent to the public or referring sources services that are not or cannot be provided. 2. Will handle employees in a fair and consistent manner. 3. Will use accepted and standard practices of the accrual accounting method in reporting and maintaining fiscal records and budgets. 4. Will not use deceptive practices in marketing its services. 5. Will use the guiding principle of "Doing unto others as you would have them do unto you" in conducting its business and marketing strategies. Procedures: All employees will review at least annually the Policy regarding Code of Ethics and documentation of such review will be kept. Violations of the Code of Ethics will be reported to a Supervisor, the CEO, or Policy and Procedures Page 65

66 the Chief Compliance Officer. There will be no reprisals to any employee for such reporting. A timely investigation of such complaints will be made by the CEO or his designee (s). Sanctions may include dismissal for any employee violating either the Employee or Organization Code of Ethics and such sanctions if any will be the responsibility of the CEO. Policy and Procedures Page 66

67 Drug Theft Effective: By: Brent Phipps, CEO Revised: Purpose: The purpose of this policy is to outline the requirements of employees in the event of drug theft within the agency. Policy: It shall be the policy of this agency to respond to any suspected drug theft within the agency in accordance with ODMH Administrative Rule Procedures: Any employee or volunteer with knowledge of drug theft by an employee or any other person shall report such information to the President of the agency. If the President of the agency is suspected of drug theft, the employee or volunteer shall notify the Ohio Department of Mental Health. Any suspected drug theft shall also be reported to the Ohio Board of Pharmacy. For controlled substances, suspected drug theft shall also be reported to the Federal Drug Enforcement Administration. L & P Services, Inc. shall take all reasonable steps to protect the confidentiality of the information and the identity of the employee or person furnishing any information about suspected drug theft. Failure of any employee to report information of drug theft shall be considered and determine the eligibility of the employee to continue to work in a secure area where drugs are stored. If an employee violates this agency's drug theft policy, we will assess the seriousness of the employee s violation, whether the violation has a direct and substantial relationship to that employee's position, the past record of employment, and other relevant factors in determining whether to suspend, transfer, terminate or take other legal actions against the employee. Policy and Procedures Page 67

68 Research Effective: By: Brent Phipps, CEO Purpose: To establish guidelines for and procedures for research within L & P Services, Inc. Policy: It is the policy of L & P Services, Inc. that research is not done with consumers or any identifiable consumer data. Aggregate anonymous data from the Ohio Department of Mental Health or anonymous inputs may be used to help enhance the performance of L & P Services, Inc. but are not used for research purposes. Policy and Procedures Page 68

69 Section E: Client Treatment Policy & Procedures Table of Contents Authorization to Release Information Consent for Treatment Diagnostic Assessment Diagnostic Assessment Service Individualized Service Plan and Progress Notes Medication/Somatic Algorithms Medication/Somatic Pharmacotherapy Handling Storage, and Dispensing of Medication Counseling and Psychotherapy Service Community Support Program Service Client Transfer Client No Show/Cancellations Agency Termination of Services Discharge of Clients Policy and Procedure regarding Self Harm Crisis Intervention Intensive Home Based Treatment Services Abuse and Neglect Urinalysis Policy and Procedures Page 69

70 Authorization to Release Information Effective: By: Brent Phipps, CEO Revised: Purpose: To establish guidelines governing the release or receipt of information concerning a specific client. Policy: It shall be the policy of the Agency, when necessary, for the Clinical Director (or designee) to have the ability to release information concerning a particular client to another individual, agency, or institution, or to receive information from another individual, agency, or institution, that the Clinical Director (or designee) shall request that the client authorize disclosure by signing an Authorization to Release Information form. All disclosures to or from other agencies will be done in accordance with Federal and State regulations governing client confidentiality. Procedures: The Clinical Director (or designee) will complete a separate Authorization to Release Information form for each individual, agency or institution that information is being released to or requested from. Specific information that is being released or requested must be noted on the Authorization form. An Authorization to Release Information form must contain the following: 1. The client's full name 2. The full name and title of the individual or agency 3. The date of signature 4. The client's signature or legal custodian 5. The witnesses signature 6. A Revocation of Consent statement (Addendum #14) 7. A date of expiration 8. Type and amount of information to be released 9. Purpose of the release Each authorization for Mental Health records, automatically expires exactly 180 days from the date of signature. Alcohol and other drug authorizations may be conditioned on events such as discharge. At the time a client, or legal custodian, signs an Authorization to Release Information form, the Clinical Director (or designee) shall inform the client that they have the right to revoke the authorization at any time they desire to do so by informing in writing of such intent. The original signed Authorization to Release Information is kept in the client's I.C.R. A copy of the original is given or provided to the individual, agency or institution receiving or releasing the information. At the time a client chooses to revoke the consent, a copy of the Revocation of Consent is mailed to the individual; agency or institution the Authorization was intended for. This may be in the Policy and Procedures Page 70

71 format of an official document provided by the Agency or any handwritten note that is provided by the client or legal custodian. Each disclosure made with the client s written consent must be consistent with 42 C. F. R. part 2 by including the following written statement: This information has been disclosed to you from records protected by federal confidentiality rules. The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C. F. R. part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of information to criminally investigate or prosecute any alcohol or drug abuse client. Policy and Procedures Page 71

72 Consent for Treatment Effective: 09/16/06 By: Brent Phipps, CEO Purpose: To ensure that all clients and their legal guardians are given the opportunity to make an informed consent or alternatively, to refuse any specific treatments being offered by L & P Services prior to the services initiation. Policy: The agency will verbally advise client and their guardians of the risks and benefits of each prescribed treatment, of alternative treatment and also of no treatment. Descriptions for clients will be age appropriate. For minors over the age of fourteen requesting treatments without the consent of a guardian, mental health services, except for medication, will be provided for a limited time, consistent with section of the revised code. In the event informed consent is denied, or withdrawn, by a minor or guardian, efforts will be made collaboratively to serve the identified needs in alternative ways, the implications and potential consequence of refusing a prescribe treatment will be discussed. Appropriate documentation will be completed as detailed below under procedure. Procedures: At intake, for the initial L & P Services evaluation, the client and their guardian will be given an explanation of the purpose of the evaluation and will at that time be asked to sign the Consent for Treatment Form (attached) if they agree to receive such service. The evaluator as well as the right to refuse treatment, the benefit of no treatment and the possible alternatives to this initial service will clarify the benefits and risks of this initial service. Where consent is granted a signed and witnessed consent form will be entered into the client's ICR. As a result of the evaluation, further L & P Services may be recommended including case management, outpatient therapies, home based services, partial hospitalization, hospitalization, or residential treatment. At the time a client/guardian comes to an initial appointment for any such treatment services, the person responsible for this service, or intake into the particular program, will inform the client and guardian of the benefits and risks of this service as well as the right to refuse treatment, the benefit of no treatment and the possible alternatives to this initial service. Where consent is granted the provider will have the guardian (or in cases relevant to section of the revised code, the client), initial the appropriate program service box on the consent to treatment form. The provider will date the signature and initial as a witness. The form will be returned to the client's ICR. For Med/Somatic services, when initiation or changes in medication is prescribed, the prescribing physician will give written and oral information regarding benefits and risks of this prescription and also answer questions, and inform them of the right to refuse treatment, the risk of no treatment and the possible alternatives to this medication. Agreement by the guardian will be provided on a specialized Policy and Procedures Page 72

73 case note, signed by the physician. (See addendum item 2). These notes will be maintained in the client's ICR under Psychiatric Treatment. In the event that, after having been given the above information, a person refuses any treatment, or should at any time request to withdraw a prior consent to services, the L & P Services staff so advised will: 1. Reaffirm the person's right to refuse treatment. 2. Explore with the client and guardian, collaboratively, alternative approaches which might meet that specific need for service. 3. Clarify to the client/guardian the implication and potential consequences for refusing or withdrawing from this treatment. 4. Document 1 3 as well as the final decision on the matter on a therapy case note, which will be entered into the ICR in the progress note section. Policy and Procedures Page 73

74 Diagnostic Assessment Effective: 09/16/06 By: Brent Phipps, CEO Purpose: To assure that all diagnostic assessments are in compliance with Ohio Department of Mental Health Administrative Code and ODADAS Administrative Code 3793: Policy: Diagnostic assessments will be performed exclusively by agency personnel qualified to provide such services according to rule of the Administrative Code and ADADAS Administrative Code 3793: Whenever, according to rule of the Administrative Code and ODADAS Administrative Code 3793:2 1 08, a person performing an assessment required supervisory consult to render a conclusive diagnosis relative to the DSMIV (or subsequent versions) such diagnosis will be ultimately established in face to face consultation with an agency supervisor of appropriate credentials and not without their signed consensus. Prior to an initial diagnostic assessment the client and guardian will be informed, verbally and in writing, of their rights as persons seeking services at this agency, the availability of a client's rights officer and the procedure for initiating and pursuing a grievance relative to their treatment at this schedule for this and subsequent services will be done on a face to face basis. Referrals will be made when appropriate, to other agencies and providers only with the knowledge and consent of the client and/or their legal guardians. In cases where the primary language of the client is other than English or a hearing impairment or other communication disorder exists the diagnostic assessment will only be performed by a person capable of competent communication with that client. In cases where no such resources exit within the agency, an external referral to meet these needs will be offered. Procedures: Employee job descriptions, orientation, clinical supervision and administrative record oversight will clearly designate and reinforce proper qualification to provide specific services and assure that these guidelines are followed. These shall include, but not be limited to, the requirements of rule of the administrative code and ODADAS Administrative Code 3793: Likewise other procedure insuring that all the agencies policies regarding diagnostic assessment be followed will be maintained in areas of protocol, employee orientation, direct supervision and administrative record review. These procedures will insure that diagnostic assessment be a face to face service only, that fees be clearly discussed on initial intake prior to any assessment and that the information concerning client rights, designated in the above policy, be clearly and completely disseminated to the appropriate party(s) prior to the beginning of any first assessment. The agency contacts local colleges to obtain services of multi lingual staff and specialists for the hearing impaired. Where it is not possible to obtain such services the designated procedure is for our staff to explore and Policy and Procedures Page 74

75 determine the availability of viable service options and present these to the client. Policy and Procedures Page 75

76 Diagnostic Assessment Service Effective Date: 09/16/06 By: Brent Phipps, CEO Purpose: To outline the requirements of a completed diagnostic assessment. Policy: It shall be the policy of L & P Services, Inc., to assure each diagnostic assessment includes all the components as required in ODMH Regulation Procedures: Each diagnostic assessment service shall be: 1. Provided on a face to face basis; 2. Provided by staff who are qualified according to Chapter of the ODMH Administrative Code; 3. Sensitive and responsive to needs of persons from varied ethnic and cultural backgrounds and persons with disabling conditions; 4. Sensitive and responsive to factors of the persons social and physical environment that may effect the persons functioning and mental health; 5. Conducted for clients with appropriate and timely collateral contact with guardian and/or other agency's providing services or individuals providing services to that person. 6. The agency may use a diagnostic assessment from an outside agency to determine diagnosis and treatment if the assessment: a. Has been completed by an eligible provider and has been signed off by an eligible supervisor if needed b. Has been completed within the past 6 months c. L & P Services, Inc. assessment update is completed prior to the delivery of services by L & P Services, Inc. The outside agency diagnostic assessment in combination with the L & P Services, Inc. diagnostic assessment update must include all elements necessary (including self health assessments) under both ODMH standard and CARF standards regarding assessment. Identification and socio demographic information shall be collected and shall include: 1. Full name (First, Middle or Maiden and Last); 2. Home address and telephone number; 3. County of Residence; 4. Name and telephone number of individual to notify in case of an emergency; 5. Name of third party payer(s), if any, or name of individual or entity responsible for payment; 6. Source of referral; 7. Name of primary physician or other primary health provider; Policy and Procedures Page 76

77 8. Name of employer and/or school; 9. Current occupation; 10. Major source of income if other than employer; 11. Date of admission; 12. Date of birth; 13. Sex; 14. Race or Ethnic group; 15. Marital Status, or parent or guardian when appropriate; 16. Highest level of education; 17. Household composition; 18. Family or significant other(s) and their importance in maintaining support for the person served; 19. Military service history and current veteran status; 20. Name and business address of case manager, if applicable; 21. Legal status. Assessment information, as appropriate, shall include the following: 1. A statement by the person seeking services about service needs and preferences; 2. Aspects of the person's social history, as applicable, that may affect treatment, including: a. Family background and relationships with significant others, including collateral family information, as appropriate; b. Employment and/or school history including current employer and job employer, usual occupation, previous jobs held, occupational training, job skills and employment interests; c. Community involvement interests and supports; d. History of involvement with the legal system, including domestic relations such as custody and protective services; e. Military service history, or military status of parent or guardian, when appropriate; f. Role of religious practices in the person's life; g. Description of current living arrangements that include each individual who lives in the home of the person being served and their relationship to the person being served, means of financial support, leisure activities; h. Ethnic and Cultural influences; i. Developmental history, when applicable, including developmental milestones and history of mother's pregnancy. 3. A description of the person's cognitive and behavioral functioning at the time of admission, including mental status examination if appropriate; 4. A description of the strengths and capabilities of the person being assessed; 5. Other considerations regarding the person, that include, as appropriate: need for diagnostic exams, i.e. psychiatric, psychological, neurological, educational, vocational, visual, auditory, etc., needs related to conditions such as hearing impairment or sensory impairment, including documentation regarding the preferred method of communication, i.e., sign language, lip Policy and Procedures Page 77

78 reading, paper and pencil, Braille etc., 6. Health history information, for the purpose of identifying any physical disorder or condition that is potentially relevant to the management of services provided or understanding of the person served, that includes: a. History of present physical symptoms or illness, including current medication; b. Past Medical History, including past medication; c. Health behaviors such as smoking, exercise, diet and sexual functioning; d. History of physical or sexual abuse including incest; e. Physical or developmental disabilities; f. History of abuse of prescription, over the counter, or illicit drugs, or alcohol; g. History of past and current pregnancy (ies); h. Pertinent family health history. 7. A summary of assessment information that includes, a diagnostic impression, or "DSM III R" Diagnosis or other appropriate diagnostic classification and the names, signatures and credentials of those individuals who have conducted the assessment. The agency shall have policies and procedures regarding the physical health assessment of persons served, including, but not limited to the following requirements: 1. For persons served who are 65 years of age or older, under 18 years of age when identified as the primary client, homeless, or have a severe mental disability, and who have received services beyond three sessions or thirty days, the agency shall obtain physical health assessment information for the purpose of identifying any physical disorder or condition that is potentially relevant to the management of services provided or understanding of the person served. For other persons served, obtaining health history information according to number 6 listed above of this Rule may suffice if appropriate to the needs of the person served. Physical health assessment information shall be obtained through one of the following methods: a. Obtaining documentation of health status from the person's physical or health care provider, or referral to a health care provider and obtaining documentation of health status; b. Conducting an assessment according to the requirements of number 3 following in these requirements of this rule. Such an assessment shall be conducted by a Registered Nurse or a Physician, or may be obtained through use of a self report evaluation tool such as a paper and pencil health status inventory. Any self report evaluation tool shall be designed in consultation with, and approved by, a Registered Nurse or a Physician. If a self report evaluation tool is used in place of documentation of health status from the person's physician or health provider, or a health assessment conducted by a Registered Nurse or a Physician, the self evaluation information shall be reviewed by a Registered Nurse or a Physician. 2. A determination shall be made whether or not a recommendation for a Physician examination or further physical health assessment is indicated through review of the health assessment Policy and Procedures Page 78

79 information. 3. The content and process of a physical health assessment conducted by the agency shall: a. Be appropriate to the needs of persons served, and include assistance from staff if necessary; b. Consider factors such as a person's age, physical abilities, functional abilities, communication patterns race or ethnic origin and cognitive and intellectual capabilities; c. Address the following content areas: i. History of present physical symptoms or illness, including current medication. ii. Past medical history, including past medication. iii. Health behaviors such as smoking, exercise, diet and sexual functioning. iv. History of physical or sexual abuse including incest. v. Physical or developmental disabilities. vi. History of abuse of prescription, over the counter, illicit drugs or alcohol. vii. History of past and current pregnancy (ies). viii. Pertinent Family health history. ix. A review of major body systems. d. Contain a diagnostic impression and/or recommendation; e. Contain the signature of the staff person conducting and/or reviewing the physical health assessment information. 4. The physical health assessment information and any laboratory and referral reports shall be kept in the ICR. If a person served refuses to provide or consent to have the agency obtain assessment information such refusal shall be documented in the ICR. Instances of inability to obtain physical health assessment information or recommended health, medical and/or laboratory services shall be reviewed as part of the agency quality assurance plan. 5. The agency shall make appropriate efforts to locate health services and resources outside the agency for persons requiring health services, which have been recommended. This may include providing assistance to the person served making an appointment for services, and obtaining the resources needed to services. Agencies shall make appropriate efforts to build interagency linkages that improve access to health and medical services for persons served. 6. The agency shall ensure that the I.S.P. reflects the presence of health conditions, if any, and that periodic review of the I.S.P. includes efforts to obtain the recommended health services or medical attention. 7. When a person is referred for health services, a release of information shall be obtained to allow information to be exchanged with the health provider accepting the referral. Refusal to sign a release of information shall be documented in the ICR. 8. The agency shall communicate the relevant findings of physical health assessment information to the person's case manager, if applicable, and work with the case manager to ensure that health and medical recommendations are implemented. 9. The agency shall make appropriate efforts to assist the person to obtain a physician examination: a. When services to a person include prescription medications, b. If the person complains of or shows signs of physical abuse or neglect, Policy and Procedures Page 79

80 c. If the person complains of or if review of the physical health assessment indicated signs or symptoms of physical illness requiring a physician examination, d. If the person served requests such an examination. 10. The agency shall make appropriate efforts to assist in obtaining prenatal support for pregnant women served by the agency and, if appropriate, for their family and significant others, particularly for pregnant women being served simultaneously in substance abuse services. Information recorded in the ICR shall include, but not limited to, the following: a. If a pregnant woman is referred for those services, the name of the Physician, provider and/or agency that will provide prenatal services. b. If the agency provides the prenatal services evidence that the service provides information on fetal and maternal health and nutrition, fetal development, maternal and fetal risks related to substance abuse and inadequate nutrition, and resources and support to assist the pregnant woman to maintain or improve her health. c. Documentation that the pregnant woman was referred for or offered prenatal services and her response to this offer. Policy and Procedures Page 80

81 Individualized Service Plan and Progress Notes Effective Date: By: Brent Phipps, CEO Revision Date: Purpose: To describe the elements of the Individualized Service Plans and progress notes required by this agency. Policy: It shall be the policy of L & P Services, Inc. to maintain individualized service plans and progress notes in accordance with ODMH Administrative Rule and ODADAS Rules 3793: and 3793: Procedures: Each person served by L & P Services, Inc. shall have an I.S.P. prepared for them and such plans shall include the following: 1. A description of the specific need of the person served based on Diagnostic Assessment and referral information; 2. A description of strengths or assets of the person served and how they will be utilized in receiving treatment goals; 3. A list of treatment goals and intermediate steps toward those goals, described in measurable terms; 4. Target dates or time frames for achievement of goals and intermediate steps; 5. The specific services provided and the frequency of service delivery; 6. The name(s) of the agency staff member(s) responsible for providing services; 7. The name of any other agencies or systems that are providing services to the person, a description of the services provided, identification by name and title of the staff persons of those agencies or systems responsible for providing such services, and evidence of interagency service coordination; 8. The signature(s) of the agency staff member(s) responsible for developing the ISP and the date on which it was developed; 9. Evidence that the person served and as appropriate, family, parent, guardian or significant other was involved in developing the ISP as documented by signature and progress notations reflecting the person's response to and participation in, the plan; 10. Evidence of ISP review and approval documented by signature of a provider qualified according to Chapter of the Administrative Code and documented evidence of clinical supervision of the individual(s) providing the service(s); 11. Evidence of collaboration with the person served and the person's family or significant other, parent or guardian as appropriate. Each staff member providing services shall participate in developing the ISP with the consent of the Policy and Procedures Page 81

82 person served and if appropriate, the agency shall invite other providers in Mental Health or related areas to participate in developing the ISP. All collaborations shall be documented in the ICR. The ISP shall be developed within seven days of admission to the agency for AOD clients or 30 days of admission for MH clients. For children receiving services, the ISP shall reflect attention to the needs of children including, but not limited to developmental, family, school and social recreational issues and interagency coordination. 1. The ISP shall include the IEP as applicable and documentation of communication and coordination of services with local school and related personnel; 2. If the IEP is judged to be inadequate to meet the needs of the child, the agency shall advocate with the parents or guardian and the school to ensure that the needed services are obtained. For persons with multiple service needs, including but not limited to children, elderly or homeless persons, and persons with severe mental disabilities or serious emotional disturbances, the ISP shall reflect consideration of the entire range of issues related to the person's life circumstances that directly affect the person's ability to respond to treatment. For involuntarily committed persons according the Chapter 5122 of the Revised Code, the ISP shall contain a description of treatment designed to effectuate discharge from involuntary commitment. For persons served who are reimbursed under mandated insurance according to sections , and of the Revised Code, the ISP shall contain evidence of ISP review and approval documented by signature of a physician or psychologist. Review of the ISP by a physician or psychologist shall include: 1. Need for service as expressed by the person; 2. Diagnostic assessment information; 3. Proposed service plan including frequency and duration of services; 4. Qualifications of the service providers according to Chapter of the Administrative Code and 3793: of the Administrative Code. The ISP shall be reviewed to reflect the desired goals and updated at least every ninety days and for involuntarily committed persons not in a hospital, at least every thirty days. A summary of the ISP review and update shall be documented in the ISP. Progress notes shall reflect ISP implementation, including documentation of the choices and perceptions of the person served regarding the service(s) received and shall: 1. Contain descriptions of changes in the person's condition and needs and of the person's responses to services provided; 2. Be dated, signed, legible and include the professional qualifications of the individual making the entry; 3. Include notes from staff member(s) providing each service; Policy and Procedures Page 82

83 4. Be recorded upon each service contact. 5. Be completed within 24 hours of providing the service If a person is terminated involuntarily from a service or from the agency, the reasons shall be documented in the ICR and reviewed as part of agency quality assurance activities. Documentation shall also include alternative services or interagency referrals that were provided prior to the involuntary termination. If client is referred without becoming a client of L & P Services, Inc., case management staff will follow up with the client, if possible, to determine their ability to access the referral. Policy and Procedures Page 83

84 Medication/Somatic Algorithms Effective: By: Brent Phipps, CEO Purpose: To maintain high standards of care for consumers and to utilize evidence based, best practice standards when possible. Policy: Although it is clearly recognized as the superior option to use algorithms as a guideline for the practice of medicine when sufficient evidence, based on sound research, exists to show that one option is clearly superior to the others for a clinical condition, evidence does not exist for the practice of psychopharmacology in children and adolescents. It is the consensus of most child and adolescent psychiatrists that what is clinically true for adults is not for youngsters. Therefore, this pharmacologic service believes adopting guidelines based on the practice of adult medicine is inappropriate. To develop an algorithm for child psychiatry is premature. At which time sufficient evidence becomes available that child psychiatry begins to develop coalescence of opinion on the treatment of various disorders, the L & P Services, Inc. system will adopt such evidence based guidelines. Meanwhile, the agency (through its staff psychiatrists) will continue to review literature and other sources of best evidenced practices, and keep updated on new developments regarding algorithmic applications regarding children, adolescents and adults. Policy and Procedures Page 84

85 Medication/Somatic Pharmacotherapy Effective: 09/16/06 By: Brent Phipps, CEO Revised: 2/11/2009 Purpose: L & P Services, Inc. shall maintain policies and procedures as outlined below regarding staff qualified to provide medication service according to chapter of the Administrative Code and other procedures including, but not limited to, the process of psychiatric evaluation, communication between the psychiatrist and the family physician, the process of responding to physician order prescribing medication, monitoring side effects and adverse reactions of medications, conducting medication education, handling of sample medications, and drug theft. Policy: The Medication/Pharmacotherapy Service Policy and Procedure is compiled with direct input from the agency's physician (s) and Medical Director. If applicable. The physician will help prepare, review and approve all additions, deletions, or modifications to the medication and somatic service policies and procedures for the agency. Any changes of the Administrative Code that indicate changes necessary to this policy and procedure will also be designed, written, and implemented with physician review and approval. Only a Physician or Advance Practice Nurse with prescriptive authority shall prescribe medications and shall supervise all medical services. Only a physician, nurse practitioner, or a registered nurse may supervise services such as medication education. Procedures: The client will be referred for Psychiatric evaluation after a diagnostic assessment has been completed, or by other staff when a change of condition has occurred, or when a psychiatric evaluation is deemed necessary. A psychiatric referral form will be completed. The physician will conduct a psychiatric evaluation, which will include, but not be limited to, allergies, substance use, current medications, medical history, physical status and review of past medication use including effectiveness and side effects. In particular, issues regarding medication of women of child bearing age and/or pregnancy will be addressed. A completed psychiatric evaluation will be completed prior to prescribing medication initially. The physician and or nurse will be required to meet with the client as indicated by the needs of the person served in order to continue medications, if applicable. There will be a completed med/somatic service plan Pharmcoplan which will be initiated at the beginning of this service. Telephone medication orders shall be received only from an authorized physician and shall be received only by a nurse practitioner, registered nurse, or a licensed practical nurse, approved by the State Board of Nursing to in accordance with chapter 4723 of the revised code. The order shall be counter signed by the prescribing physician on the physician s next working day if that is within 7 days. When a medication is prescribed, renewed, or discontinued the name of the person served, current Policy and Procedures Page 85

86 date, name of medication, dosage and route of administration, frequency and duration and signature and credentials of authorized persons shall be included in the individual client record. This may be in the form of a copy of the actual prescription included in the individual client record for prescriptions. If medication is prescribed, renewed, or discontinued the rationale shall be recorded by the physician in the individual client record. The agency shall provide observational supervision in order to monitor or provide intervention for side effects and adverse reactions to medication and to assure that the client has access to consultation with the prescribing physician, nurse practitioner, or registered nurse. The agency will provide access to consultation with a physician, a nurse practitioner, or registered nurse if the person served needs medication, needs an evaluation of side effects, or is experiencing an adverse reaction to medication. The agency shall instruct the persons served and or parent/legal guardian about how to contact staff for more information or assistance about their medications, or in case of a medication crisis. All clients, upon intake, are advised and oriented on how to obtain help after hours, including physicians by calling the Washington County Crisis Hotline. The results of the psychiatric evaluation, such as diagnosis and medication will be communicated to the person's served primary physician along with laboratory reports ordered by the physician which may be ordered due to potentially toxic or dangerous side effects. The results of such testing will also be communicated to the person's served and or their parent/legal guardian and be documented in the ICR. Changes in medication by our physician will be communicated to the primary physician and/or prescribing physician of medications which are not being prescribed by L & P Services, Inc. The person served and/or parents/legal guardian, as appropriate, shall receive written and oral information in a language and format that may be understandable to the person receiving it. This information will include, but is not limited to: 1. The anticipated benefits and side effects of the medication (s) 2. Alternatives to the medication (s) 3. Special dietary needs and/or contraindications associated with the medication use. 4. The biological principles associated with the medication 5. Contraindications 6. Risk associated with pregnancy. 7. The importance of taking medication as prescribed. 8. The need for laboratory monitoring, (if applicable) 9. The rationale for each medication 10. Early signs of relapse 11. Signs and symptoms of non compliance to medications 12. Potential drug reactions and cautions when combining prescriptions and non prescription 13. Medications, including alcohol, tobacco, caffeine, illicit drugs, and alternative medications. 14. Availability of financial supports and resources to assist the persons served with handling the 15. Costs associated with medications or the referral of the client to a Community Support Provider for this purpose. Policy and Procedures Page 86

87 (Reference Medication Information/Informed Consent Document for items 1 13) Clients will be continued on prescribed medications if the exact generic is not available. Persons served and/or their parent/legal guardian shall be given the opportunity to ask questions, seek additional information, and provide input before medications are prescribed to them. The telephone number of a poison control center will be communicated to the client and/or legal guardian. Documentation shall be kept in the ICR regarding the clients and/or parent/legal guardian's participation in this process. This education may be to an individual and/or family or in a group setting. If it is concluded that a person is not capable of self administering prescribed medication, the basis for this conclusion shall be recorded in the ICR. This decision shall be included and reviewed in the ISP and a plan shall be developed to improve the person's ability to self administer medication. Sample medications may be given to the client, if prescribed by the physician. (See policy regarding handling and storage of medication.) All waste products considered bio hazardous will be disposed of by utilizing the appropriate bio hazard waster canisters at each site and these canisters will be removed and replaced by the licensed contractor contracted with to provide such service or delivered to the Washington County Health Department. At every face to face meeting between the physician and/or nurse practitioner, or RN, the person served and /or parent legal guardian will be asked regarding current medications, including over the counter medications and any additions or changes will be noted on the psychiatric progress note. This note will contain the name of the medication, the dosage, frequency, instructions for use, and the prescribing professional (if applicable). When applicable, there will be documented assessment of abnormal involuntary movements (AIMS testing) conducted at the initiation of treatment and every three months thereafter for the persons served who is receiving anti psychotic pharmacotherapy. For those persons receiving anti psychotic medications that the physician determines testing is not applicable he will document the rational in the ICR of the client. The physician, nurse practitioner, or RN, acting under their scope of practice may administer this testing. All medication or medical errors and adverse medication reactions will be documented on an incident report and forwarded immediately to the Medical Director and President. Such incidents will be reviewed monthly by the Performance Improvement Committee. Each service provider providing medication somatic/pharmacotherapy services and supervision is governed by professional licensure standards, Ohio Revised Code, Ohio Administrative Code and Scope of Practice. Those providers must act according to these regulations and not provide services that exceed their scope of practice. Those who order medications and persons who receive medication orders shall be appropriately licensed and acting within the scope of their practice. Policy and Procedures Page 87

88 Each service provider is responsible for attending and/or receiving training needed to carry out their assigned duties, to maintain licensure, and to be qualified to provide such services according to their scope of practice. Individuals prescribing medications or providing information or education about the use of medications shall be educated regarding issues for persons such as children, elderly, minority and or culturally diverse population, and persons with severe mental disability or serious emotional disturbance and to maintain their knowledge which will promote state of the art series and that ensure the safety of the person served. Reviews may be done by medical staff within or without the organization which measures the effectiveness and satisfaction of the persons serve, which may include a program of utilization which will be conducted at a minimum annually and which will become part of the performance improvement review. Policy and Procedures Page 88

89 Handling Storage, and Dispensing of Medication Effective: By: Brent Phipps, CEO Purpose: To provide policies and procedures for the safe handling, dispensing, and storage of medications. Policy: It is the policy of L & P Services, Inc. that in order to have handle and store medication for dispensing to clients that the agency maintain a terminal distribution license from the Ohio State Board of Pharmacy. It is further the policy of L & P Services, Inc. that all medications stored by L & P Services, Inc. will be logged into a medication log book. All medications will be stored in a locked area. Up To Date documentation of receipt and dispensing of medications shall be maintained and kept on premise at all times. Two authorized persons shall witness and sign each transaction (e.g. receipt, dispensing, destruction or return of medication, and scheduled counting of controlled substances). Purchase, Transportation and delivery Receipt of medications shall require a check of each product and quantity against what was ordered for accuracy. If errors are identified, the providing party shall be contacted for correction and discrepancy noted on invoice/log. Storage and Safe Handling All medications at L&P Services will be stored and secured in a locked area to prevent access to medication by unauthorized person, diversions of medications to unintended person and to assure that they will be available to clients when needed. Ideally, two authorized individuals should be required when accessing medications, each having a different key. A limited number of keys which are NOT FOR DUPLICATION shall be accounted for and assigned via a daily log. Each medication will be stored under proper conditions with regards to security, temperature and light. A refrigerator will be provided for medications requiring refrigeration. It is to be used exclusively for the storage of medications. Extraneous materials (e.g., food, flowers, etc.) shall not be placed in this refrigerator. A daily log shall be kept revealing the refrigerator temperature. Temperature must be maintained between degrees F. Security/locking policies shall apply to this device. The refrigerator shall be kept clean and free of excessive frost. Products for external use should be separated from those intended for internal consumption. Packaging and labeling Drugs dispensed to clients are to be accurately identified and labeled with client s name, physician, medication and strength, directions, lot # (if available), expiration date and cautionary statements when needed. Any reconstituted drugs are to be labeled with reconstitution date and/or date beyond which drug should not be used. Any reconstituted drug shall bear the concentration on the label. Policy and Procedures Page 89

90 All multi dose vials will bear the date the vial was opened and are not to be used after 28 days. Safe disposal A designated log shall be maintained at L&P Services for all destroyed medications. This shall include date, client name, prescription # (if available), medication, strength or concentration of medication destroyed, quantity of medication destroyed and signatures of two authorized personnel witnessing destruction. Medications which appear to have deteriorated, have expired dating, or are not being utilized should be returned to the providing party or discarded using proper drug destruction procedure. Inventory and Off site use Controlled substances shall be counted by two authorized persons at the beginning and end of each day/shift with confirmation by signatures. Administration of medications by personnel, including Staff credentials and competencies, documentation of medication administration errors, reactions, and documentation of the use and benefits of as needed (prn) doses will be maintained on agency forms either in medication log book, client record or personal files. Policy and Procedures Page 90

91 Counseling and Psychotherapy Service Effective: 09/16/06 By: Brent Phipps, CEO Revised: 07/1/11 Purpose: To establish general responsibilities of the agency's counseling staff. Policy: It shall be the policy of L & P Services, Inc., to assure that the requirements of ODMH Regulations and ODADAS Regulations 3793: are followed regarding the counseling and psychotherapy services. Procedure: All counseling and psychotherapy services shall consist of a series of time limited, structured face to face sessions that work to the attainment of mutually defined goals as identified in the I. S.P. These sessions may include the child or the adolescent, a family member(s) and/or parent guardian or significant others when the attended outcome is improved functioning of the child or adolescent and when such interventions are part of the I. S.P. The counseling and psychotherapy service shall always be provided by staff qualified to provide that service according to Chapter of the ODMH Administrative Code and 3793: and 3793: of ODADAS Administrative Code. A counseling and psychotherapy service may be provided in the agency or in the natural environment of the person served, regardless of the location, shall be provided in such a way as to insure privacy. For the counseling and psychotherapy services for children and adolescents, the agency shall insure timely collateral contact with family members, parent(s), guardian(s) and/or with other agencies or providers providing services to the child. All designated counseling staff will provide or make available to each admitted client or referral (when applicable), the following counseling program services: 1. Counseling: Individual, family and/or group; 2. Mutually devised I.S.P. 's; 3. Provide for family involvement, if applicable; 4. Provide for follow up and aftercare; 5. Provide opportunities for client feedback; 6. Overall case management; 7. Complete I.S.P. and updates; 8. Assure Client's Rights; 9. Obtain recent or relevant medical, psychological and social information 10. Assure ongoing review process for each client through Quality Improvement as identified above; Policy and Procedures Page 91

92 11. Assure continuity of care; 12. Maintain security and confidentiality regarding client records; 13. Assure mutually devised I.S.P., active treatment, follow up, termination, therapy schedules, I.S.P. a. schedules, updated information regarding the treatment plan and aftercare as identified by the b. individual clinician; 14. Maintain legible, timely and adequate progress notes. Policy and Procedures Page 92

93 Community Support Program Service Effective: 09/16/06 By: Brent Phipps, CEO Purpose: To outline the guidelines of a quality effective community support program. Policy: It shall be this agency's policy to provide quality community support programs services in accordance with the ODMH Regulations and ODADAS Regulations 3793: Procedures: L & P Services, Inc., community support program services shall consist of the following rehabilitation, environmental support and targeted to case management activities which are considered essential to assist the person serving to gaining access to necessary services; and in the provision of rehabilitative services intended for maximum reduction of symptoms of psychiatric illness to restore the persons served to the best possible functional level; and which are identified in the I.S.P. of the persons served: 1. Performance of necessary evaluations and assessments to identify barriers that impede the development of skills necessary for independent functioning in the community. Performance of such evaluations must be consistent with professional licensure rules. 2. Participation in the development of the persons I. S.P.; 3. Assistance and support in crisis situations involving the person served; 4. Support, including education and consultation, for family/significant others which is directed exclusively to the well being and benefit of the person served and assistive to maintaining independent living in the community; 5. Individual intervention, which shall have as its objective the development by the person served of interpersonal and community coping skills, including adapting to home, school and work environments; 6. Symptom monitoring and self management of symptoms, which shall have as its objective the identification and minimization of the negative effects of psychiatric symptoms which interfere with the individuals daily living, financial management, personal development, or school or work performance; 7. Assistance to the person served in increasing social support skills and networks that ameliorate life stresses resulting from the person's disability and are necessary to enable and maintain the individuals independent living. If necessary, accompanying the person served to activity sites and assistance in daily living activities. 8. Coordination to gain access to and the coordination of necessary evaluations and assessments; 9. Coordination of services identified in the I. S.P. of the person served including Community Support Program Services; 10. Assistance in gaining access to essential community resources, including housing and other basic resources necessary to enable and maintain the individual's independent living in the Policy and Procedures Page 93

94 community; 11. Necessary monitoring and follow up to determine if the services accessed have adequately met the recipients needs and to determine needed follow up activity. The activities as defined in 1 10 in the above, are sometimes conducted in group settings when: 1. The services are not for the exclusive purpose of a social or recreational activity, but show a clear therapeutic objective specifically identified in the I. S.P. of the person served; 2. The groups CSP activities are consistent with the treatment objectives stated in the I. S.P. of each person served, and are reflected in the progress notes of the ICR. Each person served who is identified as having a severe mental disability or severe emotional disturbance shall receive community support program services, unless such services are refused by the person served, or it is determined that other mental health services are more clinically appropriate and adequate as documented on the ISP or, when the coordination and/or support functions are being adequately provided through another service system by written agreement with the Community Health Board or agency. Each community support program staff person shall maintain relevant documentation and statistical reporting data. For person receiving community support program services more frequently than one time per week, an activity notation consisting of the date, time, type of activity and name of the provider, may be used to document each service contact, and a progress note shall be placed in the ICR at least weekly. Community Support program service shall be accessible and available for all adults with severe mental disabilities, all youth with serious emotional disturbances and all other persons determined by the area Community Mental Health board to be at greatest risk. 1. Community support program services to children and youth should include coordination with family and significant others and other components of the system of care such as education, juvenile justice, retardation/developmental disabilities, and children's protective services when appropriate to treatment needs. 2. Children and youth with serious emotional disturbances located in out of home placements shall be considered a priority for Community Support Program Services with a goal of returning the child to the Community and/or family reunification where appropriate. 3. Special attention shall be given to locating and serving persons with severe mental disabilities who are homeless, and others at risk who are not already clients of the mental health system. 4. Adults with severe mental disabilities in psychiatric hospitals shall be considered a priority for community support program services. Each individual receiving community support program services shall have one staff person designated as their primary CSP staff person. This primary CSP staff person is responsible for that individual's community support program services and may designate other qualified providers within and/or external to the agency to provide CSP service interventions. The I.S.P. shall identify the staff person for Policy and Procedures Page 94

95 primary CSP staff responsibilities. Responsibilities of a primary staff person for Community Support Program Services include: 1. Primary responsibility for building and maintaining a therapeutic relationship with the person served, as evidenced by progress notes in the clinical record; 2. Provision or ensuring the provision of all necessary CSP services as identified on the ISP convening treatment team meetings, designation of responsibilities for CSP services, ETC.; 3. Knowledge of assessments made, medical history, strengths of the person served, treatment needs, individual support system, housing and financial needs, etc.; 4. Accountability to the person served for achievement of CSP treatment outcomes, whether provided by the primary CSP staff person or other designated staff. The person served would be aware that the primary CSP staff person holds the major responsibility for CSP services. 5. Responsibilities and activities of the primary CSP staff person may be provided by an employee of another agency or client serving system (children's services, mental retardation and developmental disabilities, etc.) Through a written agreement between the agency and/or community mental health board providing primary CSP staffing and the external entity. The I.S.P. shall indicate the entity and staff person responsible for the primary CSP activities; 6. The primary CSP staff person may designate the provision of the CSP activities to qualify providers in an agency of system external to the agency. Community support program service shall be provided by staff qualified according to Rule of the ODMH Administrative Code. Community Support program services are not site specific. Therefore, when a person served is enrolled in one of our residential treatment facilities, the CSP service is provided by staff that are organized and distinct and separate from the residential service as evidenced by staff job descriptions, time allocation or schedules and development of service rates. All individuals who deliver community support services shall: 1. Demonstrate the skills and ability to communicate and work with persons receiving services and service providers; 2. Manifest a commitment to community support program philosophy and standards, and foster an environment that supports recovery for persons served; 3. Possess a working knowledge of community resources; 4. When the person served is a child and family, manifest an understanding of family dynamics and a commitment to family preservation principles; 5. Be sensitive to the cultural needs of the individual and/or family served. Community support program staff composition and training shall be sensitive to the cultural needs and characteristics of the person in the context of the local service area. All staff providing community support program services shall have the ability to provide services in various environments such as jails, homeless shelters, juvenile detention centers, street locations, workplace, etc. Policy and Procedures Page 95

96 The training plan for all CSP staff and supervisors includes the following: 1. Orientation and/or training on community support program standards and functions, including: a. Psychiatric symptoms b. Emergency/Crisis services c. Benefits/entitlement d. Delivery of community support services in the county e. Recovery potential and approaches f. Expected and expressed client outcomes g. The role and responsibility of community support staff under the Board agreement h. Characteristics and description of current population of persons receiving services i. Involvement of and direct communication with persons receiving services, their families and j. significant others, and natural support systems k. Client rights 2. Orientation and/or training that emphasizes the community support program staffs role regarding the person's medication regimen, including but not limited to recognition of side effects and adverse reactions, referral to providers qualified to provide medication/somatic services as described to provide medication/somatic services as described in rule of the ODMH Administrative Code. 3. In service education and training, particularly concerning knowledge about major service systems in the community, that shall include, but not be limited to: a. Information regarding the Justice, Human Service, Health, Mental Health, Educational, Vocational and Housing Resources and Organizations that may form or be part of the natural b. support system of persons served; c. Information regarding ethnic and cultural characteristics of the service area; d. Information regarding the latest available treatment, rehabilitative, recovery, support e. technologies for person with severe mental disabilities or with serious emotional disturbances; f. Information regarding advocacy and client rights organizations. 4. Continuing education and training including, but not limited to, information and skills concerning the treatment, support, recovery, and rehabilitation of persons with severe mental disabilities or with serious emotional disturbances. Each community support program staff meets weekly for one hour with an independently licensed clinician for supervision and consultation regarding their caseload. L & P Services, Inc. includes in its agency service plan a description of the agency community support program service. This description reflects that a significant portion of CSP services are performed face to face with persons served and that a significant portion of CSP staff time is spent working outside of the employee agency facility. The service is developed in compliance with the Community Mental Health Board community support program plan as written in the board's community plan and includes the Policy and Procedures Page 96

97 following: 1. Availability of community support program services 24 hours a day, 7 days a week; 2. Description of how a person served or family can contact their assigned primary staff person for the community support program service; 3. Description of how the agency CSP staff interface with the community Mental Health Board's area crisis intervention services; 4. Description of the service that states the client to staff ratio shall not exceed 30 to 1, that caseloads are assigned by either the clinical supervisor at each agency's site service site or by the agency physician, and that staff to client ratios may be adjusted based on the special needs of the identified population groups; 5. A description of the process explaining that the development of the service plan reflects input from the person and their families, as well as revisions; 6. Description of how we identify and ensure that the population groups identified are the most in need and have priority access to community support program. Policy and Procedures Page 97

98 Client Transfer Effective: By: Brent Phipps, CEO Purpose: To establish guidelines when a client served is being transferred from one staff member to another or from one program to another within the Agency. Policy: Intra Agency Referrals whether from one staff to another or from one program to another will adhere to the procedural component as outlined below. Procedures: When a person served is transferred from one staff member to another or from one program to another within the Agency, the following information shall be documented in the ICR or primary client record: 1. The dated signature of the staff member requesting transfer of the client; 2. Name of the staff and/or service area or program to which the person is being transferred; 3. Effective date of transfer, if approved. The ICR, or primary client file, shall clearly reflect the reason(s) for transfer, including documentation that the reason(s) have been explained to the person served and, if appropriate, parent or guardian and that the person being transferred participated in the transfer decision. The person's response to the transfer decision shall be documented in the primary client file. This information will be provided in the therapy notes or, if clinician prefers, on a Client Transfer Form. The Psychologist, and/or the Clinical Supervisor may provide other documentation as well. All individuals must be in agreement with the referral to either a service provider change or program provider recommendation will provide in their own allocated notes the recommendation itself, the reason(s) for the recommendation, and if the recommendation has been approved or disapproved. The reason for the transfer will be clearly explained to the individual and/or, if appropriate, the parent or guardian. The individual client must have been involved in and/or participated in the transfer decision and the individual client's reason(s) documented as well. Also note, any individual involved or responsible for the client's individual care must confer with the recommendation or request for client transfer. Should all parties not be in compliance or agreement, the final decision will remain with the Clinical Supervisor and the individual client and/or parent/guardian. Policy and Procedures Page 98

99 Client No Show/Cancellations Effective: 09/16/05 By: Brent Phipps, CEO Purpose: To establish guidelines and procedures for clients who do not keep appointments in order that L & P Services, Inc. can provide quality and efficient services to the client and the community it serves. Policy: It is the policy of L & P Services, Inc. that if any of the following occur within a 1 year period, this can cause a client to be discharged from treatment from services provided by L & P Services, Inc. 1. Failure to call to cancel an appointment ahead of tune (no show) 2 times in a row. 2. A combination of no shows and cancellations 3 times in a row failed appointments for any reason. If the client cancels and reschedules more than 24 hours prior to appointment (giving the agency an entire day to fill the appointment), it does not count against you. This policy includes all type of appointments: therapist, CSP, Nurse, Physician and for either group or individual service. In the event a client is terminated that is receiving psychiatric services a 30 day supply of medication prescription will be offered in order to allow time for the client to make other arrangements for this service. If a client is discharged for the above reasons they may initiate re entry into the system after 6 months. Procedures: This policy, which is included in the Client Handbook, will be given to each client served by L & P Services, Inc. and this policy will be posted in the waiting areas of all facilities operated by L & P Services, Inc. The service provider who is providing the services to the client is responsible for documenting in the client chart via a progress note the failed appointments. If a client fails to meet the above obligations regarding keeping appointments and the service provider wishes to terminate the service due to noncompliance they will notify the Chief Executive Officer for review and approval of such termination. Policy and Procedures Page 99

100 Agency Termination of Services Effective: 09/16/05 By: Brent Phipps, CEO Revised: 3/4/2009 Purpose: To set forth guidelines regarding the termination of program participants. Policy: It shall be the agency's policy to terminate or to discharge clients from the programs in a consistent and an appropriate manner which allows for client evaluation of the program and aides the follow up process. Procedures: Individuals involved in a program in the agency may be terminated or asked to leave the program for any one of the combinations of the following reasons: 1. Threatening staff or another program participant. 2. Other abusive behaviors to staff or other program participants in accordance with all Federal and State statutes. 3. Carrying a concealed weapon on their person while attending programs. 4. Carrying non prescribed controlled substances on their person while attending programs. 5. Lack of cooperation in their agreed upon program. 6. Destruction of the agency s property. 7. No participation in the program for ninety days or more. 8. Program completion or achievement of program goals. 9. No need for further program involvement and/or referral to a more appropriate program. 10. Not showing or calling for an appointment; cancelling or missing three consecutive appointments as outlined in our client no show cancelation policy. Upon termination, a summary shall be prepared by the psychotherapist or the program representative. A conference of review of all the services provided from the date of admission until the person is terminated as a client. The termination summary shall include: 1. The reason(s) for the termination of services. 2. The summary of progress in treatment. 3. Documentation that efforts have been made to contact persons served who had discontinued services unexpectedly, including persons with severe mental disabilities and children with severe emotional disturbances and their families. 4. Admission and termination date. 5. Summary of ISP including client outcomes. Policy and Procedures Page 100

101 6. Unresolved problems and/or issues. 7. Summary of medication record. 8. Referrals made to other community resources. 9. Date of signature and credentials of staff member writing the summary. 10. Supervisory staff member s signature and credentials according to Chapter of the ODMH Administrative Code. 11. When possible, any notes that the person being terminated from the agency's services and/or the parent or guardian wishes to add, and a summary of the response of the persons served to the termination of agency's services. Upon termination of client services, the follow up arrangements, if indicated, shall be made with the participation of parent, family or significant other as appropriate. All follow up recommendations shall be given in writing to the person served. The information shall be given to the person served regarding the recognition of symptoms, which may indicate the need for further services. If discharge is unplanned or indicated by follow up survey, case management/cpstp staff will follow up with client. If client was discharged involuntarily for aggressive and/or assaultive behavior, follow up will occur within 72 hours to ensure linkage to appropriate care. Policy and Procedures Page 101

102 Discharge of Clients Effective: By: Brent Phipps, CEO Accountability: Outpatient Therapists; CSP providers; Clinical Supervisor; Chief Compliance Officer Purpose: To establish the policy and procedures for the discharge of clients from the L & P Services, Inc. agency. Policy: It is the policy of L & P Services, Inc. that a discharge summary be completed for all clients whose cases are being closed by the agency. Procedures: Any client whose case is being closed by L & P Services, Inc. will have a discharge summary form completed by the last service provider providing service to that client. Information to be included in the discharge summary includes, but is not limited to the following information: 1. Date of admission of the client; 2. Date of the last service provided to the client; 3. Results of the service (s) provided; 4. Recommendations made to the client, as appropriate to the individualized service plan, including referrals made to other community resources; 5. Medications prescribed by the agency upon the client's termination from service; 6. Upon involuntary termination from service, documentation that the client was informed of his/her right to file an appeal; and 7. Dated signature and credentials of the staff member completing the summary. Policy and Procedures Page 102

103 TRANSFER/DISCHARGE SUMMARY Client Name (First, MI, Last) Client No. Discharge from Agency Service and/or Program Termination Transfer From (Unit/Program/Provider/All Services) Admission Date Last Contact Transfer/Termination/Discharge Date To Presenting Problems(s) (Indicate presenting problem at admission and any additional problems addressed during treatment.) Reason for Transfer/Termination or Discharge (Please check below the appropriate reason for transfer, termination, discharge, or discharge with referral.) Transfer/Termination Discharge Discharge with Referral Increase level of care Goals met, no services needed Client needed services not available Decrease level of care Client terminated services Client referred to AoD Tx Change in type of service Referral (list program(s)/provider client referred to) Client refused referral for other services Involuntary discharge, client informed of right to appeal Client referred to MH Tx Client referred to MH/AoD Tx Client died Client referred to MH aftercare Client moved Client referred to AoD aftercare Client did not return Client referred to MH/AoD aftercare Diagnosis: At Admission DSM-IV Code (or successor) Diagnosis: At Transfer/Discharge ICD-9 CM Codes (or successor) No change in diagnosis Check Primary Axis Code Description Check Primary Axis Code Description Axis I Axis I Axis II Axis II Axis III Axis III Axis IV Psychosocial/Environmental Problems(s) Axis IV Psychosocial/Environmental Problems(s) Axis V GAF Axis V GAF Indicate Goal(s) Addressed and Progress Made as Written in ISP Goal 1 Goal 2 Goal 3 Goal 4 Goal 5 Met Met Met Met Met Partially Met Partially Met Partially Met Partially Met Partially Met Not Met Not Met Not Met Not Met Not Met Discontinued Discontinued Discontinued Discontinued Discontinued Overall Progress in Treatment Much Improved Improved No Change Worse Comments (include progress/gains achieved, client s strengths and abilities, and current status of client) Policy and Procedures Page 103

104 AoD ONLY Adult Level of Care (ODADAS requires completion of Level of Care worksheet) Level I-A: Non-Intensive OP Tx Level II-A: Non-Medical Community Residential Level III-B: 23 Hour Observation Bed Level I-B: IOP Tx Level II-B: Medical Community Residential Level III-C: Sub-Acute Care Level I-C: Day Tx Level III-A: Ambulatory Detox Level IV: Acute Hosp. Detoxification AoD ONLY Youth Level of Care (ODADAS requires completion of Level of Care worksheet) Level I-A: Non-Intensive OP Tx Level I-B: IOP Tx Level I-C: Day Tx Level II: Residential Level III: Acute Hospital Detoxification Pharm. Man./Med.- Som. CPST/Case Management Services Provided (check types of services provided during treatment) MH AoD MH AoD MH AoD Partial Hospital/IOP Residential Urinalysis Counseling/Therapy Crisis Services Other: Diagnostic Assessment Group Employment Other: Counseling/Therapy Current Medications (Prescription/OTC/Herbal) at Time of Transfer/Discharge Route Medication Dosage Frequency Prescribing Physician Oral Inj. Prescribed by this agency As reported by client Prescribed by this agency As reported by client Prescribed by this agency As reported by client Prescribed by this agency As reported by client Medication reconciliation completed, client given list of all medications (Joint Commission only) Client s Response to Treatment and Transfer/Termination/Discharge Continuity of Care/Referral Information (For internal transfer to another program, indicate program/unit, staff receiving case, location, phone no., and/or services to which the client will be transferred. For external referral(s), include agency name, contact name, phone no., location, hours of operation.) Aftercare Options (include information on symptoms client should watch for, options available if these symptoms recur, or additional services needed.) Copy of Transfer/Discharge Summary If neither, Given to client Mailed to Client explain: Provider Signature/Credentials Date Supervisor Signature/Credentials (if applicable) Date Policy and Procedures Page 104

105 Policy and Procedure regarding Self Harm Effective: By: Brent Phipps, CEO Revised: 3/4/2009 Purpose: To define the scope and level of intervention with patients exhibiting suicidal ideation. Policy: Clients, visitors, or phone callers exhibiting or verbalizing suicidal ideations will be evaluated or intervened with depending on circumstance and level of risk associated with the thoughts and/or behaviors. Definitions: Suicidal Ideation: Verbally expressed thoughts of harming oneself that may lack specific intent or associated actions and which are generally vague; passing thoughts related to poorly defined circumstantial issues. Suicidal Behavior: Actions that exhibit or reflect intent to harm oneself which may include, but are not limited to, purposeful self inflicted harm; giving things away, writing a note, writing a will, isolation, depression, often coupled with a specific intent and plan. Suicide Attempt: Specific actions that have the potential of lethality but did not become lethal due to an ineffective or interrupted process. This does not necessarily include those actions which are superficial in nature and lack lethal potential. Parasuicidal Behavior: Includes both suicide attempts and self injuries including self mutilation and selfinflicted burns with little or no intent to cause harm. Procedures: Any client, visitor, or phone caller who expresses any type of suicidal ideation, behavior, attempt or parasuicidal behavior will have an appropriate intervention depending on the circumstance. A client who exhibits any of the above will be assessed by a licensed mental health therapist (LSW, LISW, PC, PCC, RN) and a lethality assessment completed. If the client is a phone caller, the call will be transferred to a mental health professional where they may attempt to have the caller come in to the office to be seen and evaluated, prompted to go to their local emergency room, or call appropriate emergency or law enforcement personnel to go to where the caller is calling from. The parent of any child or adolescent who voices or exhibits such thoughts or behaviors will be notified as soon as possible. If a visitor or unknown caller voices or exhibits suicidal ideations, behaviors, or attempts, law enforcement or emergency personnel will be called to assist that person in obtaining appropriate services. Policy and Procedures Page 105

106 When clients or visitors are present in the facility, a staff person will remain with the person until emergency personnel or law enforcement can be obtained, or a responsible party is present, to provide transportation to a crisis intervention or hospital, if required. No harm contracts should be utilized by staff when a client expresses suicidal ideation. Reference the Crisis Intervention Policy. Policy and Procedures Page 106

107 Crisis Intervention Effective: 03/04/09 By: Brent Phipps, CEO Date: Revised: Purpose: To establish guidelines for and procedures for Crisis Intervention Services for L & P Services, Inc. Definition: Crisis intervention is that process of responding to emergent situations and may include: assessment, immediate stabilization, and the determination of level of care in the least restrictive environment in a manner that is timely, responsive, and therapeutic. Crisis intervention services are available 24 hours a day, 7 days a week. Policy: It is the policy of L & P Services, Inc. to provide effective, safe, accessible, responsive and timely service to de escalate an individual or situation, provide hospital pre screening and mental status evaluation, determine appropriate treatment services and coordinate the follow through of those services and referral linkages. Outcomes may include: de escalating and or stabilizing the individual and or environment, linking the individual to the appropriate level of care and services including peer support, assuring safety, developing a crisis plan, providing information as appropriate to family/significant others, and resolving the emergent situation. Staff who provides this service will have prior training which includes but is not limited to: risk assessments, de escalation techniques/suicide prevention, mental status evaluation, available community resources, and procedures for involuntary/voluntary hospitalization. Providers shall also have first aide and cardio pulmonary resuscitation (CPR) unless other similarly trained individuals are always present. Procedures: L & P Crisis Intervention Services will always be coordinated with other local service providers and community resources when available. This includes pre hospital screening at Marietta Memorial Hospital Emergency Room and the use of Marietta Police Department and the Washington County Sheriff s office to assist in the process as needed. A face to face assessment or telephone intervention will be conducted by trained staff within 1 hour of person experiencing crisis being available in a safe environment, and will include understanding the present crisis, risk assessment of lethality, propensity of violence, medical/physical conditions including alcohol/drug screen/assessment, and support systems; mental status; consumer strengths, and identification of treatment needs and level of care determination as well as a crisis plan that includes referral and linkages to appropriate services and coordination with other systems. The crisis plan should also address safety issues; follow up instructions, alternative actions/steps to implement should the crisis recur, voluntary/involuntary procedures and the wishes and preferences of the individual and Policy and Procedures Page 107

108 parent/guardian, as appropriate. Screenings for medical conditions are typically done at Marietta Memorial Hospital Emergency Room and if emergency medical services appear warranted staff should call emergency medical personnel available for that area. A staff list will be maintained as to who may perform crisis intervention service ensuring and this staff will have current CPR and First Aid certification. No staff can perform any procedure outside of those that they may be certified for, namely CPR and First Aide activities. L& P Services Inc. will not employ the use of any standing orders in association with crisis intervention. A separate list of Health Officers, so designated by the local mental Health Board will also be maintained as to identify those individuals who are authorized to perform involuntary hospitalizations. Documentation will include the elements of the overall assessment of the crisis and intervention. Because reception is one of the first contacts clients may have with L & P during a crisis, for example in the waiting room or over the phone, it is important to assess the situation correctly and have all staff familiar with the variety of situations that can occur. If the person in crisis is in person: First, assess the crisis for emergency services. Is the person or someone else hurt? Did the person overdose, or are they severely intoxicated? Are they putting the staff or other clients in danger? Do they have a weapon? If they or someone else is in immediate danger or needs emergency services, call 911. If you are unable to call emergency services in the presents of the person, call or tell another employee to call, Dr. Green. This fictional doctor is code for call 911. Next, contact their counselor or case manager. If the client has to wait a few minutes and you are comfortable with the person in crisis you can offer them to take a seat or offer them a cup of coffee. Try to make them feel safe and comfortable while they are waiting. Don t hesitate to call the police at or 911 if necessary. Also don t hesitate to ask another staff member for help. If the person in crisis calls over the phone: First, try to get basic information from the person such as their name, who their counselor or case manager is and if possible their phone number. Then, ask if they would like to talk to their counselor or case manager. If they say yes, transfer them to the correct person. If the person doesn t have a counselor or case manager or refuses to talk to them assess the situation for emergency services. Does the person need medical attention? If they do tell them you are going to call emergency services for them. Policy and Procedures Page 108

109 If the crisis happens in the evening: Do this by calling 911 or the police at You can also give them the Lifeline number to call at First, assess the crisis for emergency services, (I. 1), and call police at or 911 if necessary. Next, contact their counselor or case manager, if possible. If their counselor or case manager is gone for the day or not available give them the Lifeline number at Make sure if the client s counselor or case manager was not involved to inform them of the situation that happened. *Do NOT give staff member s phone number out to those who are in or may be in crisis. Pre Hospital Screening: If hospitalization is sought and appears necessary please contact the Health Officer on call. Refer the client to Marietta Memorial Hospital for medical clearance and screening. Health Officers will complete the assessment and plan and consult with appropriate supervisor for disposition. Copies of the intervention, plan and any follow up recommendations will be faxed to the client s counseling agency, if applicable, upon client consent to release. Policy and Procedures Page 109

110 Intensive Home Based Treatment Services Effective Date: 09/16/05 By: Brent Phipps, CEO I. SERVICE DEFINITION: Intensive Home Based Treatment Services is a comprehensive treatment modality encompassing the following components: mental health assessment services, behavioral health counseling and therapy services (including family therapy), community psychiatric support services, twenty four hour crisis response capacity, social services, school based services, skill development training and nutritional and health services as a single coordinated service. The purpose of this service is to prevent the out of home placement of seriously emotionally disturbed dependent minors (or qualifying young adults) or to facilitate the reintegration of those previously placed out of home by stabilizing the child and home environment. Intensive Home Based Treatment Services (IHBT) is delivered in home, school and community settings at hours which enable the family to participate. No more than 25% of the total service time per case will be provided in an office. The amalgam of services is strategically planned and organized to target the specific needs of the family and child to attain lasting stability by reducing or eliminating presenting problems which, at intake, indicate the pending need of placement. II SERVICE POPULATION: A family may be self referred or referred by any community entity (school, protective services, juvenile court, mental health, etc.) which has obtained the guardian s permission to make such a referral. If the family, after IHBT has been described to them, requests such services the following requirements for eligibility shall be determined as described. (1) Age: by report (and later through documentation) it will be determined that the client is either less than 18 years old. Alternatively the age qualification may be met by demonstrating that the client is less than 21 years of age and still living at home while either attending school or is under the jurisdiction of juvenile court or a public child serving agency or receives services from the board of mental retardation and developmental disabilities. (2) Placement Status: By report of an agency with placement authority it shall be determined (with informed consent) that this child is at risk for out of home placement, presents severe safety concerns or that IHBT is necessary to reunify a child already in placement by stabilizing them and their family. (3) Seriousness of Diagnosis: A L & P Services, Inc. Diagnostic Evaluation will be conducted to determine if the client meets the criteria of: Person with Serious Emotional Disturbance (See Appendix A). If the client or family does not meet these three criteria for IHBT, other treatment recommendations will be offered to the guardian based on the Diagnostic Assessment. III. SERVICE DESCRIPTION: Services may be provided by a team of two or by an individual. Every family will have an IHBT staff assigned with leadership responsibility. Services will be flexible and individually designed to meet the needs of the family at a point during the intervention. This will be insured through ongoing and dynamic service planning occurring from inception to post termination. Formal treatment planning meetings will be held by the team or leader with the client and family, at regular intervals, Policy and Procedures Page 110

111 determining goals for the children and family. Under consideration also will be what array of services (see I above) will be delivered, with what strategy and directed towards what client and family goal. The client and family will be equal partners in all such planning processes and implementation with the staff. Goals, progress and service delivery will be monitored and assessed in weekly consultation sessions involving the leader, team (where applicable) and the clinical supervisor. Also under consideration in supervision will be how these services should be organized such that they contribute synergistically, along with other community influences, to the overall goal of long range stability and the remission of presenting safety and placement issues. Assessment of risk will occur for each family initially and with the occurrence of any new risk elements throughout the intervention. Wherever indicated by this assessment an individual safety plans will be co created with the family with practical effective measure they can utilize in the event of a crisis. Continuous crisis assistance will be available; at least one IHBT staff involved with the family will be available by cell phone. The families will also have a backup number to call to put them in touch with our county crisis response services. Families will be instructed upon intake to identify themselves to the county crisis response services as an Intensive Home Based Client of our agency and that service will contact L & P Services IHBT Supervisor or the Coordinator and give them the name of the family and time and nature of the call, if necessary. L & P Services, Inc. maintains an affiliation agreement with Washington County Community Mental Health Services, the provider of emergency services in our county. Therapeutic services will be family centered and system oriented with the purpose of empowering the family to sustain changes which improve competence, effectiveness and stability relative to the family s functioning, i.e. skills training for youth (life skills, anger management, etc.) Parenting training, budgeting assistance, nutritional and health training will be available if determined by the family to be useful to them. Substance abuse and dual diagnosis evaluation and services will also be available if the family is in need of and accepting of such services. IHBT services will be multi system oriented engaging in such CPSP services as collaboration, advocacy and linkage with: community resources, child serving agencies, courts schools, health providers, and extended family as is useful in accordance with the family s consent and in conjunction with focal planning. A comprehensive, up to date, file of community resources will be maintained and available to all IHBT staff. IV. SERVICE FREQUENCY AND DURATION: A minimum of three direct services hours (as specified in section (I) above) will be provided to each open IHBT case each week. Such service will consist of a minimum of two separate face to face contacts and at least one contact with the child or family per week. Services within this three hour requirement may consist of phone contacts and collateral face to face contacts as long as each serves to further the IHBT Goals specified in the ICR. Every effort will be made to maintain the same staff with each family throughout the intervention. Length of stay is variable depending on presenting treatment needs/progress, risk and placement likelihood as well as the family s confidence in managing children s behaviors and symptoms in the home. Length of stay normally shall not exceed six months. A continued stay review must be conducted Policy and Procedures Page 111

112 and its criteria met (See Appendix B) before service to any family may exceeds six months. This process must be repeated each forty five days thereafter in order to gain approval for continuation of services. At discharge a treatment planning meeting involving the family, client and any aftercare personal will be conducted and decisions regarding the needs and implementation of after care will be reached collaboratively. V. SERVICE DOCUMENTATION: Each service provided will be documented by the staff providing the IHBT service on a progress note which will be stored in the client s ICR consistent with of the Ohio Administrative Code described in Appendix C. For each service the provider staff will also record a service contact note. At minimum of once per week a review and update of progress shall occur which will conform to the rules stipulated in Appendix C. For each family a written family assessment (Appendix E) will be completed after thirty days, and no later than forty five days, from intake. VI. STAFF QUALIFICATIONS: 1. Behavior health counseling and therapy services require, at a minimum, license certification, or registration (consistent with eligibility requirements under the Ohio Administrative Code: Rule (F)(1)) to provide service as: (a) Medical doctor or doctor of osteopathic medicine, (b) Registered nurse, (c) Master of science in nursing, (d) Clinical nurse specialist, (e) Nurse practitioner, (f) Social worker, (g) Independent social worker, (h) Counselor trainee, (i) Professional counselor, (j) Professional clinical counselor, (k) Psychology intern/fellow, (l) Psychology assistant, (m) Psychologist. 2. Mental health assessment services shall require at a minimum individuals eligible under the Ohio Administrative Code: Rule (C)(1) to provide the service: (a) Medical doctor or doctor of osteopathic medicine, (b) Registered nurse, (c) Master of science in nursing, (d) Clinical nurse specialist, (e) Nurse practitioner, (f) Social worker, (g) Independent social worker, (h) Counselor trainee, (i) Professional counselor, (j) Professional clinical counselor, (k) Psychology intern/fellow, (l) Psychology assistant, (m) Psychologist, (n) Physician assistant, (o) Licensed occupational therapist, (p) Licensed school psychology assistant, (q) Licensed school psychologist. 3. Community Psychiatric Support Services (CPSP ) or IHBT services, other than those named above in 1.and 2., shall require at a minimum individuals eligible under the Ohio Administrative Code: Rule (F)(1) to provide the service: a) Medical doctor or doctor of osteopathic medicine, (b) Registered nurse, (c) Master of science in nursing, (d) Clinical nurse specialist, (e) Nurse practitioner, (f) Social worker, (g) Independent social worker, (h) Counselor trainee, (i) Professional counselor, (j) Professional clinical counselor, (k) Psychology intern/fellow, (l) Psychology assistant, (m) Psychologist, (n) Physician assistant, (o) Licensed occupational therapist, (p) Licensed school psychology assistant, (q) Licensed school psychologist, (r) Licensed practical nurse, (s) Licensed occupational therapist assistant, (t) Social work assistant, (u)activity therapist, (v) Art therapist, (w) Certified therapeutic recreation therapist, (x) Policy and Procedures Page 112

113 Music therapist/board certified, (y) Trained other. 4. Supervisor of IHBT Services shall require at a minimum individuals eligible to provide service as: a) Medical doctor or doctor of osteopathic medicine, (b) Master of science in nursing, (c) Clinical nurse specialist, (d) Nurse practitioner, (e) Independent social worker, (f) Professional clinical counselor, (g) Psychologist. VII STAFF TRAINING REQUIREMENTS: Each staff will have an individualized training plan based on an assessment of their specific training needs. Each staff will receive an assessment of initial training needs within 30 days of hire. The professional training and developmental criteria which must be met are specified in Appendix D. Each IHBT supervisor will receive appropriate training specific to the clinical and administrative supervision of the service. VII CONSUMER OUTCOME DATA: Consumer outcome data will be collected in accordance with the ODMH Consumer Outcome Procedural Manual. Additionally the following data will be collected. Within 30 days of intake: Whether the child lived in out of home placement for more than a total of 14 days during the measurement period. Whether the child is living at home at time of discharge from IHBT. Whether the child is attending school and getting passing grades in school as measured by question 12 from the Ohio Scales Functioning Scale. The IHBT consumer outcome data described above will be submitted directly to the Ohio Department of Mental Health or it s designee for each child receiving IHBT services. Data which is not submitted to the mental health board will be submitted in writing or electronically, directly to the department or its designee. Moreover the following data will be collected and submitted as above: Every six months thereafter (if applicable): Data specified in the Consumer Outcome Procedural Manual Upon discharge from IHBT: Data specified in the Consumer Outcome Procedural Manual Whether the child lived in out of home placement for more than a total of fourteen days from IHBT admission to discharge. Whether the child is living at home at time of discharge from IHBT. IHBT consumer outcome data will be utilized for agency performance improvement. For the purpose of statewide evaluation L & P Services, Inc. will also submit to ODMH or its designee, all Policy and Procedures Page 113

114 consumer outcome data described previously in this policy section for each IHBT client. This data will identify the client s UCI. The ODMH IHBT fidelity tool will be completed and the resultant score reported to ODMH or its designee every twelve months. Further, six months after discharge, if available, L & P Services, Inc. may submit: Whether the child lived in out of home placement for more than a total of 14 days since IHBT discharge and whether the child is attending school and getting passing grades since IHBT discharge. Consumer outcomes will be assessed by L & P Services, Inc. against the requirements of the IHBT Consumer Outcome Thresholds (Appendix F) and the results reported to ODMH or its designee. Policy and Procedures Page 114

115 INTENSIVE HOME BASED TREATMENT SERVICES APPENDIX A DEFINITION OF PERSON WITH SERIOUS EMOTIONAL DISTURBANCE Ohio Administrative Code Rule (B)(67) "Person with serious emotional disturbance" means a person less than eighteen years of age who meets criteria that is a combination of duration of impairment, intensity of impairment and diagnosis. a) Criteria: (i) Under eighteen years of age; (ii) Marked to severe emotional/behavioral impairment; (iii) (iii)impairment that seriously disrupts family or interpersonal relationships; and (iv) May require the services of other youth serving systems (e.g., education, human services, juvenile court, health, mental health/mental retardation, youth services, and others). b) Marked to severe behavioral impairment is defined as impairment that is at or greater than the level implied by any of the following criteria in most social areas of functioning: (i) Inability or unwillingness to cooperate or participate in self care activities; (ii) Suicidal preoccupation or rumination with or without lethal intent; (iii) (iii)school refusal and other anxieties or more severe withdrawal and isolation; (iv) Obsessive rituals, frequent anxiety attacks, or major conversion symptoms; (v) Frequent episodes of aggressive or other antisocial behavior, either mild with some preservation in social relationships or more severe requiring considerable constant supervision; and (vi) Impairment so severe as to preclude observation of social functioning or assessment of symptoms related to anxiety (e.g., severe depression or psychosis). c) An impairment that seriously disrupts family or interpersonal relationships is defined as one: (i) Requiring assistance or intervention by police, courts, educational system, mental health system, social service, human services, and/or children's services; (ii) Preventing participation in age appropriate activities; (iii) (iii)in which community (home, school, peers) is unable to tolerate behavior; or (iv) In which behavior is life threatening (e.g., suicidal, homicidal, or otherwise potentially able to cause serious injury to self or others). Policy and Procedures Page 115

116 INTENSIVE HOME BASED TREATMENT SERVICES APPENDIX B GUIDELINE FOR CONTINUED STAY APPROVAL REVIEW Each of the following criteria is required for continued stay. They must be assessed by the team leader or qualified therapist and documented in the affirmative in a case note titled Justification for IHBT Continued Stay, which is: signed by the staff completing the review, the IHBT Clinical Supervisor, approved by the Director of Home Based Services and included in the ICR. At date of review client must meet the criteria for person with serious emotional disturbance as specified in Appendix A. Evidence for this conclusion shall be included in the required case note. At date of review the client s age must be either less than 18 years or else under 21 and either living at home while either attending school or under the jurisdiction of juvenile court or a public child serving agency or receiving services from the board of mental retardation and developmental disabilities. At the date of review, by report of an agency with placement authority, it is affirmed that this child is at risk for out of home placement, or by our assessment presents severe safety concerns while continuing to live at home. At date of review the client s family is requesting extended services because of safety or other serious behavioral management concerns relative to the client. At date of review, assessment on the CALOCUS (Child and Adolescent Level of Care Utilization System) yields a score qualifying the client at a minimum of level 4. A score at this level indicates a need for care incorporating Intensively Managed Home and Community Based Support Services. The CALOCUS should be reviewed and signed off by the IHBT Clinical Supervisor. Policy and Procedures Page 116

117 INTENSIVE HOME BASED TREATMENT SERVICES APPENDIX C PROGRESS NOTE Progress notes. (A) Progress notes shall reflect progress or lack of progress toward the achievement of identified treatment outcomes. (B) Documentation shall be completed for each service contact and shall include: (1) The date of the service contact and the date of documentation of the progress note, if different; (2) A narrative description of the provision of the service; (3) Clinical observations, including a description of the response by the client to the service provision; and (4) The signature and discipline of the provider of the service and the date of the signature. Policy and Procedures Page 117

118 INTENSIVE HOME BASED TREATMENT SERVICES APPENDIX D PROFESSIONAL TRAINING AND DEVELOPMENTAL CRITERIA I. Core IHBT training requirements Each staff will document core competency on the following areas within six months of hire: a) Family systems b) Risk assessment and crisis stabilization c) Parenting skills and support for SED children d) Cultural competency e) Intersystem collaboration with a focus on schools, courts and child welfare: (i) Knowledge of other systems (ii) System advocacy (iii) Roles, responsibilities and mandates of other child serving entities: f) Educational and vocational functioning (i) Assessment and intervention strategies for resolving barriers to successful educational and vocational functioning. (ii) Knowledge of special education laws (iii) Strategies for developing successful home school partnerships g) IHBT philosophy, including strength based assessment and treatment planning h) Differential diagnosis with special needs youth for staff credentialed to diagnose. Policy and Procedures Page 118

119 INTENSIVE HOME BASED TREATMENT SERVICES APPENDIX E Family Structural Assessment Sheet Date of Assessment: Agency # WHAT CONDITIONS CREATE THE RISK OF REMOVAL? IS A SAFETY PLAN NECESSARY TO INSURE CHILDREN(S) SAFETY DURNG THIS INTERVENTION? (IF SO, SPECIFY PLAN): GIVE A BRIEF HISTORY OF THE PROBLEM: (Reverse side if necessary) 1. Chronic 2. Erratically Occurring 3. A unique Crisis It started About Months Ago Policy and Procedures Page 119

120 Page 2 Family Structural Assessment Sheet Agency # WHAT IS THE PARENTING ADULT(S) VIEW OF THE PROBLEM? WHAT HAS BEEN THE FAMILY S PAST ATTEMPTS TO SOLVE THE PROBLEM? AND HAVE THEY EVER BEEN SUCCESSFUL IF SO DESCRIBE. WHAT STRENGTHS IN THIS FAMILY CAN BE UTILIZED IN THE INTEVENTION? CIRCUMSTANCES CONTRIBUTING TO THE PROBLEM (HEALTH, ECONOMIC, DISLOCATION, WORK SCHEDULING, CHEMICAL DEPENENCY, LEGAL PROBLEMS, UNFAITHFULNESS, SEPARATION, SERIAL PARTNERS, DIVORCE, RECENT SIGNIFICANT DEATHS, ETC.)? DESCRIBE: DOES THE PROBLEM HAVE MULTIPLE AGENCY INVOLVEMENT? DESCRIBE. Page 3 Family Structural Assessment Sheet Agency # Policy and Procedures Page 120

121 WHO IS IN CHARGE AT THE TIME THE PROBLEM OCCURS? HOW DO THEY HANDLE IT? WHAT ROLE OR ROLES ARE INADEQUATE IN THE FAMILY WHICH ARE NECESSARY TO STOP THE PROBLEM? ARE THESE ROLES MISSING OR PRESENT BUT INEFFECTIVE? ARE THERE FAMILY COALITIONS WHICH UNDERMINE EFFECTIVE LEADERSHIP? DESCRIBE. WHAT FAMILY STRUCTURE(S) (see Family Structures Guide) BEST DESCRIBES THIS PROBLEM? WHAT IS THE ESTIMATED COMMITTMENT TO THE INTERVENTION OF THE PARENT/GUARDIANS LOW HIGH Family Consultant Signature Reviewing Program Advisor Signature Date Policy and Procedures Page 121

122 Abuse and Neglect Effective: By: Brent Phipps, CEO Revised: 9/22/09 Purpose: That clear and written policy is available to agency staff for the handling of suspected abuse and neglect of clients of L & P Services, Inc. Policy: It is the policy of L & P Services, Inc. that all employees of our agency are mandated reporters of suspected abuse and neglect. If an employee of L & P Services, Inc. suspects that abuse or neglect of a client has occurred they should first try and contact their direct supervisor to discuss the specifics of the suspected abuse and neglect. After such contact, or if such contact is not possible in a reasonable time, notification should be made to the appropriate agency. In the case of children (under age 18)or a mentally retarded, developmentally disabled, or physically impaired child under twenty one years of age, this report should be made to the Children Service agency of the county of residence of such child. This report may also be made to the Sheriff s office or local law enforcement, if necessary, and if the local children service agency is closed and does not have a 24 hour reporting system. In the case of a client who has been determined to be MR or developmentally disabled, a report should also be made to the local DD Board, regardless of client age. If abuse and neglect is suspected with a client age 60 or more, the report should be made to Adult Protective Services in the county of residence of said client. After such a report is made, complete appropriate incident forms. Use an MUI or in house incident form depending on the circumstances. If an MUI, the employee should follow the incident reporting policy and procedure of the agency. The incident form needs placed in the CEO s mailbox and he/she will be notified by phone or in person. All agency employees should cooperate with any investigation by the investigating agencies. Reference the attached Ohio Revised Code and ; and Ohio Administrative Codes 5101: , 5101: and 5101: OHIO REVISED CODE Policy and Procedures Page 122

123 Duty to report child abuse or neglect; investigation and follow-up procedures. (A) (1) (a) No person described in division (A)(1)(b) of this section who is acting in an official or professional capacity and knows or suspects that a child under eighteen years of age or a mentally retarded, developmentally disabled, or physically impaired child under twenty-one years of age has suffered or faces a threat of suffering any physical or mental wound, injury, disability, or condition of a nature that reasonably indicates abuse or neglect of the child, shall fail to immediately report that knowledge or suspicion to the entity or persons specified in this division. Except as provided in section [ ] of the Revised Code, the person making the report shall make it to the public children services agency or a municipal or county peace officer in the county in which the child resides or in which the abuse or neglect is occurring or has occurred. In the circumstances described in section [ ] of the Revised Code, the person making the report shall make it to the entity specified in that section. (b) Division (A)(1)(a) of this section applies to any person who is an attorney; physician, including a hospital intern or resident; dentist; podiatrist; practitioner of a limited branch of medicine as specified in section of the Revised Code; registered nurse; licensed practical nurse; visiting nurse; other health care professional; licensed psychologist; licensed school psychologist; independent marriage and family therapist or marriage and family therapist; speech pathologist or audiologist; coroner; administrator or employee of a child day-care center; administrator or employee of a residential camp or child day camp; administrator or employee of a certified child care agency or other public or private children services agency; school teacher; school employee; school authority; person engaged in social work or the practice of professional counseling; agent of a county humane society; person rendering spiritual treatment through prayer in accordance with the tenets of a well-recognized religion; superintendent, board member, or employee of a county board of mental retardation; investigative agent contracted with by a county board of mental retardation; or employee of the department of mental retardation and developmental disabilities. (2) An attorney or a physician is not required to make a report pursuant to division (A)(1) of this section concerning any communication the attorney or physician receives from a client or patient in an attorney-client or physician-patient relationship, Policy and Procedures Page 123

124 if, in accordance with division (A) or (B) of section of the Revised Code, the attorney or physician could not testify with respect to that communication in a civil or criminal proceeding, except that the client or patient is deemed to have waived any testimonial privilege under division (A) or (B) of section of the Revised Code with respect to that communication and the attorney or physician shall make a report pursuant to division (A)(1) of this section with respect to that communication, if all of the following apply: (a) The client or patient, at the time of the communication, is either a child under eighteen years of age or a mentally retarded, developmentally disabled, or physically impaired person under twenty-one years of age. (b) The attorney or physician knows or suspects, as a result of the communication or any observations made during that communication, that the client or patient has suffered or faces a threat of suffering any physical or mental wound, injury, disability, or condition of a nature that reasonably indicates abuse or neglect of the client or patient. (c) The attorney-client or physician-patient relationship does not arise out of the client's or patient's attempt to have an abortion without the notification of her parents, guardian, or custodian in accordance with section of the Revised Code. (B) Anyone, who knows or suspects that a child under eighteen years of age or a mentally retarded, developmentally disabled, or physically impaired person under twenty-one years of age has suffered or faces a threat of suffering any physical or mental wound, injury, disability, or other condition of a nature that reasonably indicates abuse or neglect of the child may report or cause reports to be made of that knowledge or suspicion to the entity or persons specified in this division. Except as provided in section [ ] of the Revised Code, a person making a report or causing a report to be made under this division shall make it or cause it to be made to the public children services agency or to a municipal or county peace officer. In the circumstances described in section [ ] of the Revised Code, a person making a report or causing a report to be made under this division shall make it or cause it to be made to the entity specified in that section. Policy and Procedures Page 124

125 (C) Any report made pursuant to division (A) or (B) of this section shall be made forthwith either by telephone or in person and shall be followed by a written report, if requested by the receiving agency or officer. The written report shall contain: (1) The names and addresses of the child and the child's parents or the person or persons having custody of the child, if known; (2) The child's age and the nature and extent of the child's known or suspected injuries, abuse, or neglect or of the known or suspected threat of injury, abuse, or neglect, including any evidence of previous injuries, abuse, or neglect; (3) Any other information that might be helpful in establishing the cause of the known or suspected injury, abuse, or neglect or of the known or suspected threat of injury, abuse, or neglect. Any person, who is required by division (A) of this section to report known or suspected child abuse or child neglect, may take or cause to be taken color photographs of areas of trauma visible on a child and, if medically indicated, cause to be performed radiological examinations of the child. (D) (1) When a municipal or county peace officer receives a report concerning the possible abuse or neglect of a child or the possible threat of abuse or neglect of a child, upon receipt of the report, the municipal or county peace officer who receives the report shall refer the report to the appropriate public children services agency. (2) When a public children services agency receives a report pursuant to this division or division (A) or (B) of this section, upon receipt of the report, the public children services agency shall comply with section [ ] of the Revised Code. (E) No township, municipal, or county peace officer shall remove a child about whom a report is made pursuant to this section from the child's parents, stepparents, or guardian or any other persons having custody of the child without consultation with the public children services agency, unless, in the judgment of the officer, and, if the report was made by physician, the physician, immediate removal is considered essential to protect the child from further abuse or neglect. The agency that must be consulted shall be the agency conducting the investigation of the report as determined pursuant to section [ ] of the Revised Code. Policy and Procedures Page 125

126 (F) (1) Except as provided in section [ ] of the Revised Code, the public children services agency shall investigate, within twenty-four hours, each report of known or suspected child abuse or child neglect and of a known or suspected threat of child abuse or child neglect that is referred to it under this section to determine the circumstances surrounding the injuries, abuse, or neglect or the threat of injury, abuse, or neglect, the cause of the injuries, abuse, neglect, or threat, and the person or persons responsible. The investigation shall be made in cooperation with the law enforcement agency and in accordance with the memorandum of understanding prepared under division (J) of this section. A failure to make the investigation in accordance with the memorandum is not grounds for, and shall not result in, the dismissal of any charges or complaint arising from the report or the suppression of any evidence obtained as a result of the report and does not give, and shall not be construed as giving, any rights or any grounds for appeal or post-conviction relief to any person. The public children services agency shall report each case to a central registry which the department of job and family services shall maintain in order to determine whether prior reports have been made in other counties concerning the child or other principals in the case. The public children services agency shall submit a report of its investigation, in writing, to the law enforcement agency. (2) The public children services agency shall make any recommendations to the county prosecuting attorney or city director of law that it considers necessary to protect any children that are brought to its attention. (G) (1) (a) Except as provided in division (H)(3) of this section, anyone or any hospital, institution, school, health department, or agency participating in the making of reports under division (A) of this section, anyone or any hospital, institution, school, health department, or agency participating in good faith in the making of reports under division (B) of this section, and anyone participating in good faith in a judicial proceeding resulting from the reports, shall be immune from any civil or criminal liability for injury, death, or loss to person or property that otherwise might be incurred or imposed as a result of the making of the reports or the participation in the judicial proceeding. (b) Notwithstanding section of the Revised Code, the physician-patient privilege shall not be a ground for excluding Policy and Procedures Page 126

127 evidence regarding a child's injuries, abuse, or neglect, or the cause of the injuries, abuse, or neglect in any judicial proceeding resulting from a report submitted pursuant to this section. (2) In any civil or criminal action or proceeding in which it is alleged and proved that participation in the making of a report under this section was not in good faith or participation in a judicial proceeding resulting from a report made under this section was not in good faith, the court shall award the prevailing party reasonable attorney's fees and costs and, if a civil action or proceeding is voluntarily dismissed, may award reasonable attorney's fees and costs to the party against whom the civil action or proceeding is brought. (H) (1) Except as provided in divisions (H) (4) and (M) of this section, a report made under this section is confidential. The information provided in a report made pursuant to this section and the name of the person who made the report shall not be released for use, and shall not be used, as evidence in any civil action or proceeding brought against the person who made the report. In a criminal proceeding, the report is admissible in evidence in accordance with the Rules of Evidence and is subject to discovery in accordance with the Rules of Criminal Procedure. (2) No person shall permit or encourage the unauthorized dissemination of the contents of any report made under this section. (3) A person who knowingly makes or causes another person to make a false report under division (B) of this section that alleges that any person has committed an act or omission that resulted in a child being an abused child or a neglected child is guilty of a violation of section of the Revised Code. (4) If a report is made pursuant to division (A) or (B) of this section and the child who is the subject of the report dies for any reason at any time after the report is made, but before the child attains eighteen years of age, the public children services agency or municipal or county peace officer to which the report was made or referred, on the request of the child fatality review board, shall submit a summary sheet of information providing a summary of the report to the review board of the county in which the deceased child resided at the time of death. On the request of the review board, the agency or peace officer may, at its discretion, make the report available to the review board. Policy and Procedures Page 127

128 (5) A public children services agency shall advise a person alleged to have inflicted abuse or neglect on a child who is the subject of a report made pursuant to this section in writing of the disposition of the investigation. The agency shall not provide to the person any information that identifies the person who made the report, statements of witnesses, or police or other investigative reports. (I) Any report that is required by this section, other than a report that is made to the state highway patrol as described in section [ ] of the Revised Code, shall result in protective services and emergency supportive services being made available by the public children services agency on behalf of the children about whom the report is made, in an effort to prevent further neglect or abuse, to enhance their welfare, and, whenever possible, to preserve the family unit intact. The agency required to provide the services shall be the agency conducting the investigation of the report pursuant to section [ ] of the Revised Code. (J) (1) Each public children services agency shall prepare a memorandum of understanding that is signed by all of the following: (a) If there is only one juvenile judge in the county, the juvenile judge of the county or the juvenile judge's representative; (b) If there is more than one juvenile judge in the county, a juvenile judge or the juvenile judges' representative selected by the juvenile judges or, if they are unable to do so for any reason, the juvenile judge who is senior in point of service or the senior juvenile judge's representative; (c) The county peace officer; (d) All chief municipal peace officers within the county; (e) Other law enforcement officers handling child abuse and neglect cases in the county; (f) The prosecuting attorney of the county; (g) If the public children services agency is not the county department of job and family services, the county department of job and family services; (h) The county humane society. Policy and Procedures Page 128

129 (2) A memorandum of understanding shall set forth the normal operating procedure to be employed by all concerned officials in the execution of their respective responsibilities under this section and division (C) of section , division (B)(1) of section , division (B) of section , and section of the Revised Code and shall have as two of its primary goals the elimination of all unnecessary interviews of children who are the subject of reports made pursuant to division (A) or (B) of this section and, when feasible, providing for only one interview of a child who is the subject of any report made pursuant to division (A) or (B) of this section. A failure to follow the procedure set forth in the memorandum by the concerned officials is not grounds for, and shall not result in, the dismissal of any charges or complaint arising from any reported case of abuse or neglect or the suppression of any evidence obtained as a result of any reported child abuse or child neglect and does not give, and shall not be construed as giving, any rights or any grounds for appeal or post-conviction relief to any person. (3) A memorandum of understanding shall include all of the following: (a) The roles and responsibilities for handling emergency and nonemergency cases of abuse and neglect; (b) Standards and procedures to be used in handling and coordinating investigations of reported cases of child abuse and reported cases of child neglect, methods to be used in interviewing the child who is the subject of the report and who allegedly was abused or neglected, and standards and procedures addressing the categories of persons who may interview the child who is the subject of the report and who allegedly was abused or neglected. (K) (1) Except as provided in division (K)(4) of this section, a person who is required to make a report pursuant to division (A) of this section may make a reasonable number of requests of the public children services agency that receives or is referred the report to be provided with the following information: (a) Whether the agency has initiated an investigation of the report; (b) Whether the agency is continuing to investigate the report; Policy and Procedures Page 129

130 (c) Whether the agency is otherwise involved with the child who is the subject of the report; (d) The general status of the health and safety of the child who is the subject of the report; (e) Whether the report has resulted in the filing of a complaint in juvenile court or of criminal charges in another court. (2) A person may request the information specified in division (K)(1) of this section only if, at the time the report is made, the person's name, address, and telephone number are provided to the person who receives the report. When a municipal or county peace officer or employee of a public children services agency receives a report pursuant to division (A) or (B) of this section the recipient of the report shall inform the person of the right to request the information described in division (K)(1) of this section. The recipient of the report shall include in the initial child abuse or child neglect report that the person making the report was so informed and, if provided at the time of the making of the report, shall include the person's name, address, and telephone number in the report. Each request is subject to verification of the identity of the person making the report. If that person's identity is verified, the agency shall provide the person with the information described in division (K)(1) of this section a reasonable number of times, except that the agency shall not disclose any confidential information regarding the child who is the subject of the report other than the information described in those divisions. (3) A request made pursuant to division (K) (1) of this section is not a substitute for any report required to be made pursuant to division (A) of this section. (4) If an agency other than the agency that received or was referred the report is conducting the investigation of the report pursuant to section [ ] of the Revised Code, the agency conducting the investigation shall comply with the requirements of division (K) of this section. (L) The director of job and family services shall adopt rules in accordance with Chapter 119. of the Revised Code to implement this section. The department of job and family services may enter Policy and Procedures Page 130

131 into a plan of cooperation with any other governmental entity to aid in ensuring that children are protected from abuse and neglect. The department shall make recommendations to the attorney general that the department determines are necessary to protect children from child abuse and child neglect. (M) (1) As used in this division: (a) "Out-of-home care" includes a nonchartered nonpublic school if the alleged child abuse or child neglect, or alleged threat of child abuse or child neglect, described in a report received by a public children services agency allegedly occurred in or involved the nonchartered nonpublic school and the alleged perpetrator named in the report holds a certificate, permit, or license issued by the state board of education under section [ ] or Chapter of the Revised Code. (b) "Administrator, director, or other chief administrative officer" means the superintendent of the school district if the out-of-home care entity subject to a report made pursuant to this section is a school operated by the district. (2) No later than the end of the day following the day on which a public children services agency receives a report of alleged child abuse or child neglect, or a report of an alleged threat of child abuse or child neglect, that allegedly occurred in or involved an out-of-home care entity, the agency shall provide written notice of the allegations contained in and the person named as the alleged perpetrator in the report to the administrator, director, or other chief administrative officer of the out-of-home care entity that is the subject of the report unless the administrator, director, or other chief administrative officer is named as an alleged perpetrator in the report. If the administrator, director, or other chief administrative officer of an out-of-home care entity is named as an alleged perpetrator in a report of alleged child abuse or child neglect, or a report of an alleged threat of child abuse or child neglect, that allegedly occurred in or involved the out-of-home care entity, the agency shall provide the written notice to the owner or governing board of the out-of-home care entity that is the subject of the report. The agency shall not provide witness statements or police or other investigative reports. (3) No later than three days after the day on which a public children services agency that conducted the investigation as determined pursuant to section [ ] of the Policy and Procedures Page 131

132 Revised Code makes a disposition of an investigation involving a report of alleged child abuse or child neglect, or a report of an alleged threat of child abuse or child neglect, that allegedly occurred in or involved an out-of-home care entity, the agency shall send written notice of the disposition of the investigation to the administrator, director, or other chief administrative officer and the owner or governing board of the out-of-home care entity. The agency shall not provide witness statements or police or other investigative reports. HISTORY: 130 v 625 (Eff ); 131 v 632 (Eff ); 133 v S 49 (Eff ); 133 v H 338 (Eff ); 136 v H 85 (Eff ); 137 v H 219 (Eff ); 140 v S 321 (Eff ); 141 v H 349 (Eff ); 141 v H 528 (Eff ); 141 v H 529 (Eff ); 143 v H 257 (Eff ); 143 v H 44 (Eff ); 143 v S 3 (Eff ); 144 v H 154 (Eff ); 146 v S 269 (Eff ); 146 v H 274 (Eff ); 146 v S 223 (Eff ); 147 v H 215 ( ); 147 v H 408 (Eff ); 147 v S 212 (Eff ); 147 v H 606 (Eff ); 148 v H 471 (Eff ); 148 v H 448 (Eff ); 149 v H 510 (Eff ); 149 v H 374 (Eff ); 149 v S 221. Eff ; 150 v S 178, 1, eff ; 150 v H 106, 1, eff The provisions of 4 of S.B. 178 (150 v - ) read as follows: Section 4. Section of the Revised Code is presented in this act as a composite of the section as amended by Am. Sub. H.B. 374, Sub. H.B. 510, and Am. Sub. S.B. 221 all of the 124th General Assembly. Section of the Revised Code is presented in this act as a composite of the section as amended by both Sub. H.B. 538 and Sub. S.B. 171 of the 123rd General Assembly. The General Assembly, applying the principle stated in division (B) of section 1.52 of the Revised Code that amendments are to be harmonized if reasonably capable of simultaneous operation, finds that the composites are the resulting versions of the sections in effect prior to the effective date of the sections as presented in this act. Policy and Procedures Page 132

133 Urinalysis Effective: 09/16/05 By: Brent Phipps, CEO Purpose: To establish the policy, procedures, and definitions for urinalysis of clients to aid with treatment. Definition: Urinalysis The testing of an individual s urine specimen to detect the presence of alcohol and other drugs. Urinalysis includes laboratory testing and or urine dip screen. Policy: It is the policy of L & P Services, Inc. that urinalysis by either laboratory testing or urine dip screen shall be used as a tool to assist clients in their recovery. Procedures: Urine specimens can be collected at our agency site, which is certified by the Ohio Department of Alcohol and Drug Addiction Services, or in the client s natural environment, or at a laboratory. For a laboratory analysis there must be a standing order from a physician, clinical nurse specialist, or certified nurse practitioner for each client needing the service. Such an order is not required for a urine dip screen. Lab analysis shall be performed by a laboratory that is in compliance with all applicable federal proficiency testing and licensing standards. Urine specimens shall be collected in a manner to minimize falsification in that the specimen is correctly matched to the person who provided it and the specimen has not been tampered with or substituted. Observation of urine collection shall be requested by the primary counselor when evidence of tampering is provided by the agent responsible for the collection process. The counselor will obtain approval from the Clinical Supervisor or their designee for observation of the specimen collection. Observation of urine collection shall be conducted by a same sex staff member or the contact agent. Chain of Custody Procedure The witness should label, observe, and collect one specimen at a time. The witness should reconfirm the identity of the client before labeling. This can be accomplished by asking the client to state his/her name and Date of birth; checking the response against the information already recorded on the label. Once identity has been confirmed, the label, which contains client name and date of the specimen collection, should be immediately affixed to the side of the container. The label should never be placed on the top of the container because container caps can be switched. Policy and Procedures Page 133

134 All writing on the label should be in ink that will not run if it becomes wet. DAILY LOG Because the specimen container and the label attached to it are discarded on completion of testing, a permanent record of the collection must be established. The information will be recorded in a daily log of all specimens collected and will include the name, date of birth, and L & P Services, Inc. identification number of the client; the date and time the specimen was collected; and the name of the witness. TRANSPORTATION TO THE LABORATORY Once the specimen is collected, it must be stored in a secure setting to prevent access by unauthorized parties. Specimens stored overnight should be refrigerated to prevent possible decomposition of any drug metabolites. Lab couriers must transport specimens to the testing laboratory and for each shipment to the laboratory, records must show how many specimens are being transported, the name of the person acting as courier, the time the specimens left the collection site, the time they arrived at the testing facility, the name of the person at the testing facility who received the specimen package, and a notion by that person of any specimen containers that sustained damage or other irregularities that might be evident. The lab will maintain the urine remaining following the testing procedure in the collection container, which must be retained in the event that follow up testing is required. URINE DIP SCREEN PROCEDURE: Urine Specimens will be collected utilizing the same procedures as above for laboratory testing. Chain of custody procedure is similar with the exception the urine specimen WILL NOT leave the facility unless the client challenges the results of the dip screen, then the procedures for chain of custody and transportation of the specimen will be followed for laboratory testing. The dip screen will be performed at the office of L & P Services, Inc. and the results given to the client, who will witness the dip screen, and the primary counselor. Following the testing procedure, the client will return to the office of his/her primary counselor to discuss the results. Should further testing be necessary, staff will continue the chain of custody procedures for laboratory testing. RESULTS OF URINALYSIS AND DIP SCREENS Results of the urinalysis/lab analysis/urine dip screen shall be reviewed by the primary counselor and a copy of the results placed in the client s file. Positive results will be shared with the client. Policy and Procedures Page 134

135 Section F: Safety Policy & Procedures Table of Contents Physical Plant and Safety Emergency Physical Intervention Procedure Tobacco Free Policy Incident Reporting Client Safety Policy Infection Control Infection Control Committee Infectious Waste Management Medical Emergency Plan Bomb Threat Procedures Fire Emergency Procedures Natural Disasters & Power Failure Procedures Policy and Procedures Page 135

136 Physical Plant and Safety Effective: , By: Brent Phipps, CEO Purpose: To assure that L&P Services, Inc., meets all applicable Federal and State and Local requirements for health, safety and accessibility. Policy: It shall be the policy of the agency to comply with all applicable Federal, State and Local requirements and to maintain compliance with Regulation of the ODMH Regulations as well as CARF accreditation standards. Procedures: Each site operated by L&P Services, Inc., shall have a fire drill at least quarterly. The fire drill shall include the time it takes to evacuate the building, the evaluation of the effectiveness of the fire drill and necessary training and education provided to personnel. This agency shall also have an annual fire inspection completed by a certified Fire authority annually. Each site supervisor shall assure that all fire exit doors are kept unlocked and clearly marked, unless there is a variance issue by a certified authority of the division of the State Fire Marshall s office. All fire extinguishers at each site are to be inspected annually and recharged and replaced as appropriate. All staff of L&P Services, Inc. will receive periodic training in universal precautions to assure that they are knowledgeable in the standards of infectious waste disposal. (Reference Policy and Procedure Universal Precautions) Each site operated by L&P Services, Inc. shall have safety measures posted in any hazardous area. L&P Services, Inc. Inc., will have regular inspections of electrical equipment. This agency shall also have a safety orientation and education program for all staff. Monthly reporting of safety activities performed at each agency site will became part of the Performance Improvement data. (Reference Safety Review Form for specific areas addressed including agency vehicles) Patterns and trends of safety issues will be communicated to staff and necessary training and or education be conducted to staff and consumers as needed. Each site operated by L&P Services, Inc. shall have emergency (external) disaster evacuation procedure posted, and each staff shall receive training in the evacuation procedure. A disaster drill will be conducted at least annually. Evacuation routes will be posted in each room indicating means of egress as well as first aid box and fire extinguisher locations. This will be placed conspicuously for client and visitor recognition. Any site operated by L&P Services, Inc. that has an elevator shall have the current elevator license permit posted and copy of such permit on file at the main offices in Marietta, Ohio. Each site operated by L&P Services, Inc. shall assure that all storage areas, basements, attics, and stairwell remain uncluttered at all times. Each program supervisor at each site shall report any accident, injury, or safety hazard to the President Policy and Procedures Page 136

137 of L&P Services, Inc. Inc., within 24 hours. Serious accidents of injuries must be reported immediately. Reference Employee Policy and Procedures regarding other applicable safety polices, but not limited to: Employee Safety Workplace Violence Incident Reporting Policy and Procedures Page 137

138 Emergency Physical Intervention Procedure Effective: By: Brent Phipps, CEO Accountability: Chief Executive Officer; Chief Compliance Officer; Performance Improvement Committee Purpose: To establish guidelines for the use of physical intervention to prevent injury to the client or others. Policy: It is the policy of L & P Services, Inc. that we do not use mechanical restraint, seclusion, physical, or chemical restraint for any reason. Agency staff will utilize attempts to de escalate the client, and if necessary, contact proper law enforcement personnel. Procedures: Attempt to deescalate situations. Call for law enforcement intervention if necessary or utilize the guidelines in the Policy for Workplace Violence, if necessary. Physical altercation should not take place between agency staff and clients or families unless such measures are a last resort to defend one's self utilizing techniques that would be employed by the average lay person. Any potentially violent episode should be reported either as an MUI or a non reportable incident depending on the circumstances. Policy and Procedures Page 138

139 Tobacco Free Policy Effective: 9/16/06 By: Brent Phipps, CEO Purpose: To issue a policy to all L & P Services, Inc. facilities, programs, employees and clients regarding a tobacco free environment. Policy: L & P Services, Inc. offers a tobacco free work environment to all employees/clients. No tobacco use is allowed inside our facilities or agency vehicles. A designated tobacco use area on the grounds is specified. Tobacco users are responsible for keeping the area clean and free of tobacco debris. Violation of this policy shall result in disciplinary procedures and, ultimately, termination. Policy and Procedures Page 139

140 Incident Reporting (Incident Notification and Risk Management) Effective: 09/16/06 By: Brent Phipps, CEO Purpose: To insure that all incidents occurring within the agency are properly documented, analyzed, and reported to appropriate supervisors, legal authorities and licensing/monitoring agents. Policy: Formal reporting of incidents shall be recorded, distributed and processed according to established agency protocol consistent with Section of the ODMH regulations and ODADAS Section 3793: Two separate categories of events will be documented, Incidents and Reportable Incidents (which include Sentinel Events): 1. "Incident" means any event that poses a danger to the health and safety of clients and/or staff and visitors of the agency, and is not consistent with routine care of persons served or routine operations of the agency. 2. "Reportable Incident" means an incident that must be submitted to the department and to the mental health board, including incidents that must then be forwarded by the department to the Ohio legal rights service pursuant to section of the Revised Code. Reportable incidents are those that involve clients and shall include deaths, serious bodily injuries, alleged criminal acts, alleged abuse or neglect, any adverse reaction of a client to a life threatening degree due to an administered drug, medication errors likely to result in serious consequences to a client, and any life threatening situations. As referenced in division (C) of section of the Revised Code. "Major Unusual Incident" has the same meaning as "Reportable Incident". 3. Sentinel Event an unexpected occurrence involving death or serious physical or psychological injury or the risk there of. Serious injury specifically includes loss of limb or function. The phrase "or risk there of includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called "sentinel" because they signal the need for immediate investigation and response. Such events also include any that may be subject to litigation. Forms designed for the recording of incidents and Reportable Incidents will be completed by the staff person(s) most directly involved with the pertinent events. All such incident reports will be reviewed by the supervisor of the person completing the report and by the Agency CEO or their designee. All Reportable Incidents will be sent to the Agency Director and a copy sent to the Community Mental Health Board and the Ohio Department of Mental Health within 24 hours of the event. Review of written incident reports and any related corrective action taken will be reviewed within the function of the Performance Improvement process. Reportable Incidents involving clientele residing in this agency's residential facilities will (in addition to the above reporting requirements) be treated according to the protocol outlined in State of Ohio Department of Mental Health Regulations, Section Policy and Procedures Page 140

141 Procedures: Responsibility and procedure for the identification and reporting of incidents will be a part of all staffs' normal orientation and ongoing administrative supervision. A crucial aspect of this process will be training staff to identify what types of events require reporting and to distinguish between an incident and a Reportable Incident. The procedure for reporting an incident is to summarize the event and interview, when necessary, persons involved or in proximity to the events and then to complete an agency incident report (see attached). The employee will make a determination of what, if any action needs to be taken; this decision will be further reviewed by their administrative supervisor. The incident report signed by the supervisor will be submitted for Performance Improvement and also to the CEO or their designee. It will be the duty of the Performance Improvement personnel to insure that appropriate follow up measures have been initiated, (where indicated), and to analyze and report trends, patterns, and make recommendations as necessary. Reportable Incident by definition involves danger to clients and/or employees of the Agency. The first priority therefore in their management is the removal of danger or threat of danger and also treatment of any injury or other physical compromising status. The second priority is the immediate notification of law enforcement, guardian and agency management personnel as appropriate to the specific incident. These immediate reporting requirements may vary with respect to the nature of the incident and laws involved. The employee, if unsure, will seek administrative guidance from a supervisor. If the Reportable Incident involves a client in any of the following: 1. Client death on agency premises or result of suicide. 2. Any fire, flood, earthquake, tornado, explosion or other unusual occurrence which necessitates the temporary relocation of the residents and/or requires emergency medical interventions. 3. Allegation of physical, sexual, or verbal abuse or any allegation of staff neglect of a client. 4. Disaster, flood, earthquake, tornado, explosion, etc; any natural or unusual occurrence which necessitates the temporary relocation of clients and/or requires emergency medical intervention. In addition, any death or serious injury to person on program premises, performing tasks for the program, participating activities will be reported to ODADAS within 72 hours. All of the following types of incidents will be reported to CARF: An investigation Litigation A major catastrophe An unexpected occurrence involving death or serious physical or psychological injury or risk thereof. (Sentinel events). All Reportable Incidents require the immediate completion of the agency's Major Unusual Incident form, Policy and Procedures Page 141

142 (see attached). This, with appropriate signatures, will be sent to the agency CEO or their designee, the Ohio Department of Mental Health and/or Ohio Department of Alcohol Services and the Washington County Mental Health and Recovery Services Board within 24 hours of the event or notification. If the event involves suspected abuse or neglect, the local Children Services board, Division of Child Protective Services must be notified as soon as possible, with the report time not to exceed 24 hours from the time of the event or disclosure. Criminal action that requires immediate intervention will be reported to the law enforcement having jurisdiction. All Incident and Reportable Incidents reports become part of the agency's Performance Improvement review to insure that all corrective and otherwise necessary actions are completed including identifying trends and patterns. Each Program Director responsible for the service where a Reportable Incident may have taken place will make available the option of having a debriefing of staff regarding the incident and will document the debriefing and the documentation of the debriefing will be forwarded to the Performance Improvement personnel. Policy and Procedures Page 142

143 Client Safety Policy Effective: 9/16/05 By: Brent Phipps, CEO Revised: 6/30/06 Purpose: To issue a policy to all L & P Services, Inc. s facilities, programs, employees, and clients regarding safety issues including smoking, licit (legal) and illicit (illegal) drug use, aggressive clients, and weapon controls. Policy: L & P Services, Inc. offers a tobacco free work environment to all employees and consumers. No tobacco use is allowed inside our facilities or agency vehicles. A designated smoking area on the grounds is located outside the front door. Licit and illicit drug use policy states that clients and employees must not share any prescription/nonprescription or illegal drugs with other clients or staff. Clients may not receive services if under the influence of mood altering chemicals. Upon discovery of violations of this policy, the client or employee may be asked to leave the premises and a report given to either the counselor or supervisor depending on whether the violator is a client or is a staff member. If the person refuses to leave when asked, the police may be called to assist. Violations of these may result in involuntary termination for both staff and involuntary discharge for consumers. If it is known that a client or staff person possess a weapon on the premises, they will be asked to remove the weapon to their vehicle or leave the premises. Refusal to do so may result in law enforcement being called. Staff who are suspected of violating this policy may be placed on immediate administrative leave and may be terminated from the agency. Clients who violate this policy will be asked to leave the program at the time of occurrence and may be involuntarily terminated from the program. In the case of illegal substances, clients or staff may be reported to the proper law enforcement facility. Clients may be re admitted to the program at such a time that it is felt that client safety and treatment is no longer jeopardized. Aggressive client policy states that any clients who threaten, harass, verbally abuse, or become physically aggressive to other clients or staff may be involuntarily discharged. Weapon control policy states that unless authorized by law, no person shall knowingly possess, have under the person s control, convey a deadly weapon or dangerous ordinance onto the premises of L & P Services, Inc. or when traveling with staff or other clients within the agency. It is the policy of L& P Services to not engage in any negative sanctions towards clients other than termination of services as it relates to the cancel/no show policy and or violence and safety concerns. Policy and Procedures Page 143

144 CRITICAL INCIDENT REVIEW SUMMARY SHEET 1) Causes: 2) Trends: 3) Actions for Improvement 4) Results of performance improvement plans: 5) Necessary education and training of personnel 6) Prevention of recurrence: 7) Internal and external reporting requirements: Policy and Procedures Page 144

145 COMMUNITY MENTAL HEALTH AGENCY NOTIFICATION OF INCIDENT Certification Number 579 a) Date Report Submitted to ODMH / / b) Date of Discovery / / c) Provider Generated Incident No. ODMH USE ONLY d) Provider Name e) Provider Telephone (include area code) L&P Services, Inc. - - f) Name of ADAMH/CMH Board to Report Incident g) Provider Address h) Provider Address (street, city, state, zip) Incident No. i) Name/Title of Person to Contact Regarding Incident j) Telephone Number if Different from Provider Number Above - - ext. k) Incident Date l) Incident Time (If unknown, indicate as such) v) Incident Type / / : AM PM m) Notifications Made (select all that apply) ADAMH/CMH Board Children Services Board Family/Guardian Law Enforcement ODMH Other Protective Agency Other Client Information n) HIPAA-Compliant Identifier (No Names) o) Age p) Gender Male q) Race/Ethnicity A - Asian B - Black/African American M - Alaskan Native N - Native American/American Indian P - Native Hawaiian/Other Pacific Islander WASHINGTON 207D Colegate Dr. Marietta, Ohio W - White H - Hispanic Bi/Multiracial Unknown Female Abuse and Neglect By Staff (including allegations) Physical Sexual Verbal Neglect Defraud Use of Force Death of Client Accidental Death occurring on the grounds of the agency or during treatment Suicide Homicide/Suspected Homicide by Client Involuntary Termination of Treatment by Agency Medication Error Adverse Reaction r) Was the Client Victim Perpetrator s) Others Involved (select all the apply) Another Client Family Staff Person Unknown Other Serious Bodily Injury when Emergency/Unplanned Medical Intervention or Hospitalization is required Physical Assault Injury Restraint or Seclusion Related Injury Sexual Assault t) If another client(s) was involved, and another incident report(s) was filed, please list the providergenerated incident number(s) of the other incident notification(s) Incident number(s): u) Additional information (No Names Please) w) In regard to the selected incident, was restraint or seclusion (as defined in OAC ) used and/or involved? Yes No If Yes, Type (select all that apply): Seclusion - total min. this episode: Physical Restraint. - total min. this episode: Mechanical Restraint. - total min. this episode Involuntary Emergency Medications x) Name of Person Completing Report, if different than person identified in index (i): y) Date Report Completed, if different than the date in index (a): / / Please fax completed form to the Board, and ODMH at , to [email protected], or mail to Policy and Procedures Page 145 ODMH, 30 E. Broad Street, 8 th Floor, Columbus, OH Attention: Standards Development and Administrative Rules DMH-0484 DMH-LIC-015C Revised

146 Inde x a L&P Services, Inc. Ohio Department of Mental Health Incident Reporting Instructions for Certified Community Mental Health Agencies Please see separate instructions and form for a Licensed Residential Facility Please print legibly in dark ink when using paper form Note: There are now separate paper forms for Community and Residential reporting. Each agency should follow the reporting instructions whether utilizing a paper form or the Web Enabled Incident Reporting System (WEIRS) to submit a report. Please note that WEIRS contains incidents types that are no longer reportable and asks for information which ODMH no longer requires to be submitted. If using the Web Enabled Incident Reporting System (WEIRS), please also utilize the WEIRS column for compatibility with the instructions. There is no incident type category on the paper form that is not also contained in WEIRS, although the wording on the paper forms has been modified for ease of reporting. I. Community Mental Health Agency & Incident Date/Time Information Field Reporting Instructions WEIRS Instructions Certification Number Please fill in your Agency ODMH Certificate Number. Same Date Report Submitted The date you send the report to ODMH. WEIRS automatically fills in to ODMH this field in Date of Report b Date of Discovery The date you learn of a reportable incident. For example, on May 30, a client dies of an unknown cause. On July 31, your agency learns the coroner rules the death a suicide. The date of discovery in this example is the date your agency learned of the coroner s ruling, i.e. July 31. In accordance with paragraph (F) of OAC , an incident report must be submitted within twenty four hours of date of discovery, exclusive of weekends or holidays. c Provider Generated Incident Number A number that is assigned by your Agency to track incident reports. It should be a unique number that no other incident has and should not contain protected health information. An example of a numbering system is , with 11 representing the year and 001 representing the first incident in The next incidents are assigned , , etc. If the Department needs to contact you about an incident, we use this number to be certain that we are discussing the same incident. This number is not the same as the HIPAA Compliant Identifier. d Provider Name The official name of your Agency, which should match the name on your ODMH Certificate. e Provider Telephone (include area code) Same Same WEIRS provides automated selections WEIRS automatically fills in this field Policy and Procedures Page 146

147 I. Community Mental Health Agency & Incident Date/Time Information (continued) Inde Field Reporting Instructions WEIRS x Instructions f Name of the The name of the county board to which your Agency Same ADAMH/CMH Board to reports the incident. Your Agency should fax or send the report incident. incident to the mental health board of the client s county of residence. g Provider E Mail Address The address of the person who can speak for the WEIRS automatically fills Agency regarding the incident. in this field h i j Provider Address (Street, City, state, Zip Code) Name/Title of the person to contact regarding the incident. Telephone Number if different from provider number above. List the address of main agency location, i.e. the address for official correspondence. The person who can speak for your Agency regarding the incident. The direct number for the person who can speak for your Agency regarding this incident if different from the provider number in index (e). Include extension, if applicable. k Incident Date Use the format MM/DD/CCYY, to enter the date the incident happened. If unknown, please write unknown in the box. l Incident Time (if You may use either am & pm or military time. unknown, please indicate) m Notifications Made Please select all that apply. If other is checked, please specify on the line provided. WEIRS provides automated selections Same WEIRS will not accept extension If unknown, please enter 99/99/9999 If unknown, please leave blank Select only from ADAMH/CMH Board Children Services Board Family/ Guardian Law Enforcement ODMH Other Protective Agency Other Please See Next Page for Client Information Policy and Procedures Page 147

148 II. Client Information Inde Field Reporting Instructions WEIRS x Instructions n HIPAA Compliant Please do not use client names. This should be a UNIQUE Same Identifier identifier for the client. Your Agency should be able to identify who the client is based on this identifier. No other client should have the same identifier. This identifier should be used for each incident that relates to the same client, i.e. the same HIPAA compliant number should always be used for the same client. o Age The age of the client at the time if the incident. Please Same do not enter the date of birth. p Gender Same q Race/Ethnicity Select one Same r Was the Client 1. Victim 2. Perpetrator This designates the role the client has in the incident. For incidents in which the client has had something happen to him/her, code this as victim. For incidents in which the client has caused something to happen to him/herself or others, code it as perpetrator. s Others Involved Select all that apply Same t If another Client was If more than one client was involved in the same Same involved, and another incident report was filed, please list the provider generated incident number(s) of the other incident notification(s) incident, please note the Provider Generated Incident Number for that (those) incident(s). u Additional Information A brief description of the incident you are reporting. If Same the Department needs additional information, we will request it. An example of documentation in this section may be: The client made an allegation that a staff member hit him or The client took an OD of medication resulting in her death. v Incident Type Please see next page for instructions Same X y Name of Person Completing Report, if different than person in index (i) Please provide the name of the person completing the incident report, if different than the person to contact regarding the incident identified in index (i). Date Report Completed, if different than the date in index (a) Do not select other Person completing form date field WEIRS automatically fills in this date Please See Next Page for Incident Categories (Types) and Instructions Policy and Procedures Page 148

149 Inde x v L&P Services, Inc. III. Incident Types for Certified Community Mental Health Agencies Field Reporting Instructions WEIRS Instructions Abuse and Neglect by Definitions of abuse and neglect are found in Ohio Same Staff (Including Administrative Code (OAC) (B). Allegations) Report only those allegations that are made against a) Physical Abuse staff, including interns, contract staff and volunteers. (Example: hitting, Report both allegations and confirmed instances of any slapping, spitting at, type of abuse or neglect, regardless of level of injury or twisting arm, etc.) the location where it happened. b) Sexual Abuse Allegations of abuse or neglect regarding persons other (Example: genital than staff (e.g., a parent, uncle, family friend, etc.) may contact, kissing, petting, need to be reported to the local Children Services Board groping, asking for sex (CSB), adult protective services, or law enforcement, but or a date, etc.) are not required to be reported to ODMH. c) Verbal Abuse Report incidents related to Use of Force by Staff in this (Example: name calling, category. These are listed in the Special Treatment and berating, yelling, coarse Safety Measures section of OAC (D)(2)(a) to language directed at, (D)(2)(f). Report all incidents that involve any of the obscene gestures following: directed at, etc.) 1. Face down restraint with back pressure; d) Neglect (Example: 2. Any technique that obstructs the airways or impairs failing to provide a duty breathing; owed the client, 3. Any technique that obstructs vision; sleeping during 1:1 4. Any technique that restricts the recipient s ability to interaction, permitting communicate; others to harm the 5. Pepper spray, mace, handcuffs or electronic restraint person, etc.) devices such as stun guns, and e) Defraud (Example: 6. A drug or medication that is used as a restraint to theft of property, control behavior or restrict the individual s freedom of charging $15 for a movement that is not a standard treatment for the coffee, borrowing items individual s medical or psychiatric condition. from s, tricking a client into giving items / If use of force by staff involves a restraint (of any kind) money, etc.) or seclusion, be sure to mark the appropriate box in f) Use of Force (See index (w) and indicate the amount of time, in minutes. prohibited actions listed Important Note: this incident type is reportable in Ohio Administrative regardless of whether there is an injury to the client or Code (D)(2). not. If there is an injury, please make a note of it in the additional information section of this form in index (u). Policy and Procedures Page 149

150 III. Incident Types for Certified Community Mental Health Agencies (continued) Inde Field Reporting Instructions WEIRS x Instructions v Death of Client Report each death of a client of your Agency by one of Use death category. Use the following causes: only subtype suicide, or 1. Accidental Death occurring on the grounds or during other to indicate the provision of care accidental death. 2. Suicide Do not report when the client is a homicide victim, i.e. do not use subtype suspected homicide with the death of a client by homicide. This is not reportable until January 1, v v Homicide/Suspected Homicide by Client Involuntary Termination of treatment by Agency Report when a client is arrested for or charged with homicide. Report involuntary termination of treatment by your Agency of a client only when one or more of the following is true: 1. The client was not informed in advance of the termination; 2. The client was not given a reason for the termination; and/or 3. A referral was not offered to the client. Use death category and subtype suspected homicide Same v Medication a) Error b) Adverse Reaction Report only when the event results in permanent client harm, hospitalization in a medical unit, or death. 1. Medication Error means any preventable event while the medication was in the control of the health care professional or client. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use. 2. Adverse Drug Reaction means unintended, undesirable or unexpected effect of a prescribed medication(s). Same Policy and Procedures Page 150

151 Inde x v L&P Services, Inc. III. Incident Types for Certified Community Mental Health Agencies (continued) Field Reporting Instructions WEIRS Instructions Serious Bodily Injury when Emergency/Unplanned Medical Intervention or Hospitalization is required a) Physical Assault Injury (Ex: fights, attacks, etc.) b) Restraint or Seclusion Related Injury (Ex: an injury that occurs either while placing the person in restraint/seclusion or that happened while the person is already in restraint/seclusion) Report only when client is victim and event occurs on the grounds of the facility or during the provision of care or treatment, including during off grounds events. 1. "Emergency/Unplanned Medical Intervention" means treatment required to be performed by a licensed medical doctor, osteopath, podiatrist, dentist, physician's assistant, or certified nurse practitioner, but the treatment required is not serious enough to warrant or require hospitalization. It includes sutures, staples, immobilization devices and other treatments not listed under "First Aid", [see definition below] regardless of whether the treatment is provided in your Agency, or at a doctor's office/clinic/ hospital ER, etc. This does not include routine medical care or shots/immunizations, as well as diagnostic tests, such as laboratory work, x rays, scans, etc., if no medical treatment is provided. 2. "Hospitalization" means inpatient treatment provided at a medical acute care hospital, regardless of the length of stay. Hospitalization does not include treatment when the individual is treated in and triaged through the emergency room with a discharge disposition to return to the community, or admission to psychiatric unit. 3. "Injury" means an event requiring medical treatment that is not caused by a physical illness or medical emergency. It does not include scrapes, cuts or bruises which do not require medical treatment. Use Serious Bodily Injury category For subcategory, use only physical assault injury or restraint related injury Do not report accidental injury, injury by an unknown cause, or self inflicted injury Do Not report when the event results in First Aid. 1. "First Aid" means treatment for an injury such as cleaning of an abrasion/wound with or without the application of a Band aid, application of a butterfly bandages/steri Strips, application of an ice/heat pack for a bruise, application of a finger guard, non rigid support such as a soft wrap or elastic bandage, drilling a nail or draining a blister, removal of a splinter, removal of a foreign body from the eye using only irrigation or swab, massage, drinking fluids for relief of heat stress, eye patch, and use of over the counter medications such as antibiotic creams, aspirin and acetaminophen. These treatments are considered first aid, even if applied by a physician. These treatments are not considered first aid if provided at the request of the client and/or to provide comfort without a corresponding injury. Policy and Procedures Page 151

152 III. Incident Types for Certified Community Mental Health Agencies (continued) Inde Field Reporting Instructions WEIRS x Instructions v Sexual Assault Any allegation of one or more of the following sexual Do not complete If type offenses as defined by Chapter 2907 of the Revised Code is sexual assault, was committed by a non staff against a client and which minor involved? happens on the grounds of the Agency or during the provision of care or treatment, including during offgrounds events: Rape, sexual battery, unlawful sexual conduct with a minor, gross sexual imposition, or sexual imposition. Inde x w IV. Associated Seclusion/Restraint Field Reporting Instructions WEIRS Instructions In regard to the selected Please indicate yes or no. If yes, please indicate Same incident, was restraint the type, (i.e., seclusion, physical restraint, mechanical or seclusion (as defined restraint, or involuntary emergency medication) and in OAC ) indicate the number of minutes seclusion/restraint was used and/or involved? used. I. Seclusion total minutes this episode II. Physical Restraint total minutes this episode III. Mechanical Restraint total minutes this episode IV. Involuntary Medications Involuntary Emergency Medication means a medication, except over the counter medication, administered without the informed consent of the client (or, as applicable, the client's legal guardian), in response to an unforeseen or crisis situation that creates circumstances demanding immediate action for the prevention of serious harm or injury to the client or others. Such situations shall be determined by either a licensed physician or a registered nurse. Use of an involuntary emergency medication must be indicated and/or warranted by the client's behavior and/or medical diagnosis. CONTINUED ON NEXT PAGE FOR IDENTIFICATION OF WEIRS DATA FIELDS WHICH NO LONGER NEED TO BE FILLED OUT Policy and Procedures Page 152

153 V. No Longer Applicable WEIRS Fields An agency is not required to submit the following information when reporting an incident via WEIRS WEIRS Data Fields WEIRS Reporting Field/Question Additional Information Others Involved Was staff injured as a result of this incident? Incident Description (Type) Attempted Suicide Incident Description (Type) Illness/Medical Emergency Incident Description (Type) Use of Force Do not Report Use of Force by Police. Report Use of Force by Staff under Abuse & Neglect. Incident Description (Type) Disaster Not reportable by community agencies until January 1, Incident Description (Type) Fire Not reportable by community agencies until January 1, Incident Description (Type) If type is sexual assault, was a minor involved? Consensual sexual activity/conduct between minors, or between adults and minors of a certain age is not a reportable incident unless it involves an allegation of a crime. See Sexual Assault for reporting instructions for both adults and minors. Restraint/Seclusion As a result of the selected incident type, are criminal charges against a client/resident being pressed by staff? Policy and Procedures Page 153

154 Policy and Procedures Page 154

155 Policy and Procedures Page 155

156 ODADAS MAJOR UNUSUAL INCIDENT (MUI) REPORT FORM Date MUI Report Written: Date of ODADAS Notification: Date and Time of MUI: Date Time Date Agency Learned of MUI: Type of Major Unusual incident: Allegation (not verified by second person) Observable Evidence - (Bruises, etc.) Corroborating Observation - (two persons) Other Sexual Abuse Physical Abuse Verbal Abuse Client Neglect Death Serious Injury The Victim[s] or Alleged Victim[s] were: On Program Premises Performing Tasks for the Program Participating in Program Activities Victim[s] or Alleged Victim[s]: Perpetrator[s] or Alleged Perpetrator[s]: Client Employee Contract Staff Member Volunteer Student Intern Other Client Employee Contract Staff Member Volunteer Student Intern Other Victim[s] 42 CFR Compliant ID # (no names): Person s Name or Client s 42 CFR Compliant ID # Type of Program Certification (check all that apply): Outpatient Residential Detoxification DIP Methadone TASC Prevention Therapeutic Community Describe and elaborate on MUI in detail (use additional sheet if needed): Print Name and Title of Person Completing MUI Report: Fax Completed form to or to [email protected] or mail to: ODADAS, Division of Treatment, Recovery & Certification Attn: Jerry Jones 280 North High Street, 12 th Policy and Procedures Page 156 Floor, Columbus, Ohio

157 Policy and Procedures Page 157

158 Infection Control Effective: 9/16/06 By: Brent Phipps, CEO Purpose: To describe means for preventing the spread of infection and communicable disease. To describe systems used for monitoring infection and communicable disease. Responsibility: The enforcement of this policy is the responsibility of the Medical Director. Prevention: The primary means for preventing the spread of infection or communicable disease is by the close observance of body substance precautions, as outlined by the following: 1. Routine and periodic hand washing should be common practice. Hands should be washed: a. Immediately after contact with a body substance. b. After handling potentially contaminated objects. c. Before physical care of another client. d. After toileting or assisting with toileting. e. Before and after eating or assisting with feedings. f. After the removal of gloves. g. Any time the person feels the need to wash. 2. Most body substances, i.e., blood, mucus, feces, urine, vaginal secretions, emesis, wound exude, nasal and bronchial discharges, semen, cerebrospinal fluid, synovial fluids, pleural fluids and pericardial fluids should be considered potentially infectious; therefore, disposable vinyl, latex, or rubber gloves (for housekeeping only) should be used to prevent contact. 3. Saliva and sputum contacts do not routinely require the use of gloves, and no special precautions are required for exposure to tears or perspiration. 4. If unanticipated contact with potentially infectious body substances occurs, hands should be washed at the earliest opportunity. 5. Gowns or aprons: Gown or aprons are ONLY indicated when it is likely that clothing will become soiled with infectious material. 6. Masks and goggles: Masks and protective eyewear are only indicated when performing procedures likely to generate aerosols or splashes. A mask is also needed when caring for a person with a disease known to be transmitted by the respiratory route. 7. Protective coverings are available on each living unit to be used in circumstances where exposure to body substance is likely. 8. Disposable vinyl, latex, or rubber gloves should always be worn over hands which have broken skin or open areas for employees performing duties which might put the employee into contact with body substances. Policy and Procedures Page 158

159 Monitoring: Reporting of infectious disease. 1. Acute, chronic, or long standing client infections should be documented. This will be the responsibility of the agency nurse who is providing care to a client who develops any of the following: a. Infected wounds, skin lesions, decubitus, leg ulcers. b. Purulent drainage. c. Infections such as pneumonia, cystitis, cellulitis, etc. d. Communicable diseases, such as influenza, mumps and measles. e. Infected burns. f. Positive laboratory cultures. g. Fever 101 or above, diarrhea, productive cough and dysuria. h. Antibiotic ordered. i. Isolation ordered: include kind and date begun (notify when discontinued). j. Infestation of lice, mites or their ova. k. Abdominal discharge. l. Evidence of worms. m. Infection of long duration which has been unresponsive to treatment. 2. Each infection report should be submitted to the Performance Improvement Coordinator, the RN, and the CEO. 3. A visitor known to be exposed to a source of infection should be advised to consult their personal physician, and have such recommendations documented. 4. All infection reported upon a client's Discharge Summary will be reported to the Performance Improvement Coordinator and Caretaker/Parent, if applicable. 5. If a client expires having a known or suspected infection the Washington County Coroner will be informed. This will be the responsibility of the Medical Director. 6. Employees exposed to an infectious disease or who are suspected to harbor an infectious disease should have this reported on an Employee Accident or Illness Report. 7. If after a client's discharge, a culture or x ray report is returned to the agency indicating a possible infection, a letter will be written informing the client of his/her caregivers of the results. This will be the responsibility of the agency nurse and reviewed by the Medical Director. Surveillance: 1. The agency nurse is responsible for infection control surveillance. 2. Primary surveillance is accomplished by review of illness reports and compilation of data to note any trends. 3. A report is submitted by the agency nurse to the Washington County Health Department detailing all parasite or streptococcal infections and any other reportable conditions as needed. 4. The Infection Control Report which contains the following will be shared with Performance Improvement 5. Committee: Policy and Procedures Page 159

160 a. Each facility's Nosocomial infection rate, b. The agency's Nosocomial infection rate, c. Nosocomial infections by pathogen. Cleaning, Disinfection and Laundry Practices: Laundry 1. Since all soiled laundry is potentially infectious, it need not be segregated or otherwise identified as infectious. 2. Any clothing which is grossly contaminated with body substances should be washed separately using detergent and bleach (5.25% sodium hypochlorite) diluted to 1: Temperatures of clothes dryers are sufficient to kill microorganisms. Dishes and Utensils must be washed in a dishwasher, or in hot soapy water, followed by thorough rinsing is recommended. Educational learning devices, toys, and other mountable equipment should be washed on a daily basis. If visibly soiled, they should be washed immediately. Limited sharing of these types of items should be enforced. Body Substance Spills 1. Any EPA Approved disinfectant (e.g., and Lysol product used in accordance with instructions, or regular household bleach, 1:10 ratio) is acceptable for cleaning. 2. Disposable gloves should be worn. 3. When cleaning spills, first wash the area with detergent (soap) and warm water, then wash the area with disinfectant. 4. All wash water should be poured into a sanitary sewer system. General Housekeeping Guidelines 1. Standing mop water is not permitted. 2. Any EPA Approved disinfectant (any Lysol product or household bleach 1:10 ratio) should be used in mop water. 3. After use, mop water or other cleaning solution should be poured down a sanitary sewer. Other Infection Control Guidelines: Disposing of Sharps 1. Any area where injections are given will have at least one container used for the disposal of sharps. a. Syringes and needles should never be recapped. The entire unit (i.e. syringe and needle) will be placed intact into the Biohazard Disposal Box. b. This container will be clearly marked as a "Biohazard", with this posted upon the side and the top so that access is not hampered and so that disposal can be visualized, Policy and Procedures Page 160

161 c. When the box is to be moved, this shall be done by grasping the container from its sides, never from the top. The box should be replaced when it is three fourths full, d. If the sharp container is located in a room, for example, sitting upon a shelf, the room should have limited access to only Medical and Nursing Personnel, and a "Biohazard" sign should be posted upon the exterior to the door. If the sharp container is located within a cabinet, a Biohazard sign shall be posted upon the outside of the cabinet, e. Any inadvertent needle or sharp puncture or cut shall be reported to the employee's immediate supervisor and documented on an Employee Accident or Illness Report. i. The HIV or HB V status of the source will be evaluated by the agency nurse. ii. If the HIV or HBV status is unknown, attempts will be made to obtain informed consent from the source for this testing by the agency nurse. f. The biohazard Disposal Box is to be considered infectious waste and should be disposed of as per Infectious Waste Management (the disposal of infectious waste) requirements. "Mess Kits" used for cleanup and control of body substance spills are located on agency vehicles used of the transportation of staff and clients. General Infection Control Practices: During new employee orientation, policies and practices relevant to infection control will be broached, including the cause, prevention and clinical signs and symptoms of HIV (AIDS) and HBV (Hepatitis B). All employees will be trained in Body Substance Precautions and all employees will be periodically updated on general infection control practices. All new employees will be given information on obtaining Hepatitis B immunization. Employees will be given information on obtaining Hepatitis B immunization. Employees may obtain Hepatitis B immunizations free of charge. If an employee develops symptoms of infection while at work, this should be documented upon an Employee Accident or Illness Report, and the employee is to be referred to his/her family physician or health care professional for evaluation and treatment. On the job exposures to infection should be documented upon an Employee Accident or Illness Report. An employee is not permitted to work as long as they are considered a possible source of infection. Prior to returning to work from an absence due to an infectious disease, the employee must have a statement from the licensed physician stating that the employee may return to work and is no longer a source of communicable disease. Client Precautions: General Guidelines All clients who are suspected or have a communicable disease should be kept at a reasonable distance from other clients and staff. The nurse must be contacted whenever a communicable disease is suspected among the clients. A physician should examine the client and if the disease is serious, the Policy and Procedures Page 161

162 client must be hospitalized to avoid risking the health of other clients and staff. Disinfectant fogging is an unsatisfactorily method of decontamination. Policy and Procedures Page 162

163 Infection Control Committee Purpose: To describe the composition and function of an Infection Control Committee. Committee Composition: The Committee shall be composed of the Medical Director, the Nurse and the CEO. The Committee shall meet monthly and shall submit a written report of its proceedings to the Performance Improvement Coordinator. Responsibilities of the Committee: The committee is responsible for the surveillance of infections, the review and analysis of infections, the promotion of a preventative and corrective program designed to minimize infection control in all phases of activities, including: 1. Reviewing and/or recommending standards for a sanitary environment and the avoidance of sources and transmission of infection. 2. Reviewing and/or recommending procedures for the isolation and/or treatment of clients with communicable diseases. 3. Reviewing and/or recommending procedures and techniques for the discovery of infectious conditions. 4. The review of antibiotic usage reports and recommend corrective action when indicated. 5. Monitoring epidemiological studies. 6. Review reports and recommend corrective action for all infections and potential infections among clients and staff. 7. Establish procedures for the disposal of infectious materials. 8. Review the monthly nosocomial infection reports and make any necessary recommendation. 9. Review and/or recommend policies for infection control. 10. Review compliance with body substance precautions. Policy and Procedures Page 163

164 Infectious Waste Management Effective: 9/16/05 By: Brent Phipps, CEO Purpose: To identify infectious waste. To describe procedures for the disposal of infectious waste as to prevent the spread of infection and to comply with state law. Definition: Infectious wastes are any solid materials that contain pathogens with sufficient virulence and quantity that exposure by a susceptible host could result in an infectious disease, this includes the following as described in Ohio Administrative Code to and existing EPA regulation. Cultures and stocks or infectious agents and associated biologicals, including, without limitation, specimen cultures and stocks of infectious agents, wastes from production of biologicals and discarded live and attenuated vaccines. Laboratory wastes that were or are likely to have come into contact with infectious agents that may present a substantial threat to public health if improperly handled. Pathological wastes, including, without limitation, human and animal tissues, organs, and body parts, and body fluids and excreta that are contaminated with or are likely to be contaminated with infectious agents. Waste materials from the rooms of humans that have been isolated because of a diagnosed communicable disease that are likely to transmit an infectious agent. Human specimens and blood products that are being disposed of, except that "Blood Products" does not include patient care waste such as bandages or disposable gowns that are lightly soiled with blood or body fluids, unless such wastes are soiled to the extent that the bandage or dressing strips blood or other body substance. Sharps used in the treatment or inoculation of human beings that have or likely to have come into contact with infectious agents, e.g., hypodermic needles and syringes, scalpel blades and glass articles which have come into contact with body substances and have been broken. Procedures: All used hypodermic needles, syringes, scalpel blades, and all other sharp wastes shall be placed into a designated rigid, clearly labeled, tightly closed, puncture resistant container. These must be kept in each area where these devices are routinely used. Access will be limited to Medical and Nursing Personnel. The container must be labeled with the "Biohazard" label. All infectious wastes other than sharps will be placed into a red impervious biohazard bag. Biohazard bags are to be kept in areas that are not accessible to clients and will be stored in a metal container with Policy and Procedures Page 164

165 a lid. Under NO circumstances will ordinary trash such as paper towels or cups be placed into biohazard bags. Also, diapers from non isolated clients are NOT to be placed in a biohazard bag. Nursing staff will notify the Director of Health Care Services when a bag or puncture resistant container needs removed from a clinical area. An approved handler of infectious waste, registered with the Ohio Environmental Protection Agency, will remove boxed containers of infectious waste from the facility and transport these to areas where the waste can be properly disposed. Once the waste has been properly disposed of, Certification of disposal by the waste treating facility will be received by the facility designee denoting that the waste has been treated in accordance with the rules adopted by the Ohio Environmental Protection Agency. Proof of generation and disposal shall be included in facility records for Infectious Waste Management. Also, copies, Infectious Waste Tracking forms, etc. will be kept on file at the facility. Infectious Waste Spills Any spill of bag or boxed waster which is greater or equal to one cubic foot of waste would be designated as an "Infectious Waste Spill" and should be handled in the following manner. 1. An Unusual Incident Report should be completed. 2. The spill should be promptly cleaned up using an approved disinfectant to sanitize the area. The used mop should be placed into a plastic bag and sent to the Laundry Department for cleaning and disinfecting. Water and cleaning refuse should be immediately discarded into a sanitary sewage system. 3. Personnel responsible for the spill should take measures to ensure that they are properly safeguarded from inadvertent exposure through the utilization of protective clothing and coverings as applicable. 4. Clean up procedures should be documented upon the Unusual Incident Report. 5. Records of these actions will be kept as per facility policy for Incident Reporting Procedures. Oversight and Supervision The identification of infectious wastes, its management at the point of origin, and its proper disposal shall be the responsibility of the Agency Nurse. The arrangement for storing, handling, transporting, disposal of boxed infectious wastes, and payment for these services shall be the responsibility of the Agency Nurse. Monitoring for compliance with the aforementioned will be overseen by the Agency Nurse and will be reported periodically to the Agency's Performance Improvement Committee. Policy and Procedures Page 165

166 Medical Emergency Plan Effective Date: Revision date: By Brent Phipps, CEO Purpose: To establish guidelines in the event a medical emergency occurs on the premises of the agency. Policy: Staff will implement the Medical Emergency Plan to assist clients and/or other staff to receive additional care beyond basic first aid when needed. Procedures: A. For all occurrences in which an injury or illness involves a skin abrasion, open cut, or skin lesions, and potential contact with other bodily fluids, staff and clients providing First Aid or medical emergency care will wear latex gloves. B. For injury or illness that is not life threatening, but warrants immediate medical attention, assistance will be given to the client or staff in getting to the nearest hospital emergency room or emergency medical walk in clinic. C. If injury or illness is life threatening, or requires immediate attention and the client/staff is unable to be transported to the medical facility, the following procedure is to be followed: 1. Call for other staff assistance on premises, if needed 2. Dial 911 immediately. When placing a 911 emergency phone call the following is to be provided: a) Your name. b) Nature of call (need of ambulance, fire, or police). c) Address where the injured party is located d) Nature of injury and/or illness e) Vital signs (heart rate, breathing rate, etc.) 3. Clear the immediate area of all non essential persons. 4. If necessary, begin performing emergency techniques, such as CPR or Heimlich Maneuver. If CPR is required, perform CPR until emergency medical personnel arrive, or until the victim begins breathing on their own. D. Staff will document all serious injuries or illnesses involving client, staff or visitors via the Incident Report Form per the Incident Report Procedures. For all injuries or illnesses involving clients, staff should also document on a Client Note. E. Time permitting, staff will copy front of patient chart for emergency contact, physician, allergy information and call to 911 personnel, if emergency involves client. If staff, and time permits, copy same information located in the emergency contact folder in forms cabinet Policy and Procedures Page 166

167 Bomb Threat Procedures Effective Date: Revision Date: By: Brent Phipps, CEO Purpose: To establish guidelines in the event a bomb threat occurs at any location of the agency. Policy: L&P Services, Inc. staff will take seriously any threat or evidence of explosive or dangerous devices and will act accordingly to ensure the safety of all clients and staff. Procedures: A. Upon discovery of a bomb, what appears to be a bomb, or upon receipt of a bomb threat, staff will: 1. Evacuate the building of all clients and staff members. 2. Dial 911 and give the following information: a. Exact location of the bomb, if known, b. Time the bomb is set to go off c. Language used by the caller of a bomb threat d. Sex of caller, if it can be identified e. Estimated age of the caller f. Peculiar or identifiable accent or type of speech g. Background noises h. Whether the call was received over a pay phone, residential phone or cell phone, if known 3. Notify the Executive Director of the agency receiving a bomb threat and any other information known B. Evacuation Instructions 1. Staff will assist as necessary in the following: a. Evacuating all persons from the building. b. Taking a head count to ensure all persons have evacuated the building(s) c. After the building is searched by authorized persons (e.g. police/fire personnel) and nothing found, the appropriate authorities will declare the building safe to re enter. d. After the bomb threat emergency is over, the site supervisor will fill out an Incident Report form according to the Incident Reporting Form Policies and Procedures. C. Evacuation Procedures Depending on circumstances one building or parts of buildings at Colegate Drive may be utilized. 919 Mitchell Avenue, Beverly, Ohio may be used or arrangements may be made for service delivery at the Washington Behavioral Health Board offices in Marietta, Ohio. Policy and Procedures Page 167

168 Fire Emergency Procedures Effective Date: Revision Date: By: Brent Phipps, CEO Purpose: To establish guidelines in the event of a fire emergency at any agency location. Policy: In the event of a fire alarm/announcement, staff members shall facilitate the evacuation of all persons in the building. Procedures: Staff members on the site will quickly agree upon and identify a coordinator of the evacuation of the building following the marked exit routes. Staff members will assist the coordinator in helping all others to safety. Check each room for staff and clients, opening closed doors if necessary and leaving each door remaining open. Other staff member(s) check alarm panel to determine problem zone. Go directly to the Problem zone and determine if the alarm is false. If smoke or fire is detected, remember RACE: RESCUE: Rescue clients and staff from immediate area. Activate the alarm: Pull alarm if Alarm is not ringing Contain/confine the fire if possible Extinguish the fire. Extinguish the fire with the proper fire extinguisher, if manageable. In an electrical fire disconnect the power source if possible. FALSE ALARMS: After census account is confirmed, then give the "ALL CLEAR" signal for everyone to return to the building. ACTUAL EVENT: Upon arrival of Fire Bureau personnel, designate one staff member to communicate with them, including informing them of any missing clients and the location of the problem/smoke. Contact Program Director and /or Executive Director. No one may re enter the building without permission of the fire bureau. Policy and Procedures Page 168

169 Complete an Unusual Incident Report form (see Policy and Procedure 8.15 Incident Response and Reporting.) FIRE EXTINGUISHER PROCEDURES When using a fire extinguisher, remember to "PASS": Pull the pin; Aim low: Always keep an escape route to your back. Stand six to eight feet from the fire. Point the extinguisher hose (or nozzle) at the base of the fire; Squeeze the lever above the handle; Sweep from side to side: Moving carefully toward the fire, keep the extinguisher aimed at the base of the fire and sweep back and forth until the flames appear to be out. Watch the fire area. If the fire re ignites, repeat the process. WARNING: Portable fire extinguishers discharge quickly many within 15 to 30 seconds. Evacuation Procedures: Depending on circumstances one building or parts of buildings at Colegate Drive may be utilized. 919 Mitchell Avenue, Beverly, Ohio may be used or arrangements may be for service delivery at the Washington Behavioral Health Board offices in Marietta, Ohio. Policy and Procedures Page 169

170 Natural Disasters & Power Failure Procedures Effective Date: Revision Date: By: Brent Phipps, CEO Purpose: To establish guidelines in the event of a natural disaster or power failure at any agency location. Policy: In the event of a power failure or natural disaster agency staff will follow the procedures stated below. Procedures: Procedures During Storms: 1. Keep posted on weather conditions via radio, smartphone or television. 2. Use Land Line only for coordination of assistance or emergency reporting. 3. Have at least one flashlight or back up illumination available. 4. Stay inside until the proper authorities deem it safe to venture out. After a Severe Storm Check for injuries. Do not attempt to move seriously injured person(s) unless they are in immediate danger of further injury. Check your building for damages and report all findings to your site supervisor or facilities manager. Tornado Procedure If a tornado warning is issued for your area, take shelter immediately. The best protection is a substantial steel framed or reinforced concrete building. Take cover in the center part of the building in a small room such as a closet or bathroom, or under sturdy furniture. Stay away from windows to avoid flying debris. After the tornado: Remain where you are until informed by local authorities that it is safe to leave Stay tuned to your local radio, smartphone or television station for advice and instruction from your local government. Stay out of dangerous areas and be cautious of loose or dangling power lines. If there are electrical problems, call the local utility company immediately. Report broken sewer, water, or gas lines to the local municipality or utility company. Policy and Procedures Page 170

171 Procedure During Power Outages Staff will assist all persons into one central location to ensure safety. Staff will call the CEO and inform them of the situation. A decision will then be made regarding client appointments. Depending on circumstances one building or parts of building at Colegate Dr. may be utilized. and/or 919 Mitchell Ave. The back up illumination system will go into effect (if available) or staff will retrieve the flashlight. Once all persons are accounted for, staff will make sure all major electrical devices are turned off. Evacuation Procedures: Depending on circumstances one building or parts of buildings at Colegate Drive may be utilized. 919 Mitchell Avenue. Beverly, Ohio may be used or arrangements may be for service delivery at the Washington Behavioral Health Board offices in Marietta. Ohio. Policy and Procedures Page 171

172 Section G: Waiting List Management Policy & Procedures Table of Contents Waiting List Management Referral and Information Service Interagency Referral Individualized Service Plan and Progress Notes Policy and Procedures Page 172

173 Waiting List Management Effective date: By: Brent Phipps, CEO Revised: Accountability: Chief Executive Officer Policy: That referrals and intake calls be provided a date and appointment time in a timely manner and that if there will be a delay that the referral or intake call will be placed on a waiting list which will be handled on a first come first serve basis. Purpose: L & P Services, Inc. will provide services in a timely manner. Procedures: The scheduling personnel will offer referrals and intake callers an assessment appointment within 30 days of when the call is received. For those people being discharged from an inpatient psychiatric unit an assessment appointment will be offered within 14 days. If the referral or caller wishes to be seen sooner than the first available opening for assessment then information regarding referral to another agency providing comparable services or the option of being placed on a waiting list and notified when an assessment time becomes available. In the event of a waiting list this list will handled on a "first come first serve" basis. Support staff will notify the CEO or Clinical Supervisor each week of the status of the waiting list. Any "unusual" clinical circumstances that may require more immediate access will be communicated to the CEO for his/her disposition. L & P Services, Inc. will not provide quicker or slower access to services based on payer source. Those calls for services that are not provided by L & P Services, Inc. will be communicated to the caller and alternatives given, such as consumers seeking only MR services or children or adolescents with severe emotional disturbance. These referrals will be documented on the intake sheet and filed in the non client contact folder/chart. Policy and Procedures Page 173

174 Referral and Information Service Effective: 09/16/06 By: Brent Phipps, CEO Purpose: To describe the referral and information service provided by L & P Services, Inc. Policy: It shall be the policy of L & P Services, Inc., to provide referral and information services in accordance with ODMH Regulations Procedures: This agency shall provide referral and information services in coordination with other health and human service providers. This agency shall compile information about the various services available in the service system and in the communities we serve. This agency shall also periodically survey persons that we have referred to other agencies or services to determine if they were satisfied with those services received or if they experienced any problems with the referral source. This information shall be used to determine if a particular provider shall continue to be used as referrals for persons seeking services. All State and Federal confidentiality laws shall be adhered to in this process. L & P Services, Inc.., shall insure access and availability of referral and information service including: Our referral and information service shall publish telephone numbers, including published telephone numbers for special telephone services for the hearing impaired; Access and availability for persons whose primary means of communication is a language other than English and for persons with communication impairments such as speech, language or hearing disorders, access to telecommunication for the deaf (TDD), and for persons with visual impairments. Each call and contact shall be logged and shall include the date, the time and person answering the call or contact. Policy and Procedures Page 174

175 Interagency Referral Effective: By: Brent Phipps, CEO Revised: Purpose: To establish guidelines for interagency referral to external service providers. Policy: It will be the primary responsibility of each clinician to assure that with a referral to another agency, the client being referred has participated in the referral decision, is explained the reason for the referral and given the opportunity to respond to the referral recommendation. The clinician will also follow the ODADAS regulation 3793: for any identified drug and/or alcohol client. Procedures: Each Clinician will complete an Interagency Referral in a business letter format and will include the following specific information: 1. The name and dated signature of the staff member making the referral. 2. The name of the individual or agency to whom the interagency referral is being made. 3. The effective date of the interagency referral. 4. The reason for the referral. 5. Notation of any reports/documentation being attached, if any. 6. Copy of the Release of Information Form. Each Clinician will assure that Authorization for Release of Confidential Information has been obtained per Div. F of Section of the Ohio Revised Code 3793: Progress notes, diagnostic assessments or other pertinent information may be forwarded by the Clinician at the time of the referral, or may be released after receiving specific requests from the referral agency. NOTE: Allowing the release of any information not generated by this agency is prohibited. Each Clinician shall assure that when referring a client to a psychiatric hospital, a copy of the client s I.S.P. shall be provided to the hospital treatment team with the consent of the person served, or the person's parent or guardian, when appropriate. Policy and Procedures Page 175

176 Individualized Service Plan and Progress Notes Purpose: To describe the elements of the Individualized Service Plans and progress notes required by this agency. Policy: It shall be the policy of L & P Services, Inc. Child & Adolescents Services, Inc., to maintain individualized service plans and progress notes in accordance with ODMH Administrative Rule Procedures: Each person served by L & P Services, Inc., shall have an I.S.P. prepared for them and such plans shall include the following: 1. A description of the specific need of the person served based on Diagnostic Assessment and referral information; 2. A description of strengths or assets of the person served and how they will be utilized in receiving treatment goals; 3. A list of treatment goals and intermediate steps toward those goals, described in measurable terms; 4. Target dates or time frames for achievement of goals and intermediate steps; 5. The specific services provided and the frequency of service delivery; 6. The name(s) of the agency staff member(s) responsible for providing services; 7. The name of any other agencies or systems that are providing services to the person, a description of the services provided, identification by name and title of the staff persons of those agencies or systems responsible for providing such services, and evidence of interagency service coordination; 8. The signature(s) of the agency staff member(s) responsible for developing the ISP and the date on which it was developed; 9. Evidence that the person served and as appropriate, family, parent, guardian or significant other was involved in developing the ISP as documented by signature and progress notations reflecting the person's response to and participation in, the plan; 10. Evidence of ISP review and approval documented by signature of a provider qualified according to Chapter of the Administrative Code and documented evidence of clinical supervision of the individual(s) providing the service(s); 11. Evidence of collaboration with the person served and the person's family or significant other, parent or guardian as appropriate. Each staff member providing services shall participate in developing the ISP with the consent of the person served and if appropriate, the agency shall invite other providers in Mental Health or related areas to participate in developing the ISP. All collaborations shall be documented in the ICR. Policy and Procedures Page 176

177 The ISP shall be developed within thirty days of admission to the agency for mental health clients and within seven days of admission for AOD clients. For children receiving services, the ISP shall reflect attention to the needs of children including, but not limited to developmental, family, school and social recreational issues and interagency coordination. 1. The ISP shall include the IEP as applicable and documentation of communication and coordination of services with local school and related personnel; 2. If the IEP is judged to be inadequate to meet the needs of the child, the agency shall advocate with the parents or guardian and the school to ensure that the needed services are obtained. For persons with multiple service needs, including but not limited to children, elderly or homeless persons, and persons with severe mental disabilities or serious emotional disturbances, the ISP shall reflect consideration of the entire range of issues related to the person's life circumstances that directly affect the person's ability to respond to treatment. For involuntarily committed persons according the Chapter 5122 of the Revised Code, the ISP shall contain a description of treatment designed to effectuate discharge from involuntary commitment. For persons served who are reimbursed under mandated insurance according to sections , and of the Revised Code, the ISP shall contain evidence of ISP review and approval documented by signature of a physician or psychologist. Review of the ISP by a physician or psychologist shall include: 1. Need for service as expressed by the person; 2. Diagnostic assessment information; 3. Proposed service plan including frequency and duration of services; 4. Qualifications of the service provider(s) according to Chapter of the Administrative Code. The ISP shall be reviewed to reflect toward desired goals and updated at least every ninety days and for involuntarily committed persons not in a hospital, at least every thirty days. A summary of the ISP review and update shall be documented in the ISP. Progress notes shall reflect ISP implementation, including documentation of the choices and perceptions of the person served regarding the service(s) received and shall: 1. Contain descriptions of changes in the person's condition and needs and of the person's responses to services provided; 2. Be dated, signed, legible and include the professional qualifications of the individual making the entry; 3. Include notes from staff member(s) providing each service; 4. Be recorded upon each service contact. If a person is terminated involuntarily from a service or from the agency, the reasons shall be Policy and Procedures Page 177

178 documented in the ICR and reviewed as part of agency quality assurance activities. Documentation shall also include alternative services or interagency referrals that were provided prior to the involuntary termination. Policy and Procedures Page 178

179 Section H: Staff Policy & Procedures Table of Contents Guidelines for Legal Involvement Clinical Supervision Staff Credentialing Staff Re Credentialing Staff Recruitment Personnel Qualifications Cultural Competency Cultural Competency Plan Duty to Protect Clinical Management Alcohol & Drug Addiction Services Policy and Procedures Page 179

180 Guidelines for Legal Involvement Effective: By: Brent Phipps, CEO Accountability: Clinical Supervisors; CEO Purpose: The purpose is to establish consistent guidelines for staff to help them in case of subpoenas, search warrants, investigations, and other legal actions. Policy: It is the policy of L & P Services, Inc. to cooperate fully with the judicial system in regards to subpoenas, warrants, court orders, and investigations within the framework of Federal and State law regarding confidentiality of client's records and information. Procedures: Any employee or Director if served with legal notification, such as, but not all inclusive of, subpoenas, search warrants, court order, or is the source of investigation or questions regarding an investigation involving L & P Services, Inc. or its clients, will notify his/her supervisor as soon as possible. In the case of a board member they will notify the CEO. The employee or board member will discuss the legal notification with the appropriate Supervisor, Chief Executive Officer and Board President to determine the validity of the request in regards to Federal and State law and what information needs to be provided to fulfill the obligations as set forth in the legal notification. If needed, the President may consult an attorney for further clarification of the role of the either the agency or employee in fulfilling their legal obligations as it pertains to Federal and State laws regarding the confidentiality of information. Policy and Procedures Page 180

181 Clinical Supervision Effective Date: By: Brent Phipps, CEO Purpose: To ensure appropriate Clinical Supervision according to Chapters through 17, of the Administrative Code of the Ohio Department of Mental Health and 3793: of the Administrative Code ODADAS. Policy: It shall be the policy of this Agency to maintain compliance with the Ohio Department of Mental Health Regulations pertaining to Clinical Supervision according to the Chapters identified above of the Ohio Administrative Code and the Administrative Code of the Ohio Department of Alcohol and Drug Services. Procedures: All Clinical Staff have an identified Clinical Supervisor assigned to them upon beginning employment with this Agency. All Clinical Supervision is assigned in accordance with through and 3793: of the Administrative Code to determine that assignment. The Clinical Supervisor will arrange with their Supervisee to meet on at least a weekly basis for a minimum of one hour to provide the Supervisee with face to face Clinical Supervision. All Clinical Team Personnel will meet a minimum of one time per month for one hour or more (unless supervision for individual licensing requirements are more) in a Clinical Team Meeting for the specific purpose of supervision and client/case review. Each client's I.S.P. is reviewed in its entirety by: 1. The individual clinician assigned to the client/case 2. Clinical Supervisor, if necessary Supervision logs will be kept for each supervision meeting and will include the Supervisee name and credential, supervisee position, date of supervision, method of supervision, (individual, group, review of clinical documentation, observe skills with client, other which is specified); length and frequency of supervision; what occurred during the supervision session, progress with or towards Supervision Goals; Supervisee comments, next scheduled supervision date, and signed by the supervisee and the Clinical Supervisor. Policy and Procedures Page 181

182 Staff Credentialing Effective Date: By: Brent Phipps, CEO Policy: That all independent clinical practitioners must provide evidence of current and appropriate competence to provide and/or manage and supervise client treatment without clinical supervision. In order to assure this, L & P Services, Inc., independent practitioners will be credentialed. The L & P Services, Inc., does not allow temporary or provisional credentialing. Purpose: To ensure that all independent clinical practitioners who are initially employed to work within L & P Services, Inc. meet standard credentialing requirements. Definitions: Credentialing The process by which clinical practitioners who are licensed/certified to practice independently are authorized to provide services (including both employed and contract professionals); eligibility is determined by the extent to which applicants meet defined requirements for education, licensure, certification, training, experience and professional standing. Licensed Independent Practitioner Any clinical practitioner permitted by law and the L & P Services, Inc. to provide client care services without clinical direction or supervision, within the scope of the practitioner's licensure or certification. The following providers are considered Independent Practitioners by L & P Services, Inc.: Psychiatrist MD doctor of medicine with American Psychiatric Association approved training in psychiatry: board certified or eligible in psychiatry; Medical Physician MD doctor of medicine, DO doctor of osteopathy; MD certified in addiction medicine; Doctoral level psychologist Ph.D., Psy.D; Masters level clinical social worker LISW, ISW independent social worker; Masters level counselor LPCC,PCC professional clinical counselor; Advanced practice registered nurse APRN (clinical nurse specialist, nurse practitioner), APRN PMH, RN, CS; Registered nurse RN,C. Procedures: All independent practitioners as described above will submit an application and supporting documentation as outlined below to the Chair of Credentialing/Recredentialing Committee (who is appointed by the CEO) within 15 days of notification. For new hires, this notification may take place prior to hire date and may need submitted before actual employment begins. At the time of this notification the applicant will receive a copy of this Policy and Procedure that explains and governs the Credentialing process. The applicant will submit: Policy and Procedures Page 182

183 1. Completed application. 2. Copy of current valid license or certification to practice as an independent practitioner at the highest level of certified or approved by the state (this will be verified directly from the state licensing agency). 3. Copy of physician valid DEA or CDS certificate (if applicable, that is effective and current at the time of the credentialing decision. 4. Copy of diploma attesting to graduation from an accredited, professional school and/or highest training program applicable to academic degree, discipline, licensure, and/or certification. 5. Copy of Board Certification if such is listed on application form. 6. Documentation of work history that should include a minimum five year history. 7. History of professional liability claims or judgments paid by or on behalf of practitioner. 8. Written verification of current, adequate malpractice insurance (this may be waived by the Credentialing Committee if applicant is to be covered under agency malpractice insurance plan. 9. Written verification of completion from a school, training program, or licensing authority for non traditional practitioners with specialized training. After the Chair of the Credentialing/Re credentialing Committee receives the above application and supporting documentation the Chair will: Directly verify licensure with appropriate licensure board (if done by phone note will be made as to whom and when verification was completed. Verify by phone clinical privileges for Physicians and Psychologists (if applicable) and with whom and when verification was completed, and any restrictions on the scope of privileges. Verify, by written confirmation, the last five years of history of malpractice settlements from the malpractice carrier (if applicable) and for MD's and DO's, the National Practitioner Data Bank. Years may include residency years (no carrier confirmation is needed if these residency years were covered by hospital insurance policy during residency. The above submitted and/or verified information must provide evidence of the following criteria 1. current license in good standing 2. current certification and/or registration, as applicable 3. relevant education, training and experience 4. ability to perform responsibilities and duties as outlined in job description 5. history of relinquishment, limitation, or loss of clinical privileges 6. letters from primary sources about the level, scope, and current competence of clinical performance evidence of continuing education hours or topics applicable to the diagnosis, treatment, and/or management/supervision of persons with mental health and/or addictions problems evidence of inpatient coverage for physicians All submitted material and verifications must contain original signatures; faxed, copied and scanned Policy and Procedures Page 183

184 signatures are not permitted. All submitted material and verifications must be within 180 days. After the above documentation has been received and appropriately verified, the Credentialing Committee Chair will notify the applicant that he has three working days with in which to request to view the documentation. The applicant will also be notified if the information received substantially differs from that which was provided by the applicant. If the applicant chooses to challenge any of the documentation or verification, he has seven working days in which to do such and such corrections will be given to the Committee Chair. In the event that documentation and information obtained does not meet the organization's Credentialing verification requirements, or if disclosure is prohibited by law, the organization is not required to reveal the source. The Committee Chair has up to five working days within to schedule an appointment for this purpose if notified by the applicant that he wishes to review the documentation. After either the three days notification or the review of the documentation by the applicant, the information will be reviewed by the full Credentialing Committee and will consist of at least three members that must include one licensed mental health professional, one independently licensed mental health professional, and one licensed practitioner from the Medical/Somatic Services (Doctor, Nurse). The Committee will review all documentation and verifications and minutes of this meeting will be recorded along with the recommendations of the committee. These minutes and recommendations will be forwarded to either the President or Chief Clinical Officer for their review and comments but the Credentialing Committee will be responsible to approve or disapprove the application. The applicant will then be notified in writing by the Committee as to whether their application has been approved or disapproved. All materials will be kept in their confidential personnel file which can only be viewed by the Credentialing Committee, CEO, Clinical Supervisor of the Agency, the applicant (by request and prior arrangement and only those materials or verifications provided by outside sources), and is subject to audit by the Washington County Mental Health and Recovery Services Board s Executive Director or designee. Those applicants who are credentialed by L & P Services, Inc., are required to undergo re credentialing every two years. Policy and Procedures Page 184

185 Staff Re Credentialing Effective: 9/16/06 By: Brent Phipps, CEO Policy: That all independent clinical practitioners must provide evidence of current and appropriate competence to provide and/or manage and supervise client treatment without clinical supervision. In order to assure this L & P Services, Inc., independent practitioners will be re credentialed every two years from the date of the initial credentialing decision. L & P Services, Inc., does not allow temporary or provisional credentialing. Purpose: To ensure that all independent clinical practitioners who continue to work within L & P Services, Inc., continue to meet credentialing requirements. Definitions: Re credentialing The process by which clinical practitioners who are licensed/certified to practice independently are re authorized to provide services (including both employed and contract professionals); eligibility is determined by the extent to which applicants meet defined requirements for education, licensure, certification, training experience and professional standing. Licensed Independent Practitioner Any clinical practitioner permitted by law and L & P Services, Inc. to provide client care services without clinical direction or supervision, within the scope of the practitioner's licensure or certification. The following providers are considered Independent Practitioners by L & P Services, Inc.: Psychiatrist MD doctor of medicine, with American Psychiatric Association approved training in psychiatry; board certified or eligible in psychiatry; Medical Doctoral level psychologist Ph.D., Psy.D. Masters Level clinical social worker LISW, ISW independent social worker; Master's level clinical counselor LPCC,PCC professional clinical counselor; Advance practice registered nurse APRN (clinical nurse specialist, nurse practitioner), APRN PMH, RN, CS; registered nurse RN, C. Procedures: All independent practitioners as described above will submit a re credentialing application and supporting documentation as outlined below to the Chair of Credentialing/Re credentialing Committee (who is appointed by the President) within 30 days of notification. At the time of this notification, the applicant will receive a copy of this Policy and Procedure which explains and governs the Re Credentialing process. The applicant will submit: 1. Completed abbreviated application for re credentialing which includes attestations which would Policy and Procedures Page 185

186 indicate any inability to perform the essential functions of the position, with or without accommodations, the lack of present illegal drug use, and any professional liability claims resulting in settlements of judgments paid by or on behalf of the independent practitioner, and any limits placed on licensure. 2. Copy of current valid license or certification to practice as an independent practitioner at the highest level of certified or approved by the state (this will be verified directly from the state licensing agency). 3. Copy of physician valid DEA or CDS certificate (if applicable) that is effective and current at the time of the re credentialing decision. 4. Copy of current Board Certification if applicable. 5. Written verification of current, adequate malpractice insurance (this may be waived by the Credentialing Committee if applicant is to be covered under agency malpractice insurance plan. 6. Copies of all continuing education certificates required by licensure board for re credentialing. After the Chair of the Credentialing/re credentialing Committee receives the above application and supporting documentation, the Chair will: 1. Directly verify current licensure with appropriate licensure board and inquire regarding any restrictions (if done by phone note will be made as to whom and when verification was completed). 2. Verify by phone the status of clinical privileges for Physicians and Psychologists (if applicable) and whom and when verification was completed, and any restrictions on the scope of privileges. 3. Will gather intra agency reports including but not limited to complaints/grievances; record reviews, peer reviews, staff development, utilization reviews, consumer satisfaction surveys and continuing education hours. The above submitted and/or verified information must provide evidence of the following criteria: current license in good standing current certification and/or registration as applicable relevant education, training and experience ability to perform responsibilities and duties as outlined in job description history of relinquishment, limitation, or loss of clinical privileges letters from primary sources about the level, scope and current competence of clinical performance evidence of continuing education hours on topics applicable to the diagnosis, treatment, and/or management/supervision of persons with mental health and/or addictions problems evidence of inpatient coverage for physicians All submitted material and verifications must contain original signatures; faxed copy and scanned signatures are not permitted. All submitted material and verifications must be within 180 days. After the above documentation has been received and appropriately verified, the Credentialing/Recredentialing Committee Chair will notify the applicant that he has three working days with in which to Policy and Procedures Page 186

187 request to review the documentation. The applicant will also be notified if the information received substantially differs from that which was provided by the applicant. If the applicant chooses to challenge any of the documentation or verifications, he has seven working days in which to do so and such corrections will be given to the Committee Chair. In the event documentation and information obtained does not meet the organization's credentialing verification requirements or if disclosure is prohibited by law, the organization is not required to reveal the source. The Committee Chair has up to five working days within to schedule an appointment for this purpose if notified by the applicant that he wishes to review the documentation. After either three days notification of the Credentialing committee either at a regular specified meeting date or at a special meeting. The Credentialing/Re Credentialing Committee will consist of at least three members that must include one licensed mental health professional, one independently licensed mental health professional, and one licensed practitioner from the Medical/Somatic Services (Doctor, Nurse). The Committee will review all documentation and verifications and minutes of this meeting will be recorded along with the recommendations of the committee. These minutes and recommendations will be forwarded to either the President or Chief Clinical Officer for their review and comments but the Credentialing/Re Credentialing Committee will be responsible to approve or disapprove the application. The applicant will then be notified in writing by the Committee as to whether their re credentialing has been approved or disapproved. All materials will be kept in their confidential personnel file which can only be viewed by the Credentialing/Re Credentialing Committee, President, Vice President, and Clinical Supervisor, and the applicant (by request and prior arrangement and only those materials or verifications provided by outside sources) and is subject to audit by the Washington County Mental Health & Recovery Services Board's Executive Director or designee. Those applicants, who are re credentialed by L & P Services, Inc., are required to undergo this recredentialing every two years. Policy and Procedures Page 187

188 Name: SS# Birthdate: Position: Address: Telephone # Licensed D.EA. Certificate # if applicable Please attach: Copy of current license Copy of current certifications Re credentialing Application Copies of continuing education credits since last credential application or renewal Copy of current malpractice insurance coverage Inability to perform current essential functions of the position with or without accommodation Yes No Current illegal drug use Yes No Malpractice claims pending or settled since last credential application Yes No If yes please indicate date of claim and status: Date Status: Printed Name: Signature: Date: Received by Credentialing/Re Credentialing Committee Date: By: Re credential form Word 9/27/2005 Policy and Procedures Page 188

189 Staff Recruitment Effective: 09/16/2005 By: Brent Phipps, CEO Purpose: To establish guidelines for the recruitment of staff that assures non discrimination and confidentiality of applicants. Policy: L & P Services, Inc. is an Equal Opportunity Employer and assures non discrimination against any person or group of persons on the basis of race, ethnicity, age, color, religion, sex, national origin, sexual orientation or disability in the recruitment, selection, promotion, evaluation, or retention of employees or volunteers. Those employees, contract staff, interns, or volunteers who are hired after June 13, 2004 and who will be providing direct care and/or serving children and / or adolescents and /or have the potential to be alone with children and / or adolescents shall be at least 21 years of age, possess a high school diploma or equivalency certification. The employee may not have pled guilty to or been convicted of any of the offenses listed in Agency level 5101: except as provided in 5101: (see attached). Criminal background checks are required for those employees, contract employees, volunteers or interns who will be or have the potential to be alone with children and adolescents by BCI and if they have not been a resident of the state for the preceding 5 years then by the FBI. Copies of the employee policies and procedures are given to each new employee and verification that the employee has received the policies will be placed in their personnel files. Any changes to the Employee Policies and Procedures will be posted on the agency bulletin board and a copy placed in each employee mailbox with a new verification statement. Recruitment efforts will include that L & P Services, Inc. follows the rules and regulation governing fair employment practices, and that the applicant s right to privacy will be respected, and that the results of inquiries shall be treated in confidence by the program. Policy and Procedures Page 189

190 Personnel Qualifications Effective: By: Brent Phipps, CEO Purpose: To ensure that all Mental Health personnel are qualified by credentials, training or continuing education to serve our client population. Policy: All service providers employed by this agency shall meet professional qualification, licensure, supervision and continuing education standards appropriate to the services they provide as defined by: 1. Chapter of the Ohio Department of Mental Health Administrative Code 2. Their agency job description 3. The requirements of any third party payer providing reimbursement for those services from a specific employee. All mental health personnel shall be trained in the principles and application of appropriate mental health approaches for clients of cultural diversity and also deaf or hearing impaired individuals. Procedures: The Clinical Supervisor shall assure that all services qualified to receive third party reimbursement for mandated insurance coverage under sections , and of the revised code shall be legally performed by or under the supervision of a physician, psychologist or other person as required by the third party payer. The Supervisor shall insure that employees possess and maintain licenses, education, training and/or experience required for the specific services they provide as defined in their job description and, for all mental health personnel, the requirements of Chapter of the Ohio Department of Mental Health Administrative Code. The Clinical Supervisor shall assure that all employees delivering mental health services are competent, by training or continuing education, to provide culturally relevant and sensitive services to persons of culturally diverse backgrounds. This information should include, but not be limited to, cultural and minority sensitive issues around psychotropic medication, differentiating diagnostic languages and vernacular language patterns. Sensitivity training should also encompass language patterns of the hearing impaired and deaf. Policy and Procedures Page 190

191 Cultural Competency Effective: 9/16/06 By: Brent Phipps, CEO Accountability: Performance Improvement Committee; Clinical Supervisors; President Purpose: The purpose is to establish consistent guidelines consistent with our Cultural Competency Plan that assures the services that are provided are done in a culturally competent manner. Policy: It is the policy of L & P Services, Inc. to adhere to a policy of zero tolerance in respect to any acts of discrimination or bigotry by staff towards Consumers and/or families. It is further the policy of L & P Services, Inc. Child and Adolescent Services to review and educate staff based on cultural competencies and provide an ongoing system of improvement in providing quality culturally competent services. Procedures: 1. At a minimum of every two years staff will be surveyed as to language skills they might possess including signing and Braille. 2. At a minimum of every two years a review of information regarding delivery of contract services for signing and/or Braille will be completed and problematic delivery of such services will be reported and a plan of correction completed. 3. Annually information will be provided to Supervisory personnel as to all education and trainings that have been completed by those they supervise including those trainings of a culture nature. 4. L & P Services will perform an assessment of overall strengths and weaknesses as an agency, at a minimum of once every two years, regarding cultural competency and will review all survey data, training calendars, staff education, and identified community needs that are applicable to cultural competency. 5. The L & P Services Cultural Competency Commitment Statement will be included in the orientation information provided to each Consumer upon admission and a brief explanation of cultural competency will be provided along with a statement regarding whom to contact if the Consumer feels they have been discriminated against. 6. The L & P Services Cultural Competency Commitment Statement will be included in all marketing publications and brochures. 7. A statement regarding L & P Services commitment to diversity in employment and in delivery of services to consumers will be included in our correspondence via our letterhead. 8. L & P Services will take disciplinary action against any employee, including dismissal, who has substantiated evidence of acts of discrimination and/or bigotry against any Consumer and/or their family members. Twice a year the Quality Improvement Committee will select a "population of focus" (see Cultural Competency Plan) and all staff will receive training or education regarding this population. The education, training, or supervision of staff will include aspects of ethnocentrism and evaluation of the Policy and Procedures Page 191

192 impact of the Staffs culture on the delivery of services to the Consumer. Policy and Procedures Page 192

193 Cultural Competency Plan Introduction L & P Services, Inc. is committed to serving consumers in a culturally competent manner. Through its Affirmative Action Plan L & P Services recognizes cultural diversity as a strength in recruiting and retaining employees and, through this Cultural Competency Plan, we extend that belief in working with the Consumers we serve. We recognize the vast influence that culture has on the lives of individuals and not to address culture in the lives of the people we treat would be amiss. We are committed to become more competent as an Agency in regards to Cultural Competency and have set forth this plan as another mechanism within our agency to improve the quality of services we provide. We recognize the importance of Cultural Competency in positively affecting the outcomes of clients. This plan helps coordinate and incorporate skills, attitudes, and policies to ensure effective treatment of Consumers and their families with diverse values, beliefs, sexual orientations, race, ethnicity, religion, disability, age, socio economic status, and/or language. Cultural Competency Statement of Commitment The L & P Services, Inc. is committed to providing quality services to all people we serve and the acceptance and value of people from all ethnic and religious backgrounds, regardless of their age, gender, sexual orientation, socio economic status or disability. We are committed to a plan which improves our agency s competency as a whole and as individuals to help carry out this commitment. Cultural Competence Defined Cultural competence is defined as a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enables that system, agency, or those professionals to work effectively in cross cultural situations. (Cross et al., Isaacs & Benjamin, 1991). Operationally defined, cultural competence is the integration and transformation of knowledge about individuals and group of people in specific standards, policies, practices, and attitudes in appropriate cultural settings to increase the quality of services; thereby producing better outcomes. (Davis, 1997) Culture Competence Assessment At a minimum of every two years L & P Services, Inc. will review the effectiveness of its Cultural Competency Plan and assess the skills and strengths of its staff in treating specific culturally diverse populations. This assessment will include a survey of staff to identify strengths of individual treatment professionals in working with diverse populations and to identify language skills of staff including signing. This review will also include information regarding problematic delivery of services that have been identified with staff such as contract services for signing and/or Braille materials for the visually impaired. Included in this review will be a report on Agency Training of Staff and a review of individual staff members personnel files to access the training needs of staff in regard to Cultural Competency. This information is provided at least annually, and more often if needed, to Clinical Supervisors in helping determine training needs and to access the performance evaluation of each staff member. Policy and Procedures Page 193

194 The assessment of the strengths and weaknesses of L & P Services performed bi annually will be reviewed by the Quality Improvement Committee for its recommendations and action. All other survey information completed by L & P Services will be reviewed for issues of Cultural Competency and will be included in the assessment. Also included in this review will be data from Community Education Events that may help to identify specific populations that may benefit from outreach and/or which the agency may need special training in order to improve the quality of delivered services. Zero Tolerance Initiative The L & P Services, Inc. adheres to a Zero Tolerance Policy regarding acts of discrimination or bigotry towards Consumers and/or their families. Any substantiated claims of discrimination or bigotry by staff towards Consumers and/or their families will not be tolerated by L & P Services and appropriate disciplinary action will be taken which may include immediate dismissal. Competency Training L & P Services, Inc. is committed to staff receiving appropriate trainings based on culturally competent practices and sensitivities. Staff are accessed individually and collectively to help determine training needs. The Quality Improvement Committee selects every 6 months a "population of focus." This "population of focus" may be any identifiable group that the committee feels staff would benefit from education, training, or focus on. This could include a populations based on gender, race, ethnicity, religion, sexual orientation, socio economic status, disability, language, impairment or disability, age, or any group which has identifiably diverse values or beliefs. All L & P Services Staff will receive training and education on this "population of focus". It is the intent of the selection of the "population of focus" to engage staff in dialogue regarding these populations and to increase knowledge and skills associated with diverse groups. The competency based trainings will address ethnocentrism of the staff in their interactions with Consumers and their families and to be aware of the impact of their own culture on the therapeutic relationship and to take these factors into account when planning and delivering services to Consumers and, in particular, for children and adolescents and their families. Emphasis will be placed on the importance of being aware and respectful of the values, beliefs, traditions, customs, and parenting styles of the people they serve. Reference L & P Services, Inc. Policy and Procedure Cultural Competency. References Cross T., Bazron, B., Dennis, K,. & Isaacs, M. (1989). Towards a culturally competent system of care, volume I. Washington, D. C.: Georgetown University Child Development Center, CASSP Technical Assistance Center. Per http: //ceco.air.org/cultural/0integrated.htm Isaacs, M. and Benjamin, M. (1991). Towards a culturally competent system of care, volume II, programs which utilize culturally competent principles. Washington, D.C.: Georgetown University Child Development Center, CASSP Technical Assistance Center. Per integrated.htm Policy and Procedures Page 194

195 Duty to Protect Effective: By: Brent Phipps, CEO Accountability: Mental Health Professionals (Licensed Clinical Staff); Clinical Supervisor; Chief Compliance Officer Purpose: To protect known persons and property and to be in compliance with Ohio House Bill 71 regarding known explicit threats to such. Policy: It is the policy of L & P Services, Inc. that licensed staff will communicate and take appropriate action if they are provided direct knowledge of an explicit threat made by a client to a person and /or property OR obtain this knowledge from another credible reliable source. This action can range from calling law enforcement and providing them information regarding the threat AND notifying the intended victim to developing treatment plan goals and objectives to minimize this threat. Upon either hearing the explicit threat OR receiving knowledge of such from a credible source the licensed staff will do the following: 1. Complete the Duty to Protect Form utilizing the decision tree incorporated in the form and make a clinical judgment based on the specifics of each case as to what action needs taken. Attempting to hospitalize the client voluntarily or involuntarily should be considered strongly depending on the specifics of the situation. 2. Notify/confer with the Clinical Supervisor or the CEO, if available, or the Director of Pharmacological Services or his designee if neither the Clinical Supervisor nor CEO can be reached. If this is untimely the licensed staff may take what action he/she deems appropriate and notify the above party of what action was taken. 3. Fax the Duty to Protect Form to the Administrative Office as soon as possible to the attention of the Clinical Supervisor and the President. 4. Complete a progress note in the chart documenting the threat, the intervention, and the response of the client to the intervention. Unlicensed staff should communicate any explicit threats directly to their supervisor who, if a licensed mental health professional, may complete the above procedures based on knowledge from a credible source. Policy and Procedures Page 195

196 Name of client/patient Date of Birth Chart Number DUTY TO PROTECT On a threat to seriously physically harm another identifiable person or (date) Identifiable structure was communicated to me by (name of person) (relationship to patient/client) The nature of the threat was (Explicit threat) to the following person(s) or structure (Specific person(s) or structure) Based on my knowledge of the patient/client, it is my judgment that the patient/client does not have the intent or ability to carry out me threat because: Note: If the client/patient does not have the ability or intent to carry out the threat, no further action is legally mandated. However, clinical steps should be considered. OR does have the intent and ability to carry out the threat In accordance with Ohio Revised Code Section ,1 have initiated the following option(s) and, after consideration have chosen not to pursue other options at this time, based on the following reasons in order to fulfill my duty to protect potential victims from threatened violence. (ALL FOUR SECTIONS BELOW MUST BE COMPLETED). Policy and Procedures Page 196

197 1. Voluntary hospitalization Chosen Not Chosen Reason: 2. Involuntary hospitalization (Emergency or Judicial) Chosen Not Chosen Reason: 3. Establish and undertake a documented treatment plan reasonably calculated to eliminate the threat and concurrently initiate a risk assessment and management consultation with a consultant as described in the law. Chosen Not Chosen Reason: 4. Warning to law enforcement and, if feasible, intended victim(s) Chosen Not Chosen Reason: Information shared if this option is chosen (name of client/patient, nature of threat, and names of potential victim(s)/structure) STEPS TAKEN to implement the option(s) I have chosen are: (include any persons to whom a warning is given, as well as the date and time and specifics; or specific changes in the treatment plan, the initiation of the required consultation and name of consultant; or specific steps taken to hospitalize the client/patient) Mental Health Professional Signature Print Name Date Policy and Procedures Page 197

198 Clinical Management Alcohol & Drug Addiction Services Effective: By: Brent Phipps, CEO Purpose: L & P Services, Inc. shall maintain, at a minimum, the clinical management requirements of the Ohio Department of Alcohol & Drug Addiction Services for outpatient treatment services. Policy/Procedure: It is the Policy of L & P Services, Inc. that all substance abuse programs are abstinence based. The admission, continued stay and discharge/referral to each level of care based on the Ohio Department of Alcohol and Drug Addiction Services protocols for level of care clients shall be predicated upon the following factors: A substance related disorder diagnosis based on the current Diagnostic and Statistical Manual of Mental Disorders for adult clients admitted to levels I IV. The degree of severity for the following dimensions: Intoxication or withdrawal potential. Biomedical conditions and complications. Emotional/behavioral/cognitive conditions and complications. Treatment acceptance/resistance. Relapse potential. Recovery environment. The admission criteria including criteria for financial eligibility and for determining appropriateness of services shall be: Consumers must have some form of payment or agree to a payment plan, Board payment, sliding fee, and executive waiver may be utilized. Consumers must be eighteen years of age or older. Consumers must be diagnosed with a substance abuse disorder based on the current Diagnostic and Standard Manual of Mental Disorders. Consumers must meet the Adult Protocol Level of Care for Non Intensive Outpatient Treatment (Level 1 A) using the Ohio Department of Alcohol & Drug Addiction Services. Consumers cannot be actively homicidal or suicidal. Clients shall not be denied admission due solely to their use of prescribed psychotropic medication(s). Policy and Procedures Page 198

199 Admission Procedures Upon contacting L & P Services, a consumer will be provided a summary of the services provided by L & P Services and will be offered an appointment for initial intake and diagnostic assessment. The appointment will be scheduled to be within seven days of the initial contact. Pregnant women and IV drug users take priority. Following the diagnostic assessment, individuals who require a higher level of treatment than nonintensive will be provided the names, addresses and phone numbers of alternative agencies and resources available. The Counselor will provide this information and offer assistance to the consumer for accessing the needed services, including obtaining properly completed release forms. In the event a consumer needs to be transported to a hospital, an ambulance service will be contacted and pre instructions given regarding the amount of assistance that may be needed. In the event that a consumer needs transported to another mental health facility due to presenting a danger to either self and/or others, staff will call law enforcement or emergency squad, depending on the severity and the lethality being displayed. Discharging Clients Clients will be discharged when they have achieved the goals established in their individualized treatment plans, if they are unable or refuse continued treatment, or if they are non compliant with treatment plan. Three consecutive missed appointments without notification will also result in termination of services. A client who terminates services against the advice of L & P Services will be sent a discharge summary from the counselor outlining the risks associated with discontinuing services and offering options for the client, including referral to other agencies and resources. Clients who are under court order to attend counseling will be notified that L & P Services will be notifying their parole or probation officer of their non compliance. Client Readmissions Clients readmitted to L & P Services must have an updated diagnostic assessment if their discharge was within twelve months. Clients who have been discharged for more than twelve months must have a new diagnostic assessment. Clients who have diagnostic assessments completed by another agency certified by the Ohio Department of Alcohol & Drug Addiction Services or an assessment containing comparable elements of assessment per Agency Level 3793: that has been performed within one year of the admission or re admission date of the client, will be given a diagnostic update only. A copy of the assessment (and the diagnostic update) shall be filed in the client s record, signed and dated by a staff member of L & P Services authorized to conduct diagnostic assessments. Client Behavioral Interventions L & P Services prohibits the use of any cruel or unusual punishments or practices, including, but not Policy and Procedures Page 199

200 limited to physical or verbal abuse. Specific interventions shall include cognitive, client centered approaches. L & P Services prohibits the use of any type of isolation, including isolation in a locked, unmonitored room. L & P Services, Inc. s behavioral interventions shall only be administered by the program director, clinical director or program employees with direct care responsibilities who have been trained in the programs approved behavioral interventions and procedures. Client Exposure to Disease All clients will be provided information and education regarding the transmission of tuberculosis, hepatitis type B & C, and HIV. Documentation of such education shall be kept in client s record. Informational material will be distributed to each client upon intake and will be documented in the client record that this occurred. Clients may be referred to the local health department for more information and documentation of this referral will be found in a progress note in the client record. Clinical Supervision L & P Services provides clinical supervision by a licensed independent clinical counselor. (LICDC) Clinical Supervision includes the following: 1. Weekly individual sessions. 2. Written goals and objectives for supervision that are agreed upon with the supervisee. 3. Documentation of what occurred during the supervision sessions and progress with supervision goals. Level of Care L & P Services, Inc. provides Level 1 A level of Care Non Intensive Outpatient Treatment. This level of care consists of any one or more of the following, Assessment, Crisis Intervention, Case Management, and Individual and/or Group Counseling. Assessment includes at a minimum, the following information: Presenting problem(s) and/or precipitating factors leading to the need for an assessment; History of alcohol and other drug use by client and family members and/or significant others; Current over the counter and prescription medications being used; History of treatment for alcohol and other drug abuse; Medical history; Allergies to include food and drug reactions; Employment history; Educational history; Legal history to include pending charges and parole/probation status; Policy and Procedures Page 200

201 Mental status screen including but not limited to, appearance, attitude, motor activity, affect, mood, speech and thought content; Psychiatric history; Family history; Sexual history; Religion/spiritual orientation; Strengths/assets; Weaknesses/limitations; Degree of severity for the following dimensions: intoxication and withdrawal potential, biomedical conditions and complications, emotional/behavioral/cognitive conditions and complications, treatment acceptance/resistance, relapse potential, recovery environment and family or care giver functioning (youth only); Recommendations for treatment A program may accept an assessment from a program certified by the department or an assessment containing comparable elements of assessment required by this rule that has been completed within one year of the admission date of a client; updated, signed and dated by a staff member of the admitting program authorized to conduct an assessment pursuant to agency level 3793 of the Administrative Code. Crisis intervention services involve a face to face response to a crisis or emergency situation experienced by a client, family member and/or significant other. Crisis intervention services can be provided at a program site certified by the Ohio department of alcohol and drug addiction services or in the client s natural environment. The goal of crisis intervention services is to provide or assist the person(s) in obtaining those services necessary to stabilize the crisis situation. Individuals who have unstable medical problems shall be referred to a medical facility. Individuals who have unstable psychiatric problems shall be referred to a psychiatric facility. Individuals who are experiencing withdrawal symptoms from use of alcohol and/or other drugs shall be referred to a person and/or entity that can provide the appropriate level of detoxification services. Individual service providers of crisis intervention services shall have current training and/or certification, with documentation of same in their personnel files, in the following: Cardio pulmonary resuscitation techniques First aid De escalation techniques Case management services means those activities provided to assist and support individuals in gaining access to needed medical, social, educational and other services essential to meeting basic human Policy and Procedures Page 201

202 needs. Case management services may include interactions with family members, other individuals or entities. Examples of case management activities include: coordinating client assessments, treatment planning and crisis intervention services; providing training and facilitating linkages for the use of community resources; monitoring service delivery; obtaining or assisting individuals in obtaining necessary services, for example, financial assistance, housing assistance, food, clothing, medical services, educational services, vocational services, recreational services, etc.; assisting individuals in becoming involved with self help support groups; assisting individuals in increasing social support networks with family members, friends, and/or organizations; assisting individuals in performing daily living activities; and coordinating criminal justice services. Transportation in and of itself does not constitute case management. Waiting with clients for appointments at social service agencies, court hearing and similar activities does not, in and of itself, constitute case management. Case management services can be provided at a program site certified by the Ohio Department of Alcohol and Drug Addiction Services, in the natural environment of the client or by telephone. Case management services may be provided by any staff member approved by the program director. Individual counseling involves a face to face encounter between a client or client and family member and a counselor. Individual counseling means the utilization of special skills to assist an individual in achieving treatment objectives through the exploration of alcohol and other drug problems and/or discussing didactic materials with regard to alcohol and other drug related problems. Individual counseling services can be provided at a program site certified by the Ohio Department of Alcohol and Drug Addiction Services or in the client s natural environment. Group counseling means the utilization of special skills to assist two or more individuals in achieving treatment objectives. This occurs through the exploration of alcohol and other drug problems and/or addiction and their ramifications, including an examination of attitudes and feelings, consideration of alternative solutions and decision making and/or discussing information related to alcohol and other drug related problems. Group counseling services shall be provided at a program site certified by the Ohio Department of Alcohol and Drug Addiction Services or in the client s natural environment. The client to counselor ratio for group counseling shall not be greater than 12:1. Group counseling services shall be documented per paragraphs (M) and (N) or rule 3793: of the Administration Code. Group sessions, which focus on helping individuals increase awareness and knowledge of the nature, extent and harm of their alcohol and drug addiction do not have a client to counselor ratio requirement. Such group sessions can consist of lecture, viewing a video or a structured discussion session and shall be documented per paragraph (O)(1) of rule3793: of the Administrative Code. The provision of this type of group session shall not eliminate the requirement for group counseling in outpatient and residential treatment. Policy and Procedures Page 202

203 Social Media Subject: Social Media Effective: 8/15/2012 By: Brent Phipps Social Media are works of user created video, audio, text or multimedia that are published and shared in an electronic environment. Examples include, but are not limited to: Facebook, You Tube, Twitter, LinkedIn, blogs, instant messaging, and text messaging. We recognize social media is a growing phenomenon and L & P s policy is that employees may use Social Media for personal use only during non working time and in adherence to the policies and procedures of L & P Services, Inc. Employees need to ensure that Social Media activity does not interfere with work responsibilities. Employees who use Social Media, (including after work hours) are expected to refrain from presenting themselves as representatives of L & P Services, Inc. or from portraying L & P Services, Inc. in a negative manner. Employees are expected to use good judgment and discretion when using Social Media. Conduct that would be illegal or a violation of L & P Services, Inc. s policies in the offline world would still be illegal or a violation of the policy when it occurs online. While you are entitled to express your opinions and ideas, you have a responsibility not to violate L 7 P Services, Inc. s policies or negatively affect the operations of the agency. The agency is particularly sensitive to those expressions that might be prohibited by Ohio Revised Code affecting mental health agencies such as discrimination or derogatory language towards those of a particular religion, gender, national origin, sexual orientation, physical or mental handicap, developmental disability, genetic information, human immunodeficiency virus status, or in any manner prohibited by local, state, or federal laws. Employees are expected to respect the privacy of other employees and clients and refrain from posting material or information which may portray other employees, the agency, or others in business relationships with the agency in a negative manner. Disclosing confidential patient Protected Health Information (PHI) in an inappropriate manner is prohibited. Employees should never make comments or acknowledge the case of a specific patient. Employees cannot use Social Media to harass, threaten, discriminate or disparage against employees or anyone associated with or doing business wilt L & P Services, Inc. Employees cannot post on Social Media site photographs of other employees, clients, doctors, Policy and Procedures Page 203

204 vendors or suppliers, nor can employees post photographs of persons engaged in agency business or at agency events. If employees are uncertain whether information is confidential, they should consult their supervisor or other responsible person. Social Media that indicate the individual s place of employment should include disclaimers that the opinions provided do not represent the agency, such as: The views expressed on this (blog, website, etc.) are my own and do not reflect the views of my employer. Employees are cautioned that they should have no expectation of privacy while using the internet. Members of the public can view your postings. Remember that bloggers and commenters are personally responsible for their commentary on blogs and social networking sites. Bloggers and commenters can be personally liable for commentary that is considered defamatory, obscene, proprietary or libelous by any offended party, not just L & Services, Inc. Employees are cautioned that they should have no expectation of privacy while using agency equipment or facilities for any purpose. L & P Services, Inc. Reserves the right to use content management tools to monitor, review or block content on agency computers that violate agency rules and guidelines. Employees are expected to comply with copyright laws and avoid plagiarism. Agency logos and trademarks may not be used without prior written consent by the marketing department. These policies and procedures apply not only to employees Social Media sites, but also to postings on other websites, including Social Media sties of non employees. L & P Services, Inc. request and strongly urges employees to report any violations or possible or perceived violation to their supervisor. Violations include discussions by L & P Services, Inc. between its employees and patients, any discussion of proprietary information and any unlawful activity related to Social Media. Policy and Procedures Page 204

205 Policy and Procedures Page 205

206 Section I: Affiliation Agreements Policy & Procedures Table of Contents Affiliation Agreements Policy and Procedures Page 206

207 Affiliation Agreements Effective: By: Brent Phipps, CEO Revised: 3 4/2009 Purpose: To ensure compliance with Ohio Department of Mental Health Administration Code, Section Policy: The agency will maintain any and all affiliation agreements required to maintain compliance with ODMH Administrative Code Procedures: L & P Services, Inc. maintains no affiliation agreements at this time. Policy and Procedures Page 207

208 Section J: Business Policy & Procedures Table of Contents Governing Body Table of Organization Contractual Relationships Service Evaluation Performance Improvement Risk Management Corporate Compliance Policy & Procedure Governing Authority Corporate Compliance Technology and Information Policy and Procedure Budget Management and Control for Cash Disbursements Management and Control for Cash Receipts Policy and Procedures Page 208

209 Governing Body Effective: 9/16/05 By: Brent Phipps, CEO Revised: : Purpose: Establish the agency leadership structure identifying who is responsible for governance, agency administration, i.e. planning, management and operational activities and provision of clinical services. Policy: It is the policy of L & P Services, Inc. that the owner shall assume sole responsibility for the governance, agency administration and the provision of clinical services. Procedures: The owner shall represent the interest of the agency. The owner shall assume sole responsibility for the following governance activities: 1. To provide financial oversight and develop an annual budget and plan for services. 2. Conduct meetings at least quarterly which shall include summary of client rights activities, review of the summary of performance improvement activities, including but not limited to quality assurance and risk management activities maintain meeting minutes which reflect the date, time, and place of the meeting, names of those attending, topics discussed and action taken, establish duties and responsibilities of the executive director, select the executive director. 3. Establish, review, and update annually the agency s policies and document the review has occurred. 4. Ensure the agency has a written table of organization which documents the lines of responsibility of the governing body, if applicable, the executive director, administrative leadership and clinical oversight. 4. Review the annual service evaluation. 5. Conduct an annual review and evaluation of the executive director. 6. Identify responsibility for leadership in the absence of the executive director. 7. Ensure adequate malpractice/liability insurance for the corporation, agency, agency staff, and shall conduct such a review annually. 8. Ensure that opportunity is offered for input regarding planning, evaluation, delivery, and operation of mental health services, which shall include but not be limited to the opportunity to participate in the activities of or participate on the governing body, advisory groups, committees, or other agency bodies to: Persons who are receiving mental health services and their family members, persons who collectively represent a wide range of community interests and demographic characteristics of the service district in categories such as race, sex, and socioeconomic status; ensure hours of operation for services and/or activities accommodate the Policy and Procedures Page 209

210 needs of the persons served, their families, and/or significant others; and ensure that services provided and employment practices are in accordance with non discrimination provisions of all applicable federal, state, and local laws and regulations. 9. Ensure the hours of operation for services and/or activities accommodate the needs of persons served, their families and significant others 10. Ensure that all services provided and employment practices are in accordance with nondiscrimination provisions of all applicable federal laws and regulations. Policy and Procedures Page 210

211 Table of Organization Shareholders Board (when applicable) CEO Advisory Board Director of Operations/Human Resources Officer Agency Development Director Accounting Coordinator Operational Support Administrator Billing Coordinator Financial Coordinator Clinical Director Medical Records/Performance Improvement Coordinator Emergency Services Coordinator AOD Supervisor Pharmacological Coordinator Mental Health Supervisor Child & Adolescent Supervisor Support Staff Crisis/Health Officer Counselor Physician Therapist Therapist Case Management APRN Community Psytchiatric Support Treatment Provider Community Psychiatric Support Treatment Provider RN LPN Policy and Procedures Page 211

212 Contractual Relationships Effective: By: Brent Phipps, CEO Purpose: To establish guidelines and procedures for the creation, approval and implementation of all contracts for the L & P Services, Inc. Policy: It is the policy of L & P Services, Inc. that all contractual relationships must be approved by the CEO. Major contractual relationships must be authorized by the CEO. All contracts which the contractee has the potential to access protected health information will review and sign a PHI agreement and receive a copy of our HIPAA guidelines. The language of the contract will also specify our non discrimination clause and for those providing direct service a non competition clause may be added. Procedures: All contracts will be approved and signed by the CEO or their designee with the approval of the CEO. Major contracts will be approved by the CEO. The CEO is the statutory agent for the corporation. Copies of all contracts will be given to the Chief Compliance Officer for review and filing. The agency will assure that PHI and confidentiality agreements are completed if applicable. Policy and Procedures Page 212

213 Service Evaluation Effective: 9/16/06 By: Brent Phipps, CEO Purpose: L & P Services, Inc., shall have an evaluation plan that covers a two years period and describes the specific methodologies to be used to carry out the goals of service evaluation activities. The service evaluation activities shall include analysis of the following components: 1. Annual summary of service evaluation activities 2. Needs assessment 3. Patterns of use 4. Feedback from persons served, their families and significant others 5. Community acceptance data 6. Outcome Evaluation Include separate analysis for minority groups when those minorities are significantly represented in the service district. Be implemented in coordination with the local Community Mental Health Board's service evaluation efforts. Interrelate with Performance Improvement Activities. Results of service evaluation studies shall be shared with Performance improvement staff and information from performance improvement mechanisms shall be used by service evaluation staff in planning which areas shall be the focus of subsequent evaluations. Be conducted in such a manner to ensure that confidentiality is maintained. The annual summary of service evaluation activities shall: 1. Include a description of the methodology used for each of the evaluation activities, the general findings or results of these activities, and a description of how these activities, and a description of how these findings or results have been or will be used for service or administrative planning 2. Be provided to the agency board and to the local Community Mental Health Board 3. Be made available to: a. The staff b. Persons served, their families and significant others and the general public c. Organizations with which the agency has affiliation agreements d. Local county commissioners e. The department Procedures: L & P Services, Inc. will obtain from the Community Mental Health Board a needs assessment of Policy and Procedures Page 213

214 constituents in its service area. L & P Services, Inc. will review the results of the needs assessment every two years and integrate the findings into the agency service plan and other planning efforts. The needs assessment the agency will: 1. Coordinate the design and implementation with the Community Mental Health Board 2. Ensure the participation of persons served, their families and significant others in the design of the needs assessment 3. Integrate the findings into the agency service plan and other planning efforts 4. Make available the data and results of the needs assessment to the department upon request 5. Conduct the needs assessment by using one or more of the following general methods, one of which shall include input from persons receiving services or their families: a. Client oriented techniques, which refers to any standardized qualitative assessment of expressed or observed needs existent among groups of persons receiving services within a specified time period b. Community forum, which means a method of securing public participation such as a town meeting in which community members are brought together to respond to formulated questions regarding community needs for Mental Health Services and of the priorities to be placed on these needs c. Community Survey, which means a survey by questionnaire or interview of a representative sample of the general population of a geographic area. Responses are sought to questions regarding past and present needs for mental health services, degree of mental health or impairment, predilection to use public mental health services and related matters d. Demographic analysis which refers to the collection, analysis and interpretation of demographic data, including U.S. census data and other publicly available information, to infer the various levels of need for mental health services within a given geographic area e. Key informant techniques which refers to any survey, by questionnaire, interview or joint meeting of significant members of the community who represent Human Service Organizations, persons served including ethnic, minority and cultural groups to determine perceived needs for Mental Health Services f. Rates under treatment techniques, which refers to any collection of data describing persons who have received mental health services (public and/or private) and the service received within a specified time period for a given geographic area g. Research or evaluation results from Mental Health sources or other systems that affect mental health h. Any other technique that secures needs assessment information in an efficient and methodologically sound manner L & P Services, Inc. shall determine the number and types of persons using services of the agency. For Policy and Procedures Page 214

215 purposes of this determination, L & P Services, Inc. shall collect and analyze patterns of use data: 1. Pertaining to clinical and demographic characteristics of persons served and the amounts and types of services delivered 2. Aggregated for characteristics of persons served such as age, sex, race and for such populations of persons served as are appropriate to the purpose of the agency 3. Regarding information on the source of client referral L & P Services, Inc. shall assess the levels of accessibility, availability, appropriateness and acceptability of its service every two years through patterns of use information that: a) Is analyzed in terms of needs identified from the needs assessment Process and demographic characteristics of the service area b) Includes attention to cultural and ethnic needs, i.e., an examination of the kinds and levels of specific services that are received by each ethnic or cultural group c) Includes trends in the income level and employment status of persons served to determine the number of persons who may benefit from employment, vocational and adult educational services If services are not utilized as expected by population groups represented by the demographic characteristics of the service area, analysis shall be conducted to determine the cause. L & P Services, Inc. shall obtain feedback from persons served and their families regarding services received, the manner in which these services were delivered and whether the services met their needs. Such feedback shall be routinely collected, analyzed and used for service improvements within the agency. Feedback from persons served and their families shall be obtained using at least one of the following mechanisms, and shall ensure that at least one of the mechanisms used involves direct participation of persons served and their families: a) A satisfaction questionnaire b) A series of telephone or face to face interviews with persons served or their families c) A suggestion box made available especially for collecting feedback from persons served or their families d) Meetings with advocacy or self help groups e) An ombudsman on the staff of the agency f) A telephone call in line designated for use by persons served and their families in an efficacious manner The mechanisms used to obtain feedback shall be made available to all persons served their families or shall ensure, as much as is practicable, that an accurate representation of opinions is obtained. The mechanisms used shall ensure that the persons served and their families may remain anonymous and/or have their responses remain confidential. Policy and Procedures Page 215

216 L & P Services, Inc. may obtain feedback from police, human services, schools, children's service boards, area agencies on aging, community mental health boards, mental retardation/developmental disabilities boards and other systems that interact with our agency regarding the levels of acceptance and perceived qualify and effectiveness of services provided by the agency, including but not limited to the following: 1. Special efforts shall be made to identify problems that might exist in coordination of services, particularly for persons with severe mental disability or serious emotional disturbance and for special needs groups served by the agency 2. Community acceptance surveys or interviews shall be conducted in coordination with the community mental health board so as not to duplicate efforts in the service area L & P Services, Inc. shall assess the impact of services on the lives of persons using quantitative and qualitative techniques to measure: 1. Progress toward meeting individual treatment goals, which are based on the needs, strengths and preferences of the persons being served. 2. Level of improvement in functioning or community integration of the person served 3. Level of improvement in feelings of well being or quality of life from the perspective of the person being served L & P Services, Inc. shall establish baseline data on key client outcome indicators as a way of measuring progress toward meeting outcome goals. L & P Services, Inc. shall use the results of quality assurance mechanisms to determine the services to be evaluated. When evaluating the outcomes of its services, L & P Services, Inc. shall assess both the short term and long term impacts, as appropriate, on the lives of persons served. Outcome measures shall be based upon what persons served and their family's report as being important to them in their lives. Results of outcome evaluation shall be used, as appropriate, in revisions of the agency service plan and in management and policy decisions. L & P Services, Inc. may choose different services with which to evaluate client and service outcomes from year to year, but at least two outcome evaluations shall be conducted every two years. Policy and Procedures Page 216

217 Performance Improvement Effective: 9/16/05 By: Brent Phipps, CEO Revised: 6/10/06 Purpose: To establish guidelines, description, and procedures of the Performance Improvement Plan of L & P Services, Inc. which will be utilized to identify opportunities for improvement, and identify changes that will lead to improvement, and sustain improvements. Policy: L & P Services, Inc. is committed to performance improvement that is both collaborative and interdisciplinary. This policy (developed with input from an interdisciplinary team, must be continuously monitored, analyzed, and enhanced so that the ultimate goal of improved client outcomes can be realized. L & P Services, Inc. will utilize evidence based practices, key reports and evaluative tools to enhance and improve all aspects of the agency, including service delivery to consumers, communications to stakeholders, and to provide sound data to agency leaders and interdisciplinary team members that can utilized to improvement overall performance. Procedures: The President will appoint a Performance Improvement Coordinator whose responsibility will be to collect, analyze and disseminate performance improvement data to an interdisciplinary team. This coordinator will assign data collection activities and may create special focus review committees as needed or at the direction of the interdisciplinary team. Data will be submitted monthly to the PI coordinator, or as applicable, and reports will be given monthly to the interdisciplinary team. Such data will include at a minimum the following: 1. Consumer satisfaction (Ohio Scales; satisfaction and accessibility surveys; CQRT reports) will be conducted at a minimum annually but some will be conducted at a minimum quarterly. Finding in the forms of trends and patterns will be used to enhance services to consumers. At least one survey per year will be conducted so that consumer input can be anonymous in participation, data collection, analysis, and reporting of findings. These surveys will address accessibility, appropriateness, cultural competency, recommendation of services to others and overall satisfaction. 2. Client protection (Health and Safety; Fire Inspection; Client rights and grievances; Major unusual incidents and other incidents. 3. Consumer outcomes (indicating clinical status, community functioning, quality of life and safety and health and which will include periodic review of the effectiveness and efficiency of the services 4. High volume, high risk, or problem prone areas which are aligned with the Agency's overall mission Policy and Procedures Page 217

218 and values (Peer review of clinical staff; drug utilization review; other focus reviews and studies of areas deemed appropriate in regards to being high volume, high risk, or problem prone) 5. Overall agency performance data which include but is not limited to: a. Strategic planning information b. Financial information c. Accessibility plans d. Resource allocation e. Risk analysis reports f. Governance reports g. Human Resource Reports h. Technology analysis i. Environmental health and safety reports j. Field trends, including research findings, if applicable k. Statistical sample and procedure l. Peer Review (assessments are thorough, complete, and timely, treatment plan problems, goals, and objectives were based on the results of the assessment. Services were related to the treatment plan goals and objectives, documentation accurately reflects the services that were provided) m. Appropriateness of admission and discharge n. Document reviews (at a minimum quarterly) o. Billing Reviews (at a minimum quarterly) It is the responsibility of the PI Coordinator to ensure that performance improvement process and activities are both collaborative and interdisciplinary and involve those individuals, disciplines, and departments closest to the process, function, or service identified for improvement. Data should be specific, meaningful, understandable, attainable, reliable, valid, responsive, and time specific. Data collection and reports will include and target key agency processes such as consumer outcomes, consumer satisfaction, client protections, risk status, capacity (the ability to provide specific services such as clinical screening and needs assessment), and process (what is done to, for, with, or by selected individuals or groups as a part of the delivery of services such as performing an assessment or procedure, or offering an educational service). Data will be systematically analyzed on an ongoing basis using performance improvement techniques and display methods as appropriate. Performance improvement tools that may be utilized include: 1. Run charts that display summary and comparative data; 2. Control charts that display variation and trends over time; 3. Histograms; 4. Pareto charts: 5. Cause and effect or fishbone diagrams; 6. Other performance improvement tools Policy and Procedures Page 218

219 The agency shall establish performance expectations and shall compare its performance internally over time and with other external sources of information. The agency will demonstrate that the data collected and analyzed are used to improve performance, practices, and processes in that: Undesirable patterns or trends in performance shall trigger additional analysis or focused review. The agency shall initiate such an analysis or focused review when the comparisons show that important single events, levels of performance, patterns, or trends vary significantly from set expectations. The agency will provide information to and gather feedback from, as appropriate, staff, leaders, consumers, and families, and the Executive leadership about the redesigned processes and other changes. The agency shall establish and sustain a culture supporting continuous performance improvement through such activities as offering opportunities for education and training, involvement in ongoing performance improvement activities, and conducting focused training on improvement processes. The agency will maintain documentation demonstrating utilization of the four performance methodologies: 1. Design, enhancement, and utilization of resources for the plan which utilize individuals, disciplines, and departments closest to the process, function, or service identified for improvement. 2. Collection of data 3. Analyzing data and performance 4. Use of data collected and analyzed to improve performance practices and processes. Any service provider cannot review his/her own client records for quality assurance and improvement activities. Provisions for conducting activities to determine that the client s admission to, continued stay and discharge from the program is appropriate based on the Ohio Department of Alcohol and Drug Addiction Services protocols for levels of care (youth and adult) for publicly funded drug abuse and alcohol clients, including, at a minimum, the methodology, frequency, and content of these activities. The agency shall routinely submit reports to the Ohio Department of Mental Health and to the Washington Behavioral Health Board regarding the status of its performance improvement process in a manner prescribed by the Ohio Department of Mental Health. Such reports shall be submitted no more than semi annually and no less than annually on forms prescribed by the Ohio Department of Mental Health. Key indicators of performance will be shared at least annually with clients, staff, and other stakeholders in the form of the annual performance improvement summary. Policy and Procedures Page 219

220 Minutes are reviewed, at a minimum, quarterly by the CEO, and any corrective actions directed by the CEO will be reviewed through the review of the Performance Improvement Minutes. The performance improvement plan is updated and approved annually by the CEO. The agency maintains documentation of performance improvement, quality assurance, risk management, and quality improvement activities it conducts and this information is considered proprietary information of L & P Services, Inc. Policy and Procedures Page 220

221 Risk Management Effective: 9/16/05 By: Brent Phipps, CEO Purpose: To establish guidelines and procedures for risk reduction of assets of L & P Services, Inc. Policy: It is the policy of L & P Services, Inc. that Policies and Procedures be in place and utilized that reduce risk and exposure to the agency. In addition it is the policy that adequate insurance coverage be maintained for all property and physical assets. It is also the policy that shredding of any records or documents of the agency will cease upon issuance of any subpoena or court order issued related to any particular category of documents, including but not limited to: Financial documents Audits Client information Check registers Billing documents Procedure: The CEO will determine assets of the agency annually and review all insurance policies to determine that adequate coverage is maintained. The Chief Compliance Officer will coordinate annually with key staff a risk management assessment of current risks, including severity and likely hood and work with the President, Performance Improvement Committee, and Compliance Committee to implement strategies to reduce risk. (See Risk Management Plan) The Chief Compliance Officer will complete an annual report to the CEO detailing risk assessment activities for the year. The Performance Improvement Committee will be responsible for service evaluation activities such as inter agency surveys and other data that may indicate problems with service delivery that may affect the reputation, health and safety of clients and employees, and other potential liability issues. Reference policies related to risk management activities regarding clinical services and other risk management activities including but not limited to: Client Rights and Grievances Incident Reporting Performance Improvement Plan (including Peer Review, Health and Safety, Incident Reports, Use of Restraint, Client Rights and Grievances) Medication Handling, Pharmacotherapy Service Evaluation Activities Policy and Procedures Page 221

222 Corporate Compliance Policy & Procedure Effective date: 09/16/05 By: Brent Phipps, CEO Revised date: 03/06/07 Purpose: To establish and publish the official policy of L & P Services, Inc. regarding the organization's corporate compliance program and plan. Policy: L & P Services, Inc. is dedicated to the delivery of behavioral health care in an environment characterized by strict conformance with the highest standards of accountability for administration, clinical, business, marketing and financial management. L & P Services, Inc. s leadership is fully committed to the need to prevent and detect fraud, fiscal mismanagement and misappropriation of funds and therefore, to the development of a formal corporate compliance program to ensure ongoing monitoring and conformance with all legal and regulatory requirements. Further, the organization is committed to the establishment, implementation and maintenance of a corporate compliance program that emphasizes (1) prevention of wrong doing whether intentional or unintentional, (2) immediate reporting and investigation of questionable activities, and practices without consequences to the reporting party and (3) timely correction of any situation which puts the organization, its leadership or staff, funding sources or consumers at risk. Procedures: By formal resolution, the Board of Directors has delegated overall responsibility for the Corporate Compliance Program to the President. The President has formally designated a Corporate Compliance Officer to monitor the organization's corporate compliance program and provide periodic and regular reports to the Board of Directors on matters pertaining to the program. The Corporate Compliance Officer (CCO) shall (1) chair the organization's corporate compliance team and serve as the organization's primary point of contact for all corporate compliance issues, including scheduling team meetings, reporting on team activities and making recommendations to the Executive Director and Board of Directors as required; (2) develop, implement and monitor on a regular and consistent basis the organization's corporate compliance plan, including all internal and external monitoring, auditing, investigative and reporting processes, procedures, and systems; (3) prepare, submit and present periodic reports to the President and/or Board of Directors as may be required to provide clear communication to the organization's leadership for corporate compliance oversight; and (4) coordinate development of the organization's formal corporate compliance plan. The CCO shall submit an annual report to the President and the Board of Directors. Annual reports will, include at a minimum include: (1) a summary of all allegations, investigations and/or complaints processed in the preceding 12 months in conjunction with the corporate compliance program; (2) a complete description of all corrective action(s) taken, and (3) any recommendations for changes to the Policy and Procedures Page 222

223 organization's policies and/or procedures. In the performance of his/her duties, the CCO shall have direct and unimpeded access to the Executive Director, Board of Directors and the organization's accounting firm and/or legal counsel for matters pertaining to corporate compliance. As part of corporate compliance plan development, the CCO shall schedule, coordinate and monitor regular and periodic reviews of risk areas for competent persons external to the organization. Such reviews will be conducted as a way to ensure ongoing conformance with billing, accounting and collection regulations imposed by the federal government and other "third party" funding sources. More critically, these reviews will augment the organization's annual audit of its accounting system and provide an additional, internal measure to ensure conformance with billing and coding policies and practice that will withstand the scrutiny of any regulatory audit or examination. Corporate Compliance Officer: Marcia Sellers Contract Financial Supervisor: Bob Boersma Audit Firm: Perry and Associates Legal Counsel: Buell and Sipe Reports can be made in a variety of formats which include anonymous reporting by mail or phone: L & P Services, Inc., PO Box 4006, Marietta, OH or (740) or by e mail. No reprisal of any sort is to occur for reporting based on this Corporate Compliance Policy. Investigation: The CCO, once he/she receives the complaint has five working days to investigate the complaint and attempt to substantiate and/or resolve the issue. If this cannot be done within five working days, the complaint will be taken to the CEO for his direction, unless the complaint involves the CEO. Under his direction, the CCO has five more working days to complete the investigation and attempt to resolve the complaint and then make a report including suggestions for improvements or policy changes to address similar types of occurrences. If the complaint is against the CEO and cannot be resolved or the complaint cannot be resolved after the added five working days under the direction of the CEO, the matter is turned over to legal counsel. Policy and Procedures Page 223

224 Governing Authority Corporate Compliance Effective: 9/16/05 By: Board of Directors Accountability: Board of Directors, if applicable; President, if applicable; Chief Compliance Officer Purpose: To establish and publish the official policy of L & P Services, Inc. regarding the organization s corporate compliance program and plan. Policy: L & P Services, Inc. is dedicated to the delivery of behavioral health care in an environment characterized by strict conformance with the highest standards of accountability for administration, clinical, business, marketing and financial management. L & P Services, Inc. s leadership is fully committed to the need to prevent and detect fraud, fiscal mismanagement and misappropriation of funds and, therefore, to the development of a formal corporate compliance program to ensure ongoing monitoring and conformance with all legal and regulatory requirement. Further, the organization is committed to the establishment, implementation and maintenance of a corporate compliance program that emphasizes (1) prevention of wrong doing whether intentional or unintentional; (2) immediate reporting and investigation of questionable activities and practices without consequences to the reporting party; and (3) timely correction of any situation which puts the organization, its leadership or staff, funding sources or consumers at risk. Procedures: By formal resolution, the Board of Directors has delegated overall responsibility for the Corporate Compliance Program to the President. The President will formally designate a Corporate Compliance Officer (CCO), monitor the organization s corporate compliance program and provide periodic and regular reports to the Board of Directors on matters pertaining to the program. The CCO shall submit an annual report to the President and Board of Directors. Annual reports will include a minimum: (1) a summary of all allegations, investigations and/or complaints processed in the preceding 12 months in conjunction with the corporate compliance program; (2) a complete description of all corrective action(s) taken; and (3) any recommendations for changes to the organization s policies and/or procedures. In the performance of her/his duties, the CCO shall have direct and unimpeded access to the President, Board of Directors, and the organization s accounting firm and/or legal counsel for matters pertaining to corporate compliance. As part of corporate compliance plan development, the President and CCO will schedule, coordinate, and monitor regular and periodic reviews of identified risk areas by competent persons internal and external to the organization. Such reviews will be conducted as a way to ensure ongoing conformance Policy and Procedures Page 224

225 with billing, accounting and collection regulations imposed by the federal government and other third party funding sources. More critically, these reviews will augment the organization s annual audit of its accounting system and provide an additional, internal measure to ensure conformance with billing and coding policies and practice that will withstand the scrutiny of any regulatory audit or examination. Policy and Procedures Page 225

226 Technology and Information Policy and Procedure Effective Date: By: Brent Phipps, CEO Revised Date: Purpose: Computerization has become more important in the management and control of information in most businesses, and L & P Services, Inc. is no exception. Confidentiality of information including patient information and financial information needs to be safe guarded. Access of information by those staff that need such information in performance of their duties needs to be easily accessible while protecting the confidentiality and the integrity of the information. Policy: The following are key elements to the Technology and Information Systems of L & P Services, Inc. 1. That all computer software be installed responsibly this will be done via the CEO or his designee. 2. That all computers are password protected and only those staff needing access will have access. 3. That routine inspections of software and computer functioning will be completed and problems will directed to the President and Security officer. 4. That virus protection is installed on all computers. 5. That agency maintains that fax machines are located in a secure manner as not to be readily accessible to the public. 6. The agency maintains privacy and that computer display screens are not viewable by visitors, consumers, or the public. 7. That the agency assures that information is accessible to only those staff that needs such information in the performance of their jobs. 8. That the agency maintains back up of vital server information and such backup is routinely performed, at a minimum of once a week. Procedures: That the responsibility of the above is held with the CEO and such problems that are identified by staff will be brought to his attention. Policy and Procedures Page 226

227 Budget Effective10/10/2005 By: Brent Phipps, CEO Revision date: Purpose: This is to establish policy and procedures for the development of an annual operating budget. The budget process serves to establish funding and program service levels and unit cost development for the upcoming fiscal year. Policy: The budget will serve as an operating guide for measuring the actual costs of service to estimated costs and projected revenues to actual receipts. Procedures: (1) The agency budget will be developed using the ufms budget package or whatever budget process required by the Ohio Department of Mental Health. (2) The budget will be developed using the service taxonomy of the Ohio Department of Mental Health. (3) The budget process will use historical data as well as emerging trends to project services levels for the new fiscal year. (4) Unit projections will be consistent with the standardized unit definitions. (5) The process of budget development will begin in fourth quarter of the current fiscal year. (6) The budget will be approved by the board of directors prior to submission to the Mental Health & Recovery Services Board. (7) Cost allocation will be distributed to various programs either by a direct method or allocated by a percentage. (8) Personnel costs will be distributed by utilizing the direct and indirect method as prescribed by the ufms budget process. (9) Fringe benefits will be distributed to programs based on a percentage of salaries. (10) Facility costs will be distributed either by a direct method or use of a percentage method. The percentage method maybe based on square footage or a percent of salary. (11) Patient care cost will be distributed using a direct method. (12) General operating costs will be distributed either by a direct method or by a percent of salary. (13) Non cash cost will be distributed by a direct method. (14) All unallowable cost will be identified and backed out of the unit cost for Medicaid billable services. (15) Administrative cost will be allocated by utilizing one of the methods approved by the Ohio Department of Mental Health. These methods include distributing costs based on a percentage of units, number of FTE's, or program cost. (16) At least quarterly the performance improvement committee will review projected units to actual units, projected cost to actual cost; and projected unit cost to actual unit cost. Policy and Procedures Page 227

228 (17) Budget revisions will be completed semiannually. Policy and Procedures Page 228

229 Management and Control for Cash Disbursements Effective: 10/10/2005 By: Brent Phipps, CEO Revision date: 3/12/2010 Purpose: This is to establish the policy for the management and control of cash disbursements and to establish a system of internal controls that will ensure the appropriate use of funds. Policy: It is the policy of L&P Services, Inc., to follow the procedures below for cash disbursements. Procedures: 1. All purchases orders must be pre approved by one of the following people: CEO/Director of Operations. 2. All purchasing will be done from the home office location in Marietta, Ohio to take advantage of volume discounts when ordering quantities of items. 3. All purchases require a purchase order or initialed approval. 4. Requisitions from the various staff are to be submitted bi weekly and signed or initialed by the CEO. 5. The CEO maintains agency credit card. 6. Purchases to be made by use of the agency credit card require a PO, signature of staff person using credit card, and receipts of purchases made to be returned with credit card and attached to PO. 7. Agency will use pre numbered checks. 8. All checks require the signature of at least one officer of the corporation. 9. Checks are issued at least bi weekly. 10. All invoices for payment is to be approved by either the CEO or his designee. 11. Either the CEO will initial all invoices. 12. Checks will be attached to the appropriate invoice when presented for signatures. 13. All invoices will be attached to the copy of the check and include the check number. Checks may be pulled to indicate date paid. 14. Invoices will include the general ledger account number and program number for which it is costed to. 15. Blank checks will be maintained in a locked filing cabinet. 16. No checks are to be signed in advanced. 17. No checks are to be made payable to "cash". 18. Voided checks will be filed with the monthly payments after the signature lines have been destroyed and "void" has been stamped across the face of the check. Daily procedure: 1. Upon receipt of invoice the fiscal department will stamp the invoice with the stamp for approval Policy and Procedures Page 229

230 initials and date received. 2. All invoices will be checked for mathematical accuracy. 3. The invoice will be coded with the general ledger account number and program number or numbers for which the invoice is to be charged. 4. The invoice will then be recorded into the agency accounting system with indication of the due date. 5. Invoices will be filed in the appropriate unpaid invoice file. Bi weekly procedures: 1. Checks for payment of invoices will be processed electronically from the agency's accounting system. 2. Checks are attached to the appropriate invoice and delivered to either the CEO for approval. 3. Signature of CEO authorized to sign checks will be obtained. 4. Checks will be mailed by the Friday of the week in that they are written. 5. Copies of the checks with supporting invoices and documentation will be filed in the monthly paid bill file. 6. Payroll checks are processed once monthly by corporation staff. 7. Time cards are to be completed by the employee. Appropriate leave forms are to be attached to the time card signed by the employee and their immediate supervisor. 8. Time cards are to be signed by the employee and submitted to their immediate supervisor for signature and submission to the accounting department for processing. 9. Hours entry forms, employee updates, and new hire forms are to be submitted to the president or vice president for review and approval. 10. Employee expense reports are to be submitted with their time card to their immediate supervisor for approval and submission to the fiscal department. 11. Payroll checks and employee reimbursement checks will be delivered to the appropriate site for distribution to the employee. 12. All checks will be recorded into the agency checkbook when written. 13. All federal payroll tax deposits will be made according to federal law. Monthly procedure: 1. All checks processed for the month will be recorded on the accounts payable docket. 2. All wire transfers will be recorded on journal entry forms. 3. The accounts payable docket and journal entries will be submitted to the mental health & recovery services board for input into the accounting system maintained by the board. 4. The accounts payable docket should be submitted to the president or vice president by the 10th of the following month. 5. All cash disbursements will be recorded on the checkbook recap worksheet. 6. Checkbook will be reconciled with the bank statement, checkbook recap worksheet and general ledger. Monthly financial statement will be distributed to the CEO for review. Policy and Procedures Page 230

231 Management and Control for Cash Receipts Effective: 10/10/2005 By: Brent Phipps, CEO Revision date: 3/12/2010 Purpose: This is to establish the policy and procedure for the management and control of the funds received by L&P Services, Inc. for services rendered, and to establish a system of internal controls that will ensure the safe guarding of assets. Policy: It is the policy of L&P Services Inc. that the following procedures be utilized to manage and control cash receipts. Procedures: 1. Pre numbered receipts shall be used as the source document to record all cash income received. 2. Cash receipts shall be deposited intact on a timely basis into the bank checking account, but in no instance later than every Friday, ensuring no funds remain on the grounds over a weekend. The deposit amount shall be posted in the checkbook from the certified amount listed on the bank deposit ticket. 3. All monies accruing in excess of current needs should be invested in an interest bearing account(s) if possible. 4. To the extent possible, there shall be a division of responsibility between the cash receiving and cash disbursing functions. These duties should be divided into two positions. The first will receive all income and deposit it intact into the appropriate account. The second will tender all accounts payable and prepare checks. This separation should reduce the possibility of records being manipulated for personal gain. Daily procedures for maintaining funds: 1. Checks or cash received shall be given to the appropriate personnel where a per number receipt shall be written and all checks will be stamped "for deposit only" and a copy made. Checks and cash will be recorded on the appropriate bank deposit ticket and given to the appropriate staff personnel for deposit into the bank. 2. The check stub, copy of check, back up documentation, and in the case of cash copy of the prenumbered receipt will be attached to the deposit ticket and turned over to the appropriate fiscal staff. 3. The fiscal staff will record the deposit in the checkbook, record the general ledger account number, program account number, and record the deposit on the advice of cash receipts for input into the accounting system. Monthly procedure: 1. The advice of cash receipts shall be summed and sent to CEO for review. Policy and Procedures Page 231

232 2. Deposits will be recorded on the checkbook recap worksheet. 3. All deposits shall be reconciled with the bank statement, advice of cash receipts, checkbook and general ledger Monthly financial report of revenues will be presented to the CEO for review. Policy and Procedures Page 232

233 Human Resources Management Effective: 7/1/2011 By: Brent Phipps, CEO Human Resources Management Purpose: To establish guidelines and procedures for human resources management of L & P Services, Inc. Policy: It is the policy of L & P Services, Inc. that Policies and Procedures be in place and utilized to ensure that a human resources management program is utilized for all agency personnel, including: paid, unpaid, volunteer, contract, student intern or other person who is part of L&P Services, Inc. s workforce. Procedure: The human resources management program shall ensure: 1. That the agency has the necessary staff to support the agency s mission, value and goals, and to provide services to persons served; 2. That the agency personnel policies and procedures include the following provisions: a) Prohibit discrimination in employment, training, job duties, compensation, evaluation, promotion, and any other term or condition of employment based on race, ethnicity, age, color, religion, gender, national origin, sexual orientation, physical or mental handicap, developmental disability, genetic information, human immunodeficiency virus status, or in any manner prohibited by local, state or federal laws; b) Describe a formal process to express and process employee grievances; c) Establish recruitment and hiring practices; d) Establish skills, qualifications and competencies required for each position, based on mission of organization, services provided and characteristics and needs of population(s) served. The agency shall maintain a written job description for each position. e) All personnel for whom licensure is required by law shall maintain current licensure by the appropriate body in the state of Ohio, and shall practice only within the scope of their license. f) Verify staff credentials, including licensure, certification or resignation, education, and experience; g) Develop and maintain a staff orientation program, which shall include training on: i) Employee and client safety; ii) Agency s mission, vision and goals; iii) Characteristics of the population served; iv) Sensitivity to cultural diversity v) Agency policies and procedures, including personnel policies, and those specific to individual job duties; vi) Confidentiality: vii) Reporting abuse and neglect; viii) Client rights. h) Ensure direct service and supervisory staff participate in education and training. Policy and Procedures Page 233

234 Training may be provided by direct supervision, attendance at conferences and workshops internal and external to the agency, on line training, educational coursework, etc. Training shall: i) Maintain or increase competency; ii) Include topics specific to population served; and, iii) Ensure culturally competent provision of service. i) Ensure each staff providing direct services receives documented supervision appropriate to his/her skill level and job duties, and in accordance with the requirements of his/her license, certification or registration, if applicable. Supervision may be provided in individual and group sessions, including supervisory participation in treatment plan meetings. j) Evaluate staff performance annually k) Ensure that a copy of the written personnel policies and procedures shall be available to each employee. L&P Services policies and procedures are also available on the employee website. l) Employees shall also be notified of changes in personnel policies and procedures. m) L&P Services, Inc. Shall maintain a personnel file on each staff person. Employees may access the personnel file with reasonable notice. n) L&P Services, Inc. Personnel files shall be stored in a locked cabinet to maintain the privacy of each staff person. Administrative personnel access to personnel files is on a :need to know basis. Requests for access to agency personnel files shall be reviewed by the Director of Operations or their designee. o) Each personnel file shall include: i) Identifying information and emergency contacts; ii) Application for employment or resume; iii) Verification of credentials, if applicable; iv) Documentation of education, experience and training; v) Verification of references, if required for position; vi) Job description; vii) Compensation documentation, if applicable; viii) Performance évaluations ; ix) Documentation of orientation ; x) Documentation of on going training, as required by position, state law and agency policy ; xi) Commendations or awards, if applicable; xii) Disciplinary actions, if applicable. p) L&P Services, Inc. shall have policies and written procedures for handling cases of staff neglect and abuse of persons served, and documentation that each employee has received a copy of these policies and procedures. q) L&P Services, Inc. shall have a policy that appropriate disciplinary action, up to and including dismissal from employment, shall be taken regarding any employee misconduct or criminal conviction that bears a direct and substantial relationship to that employee s position. Policy and Procedures Page 234